Here is a simple slidedeck of research done that examined which systemic care coordination practices should be maximized according to the literature to improve clinical integration within and between healthcare organizations.
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Soraya Ghebleh - Clinical Integration and Care Coordination
1. Which systemic care coordination strategies should be
maximized to improve clinical integration in hospitals and
integrated healthcare delivery systems?
Soraya Ghebleh
May 29, 2013
The Dartmouth Institute for Health Policy and Clinical Practice
2. Background
Trends in Current Healthcare Environment
Clinical Integration
Systemic Care Coordination Strategies
Conceptual Framework
Methods and Search Strategy
Overview
Inclusion Criteria
Search Results
Limitations
Results
Characteristics of Included Studies
Summary of Results
Methodological Quality
Synthesis
Completeness and Applicability of the Evidence
Common Themes of Care Coordination Interventions
Recommendations
Implications for Institutions Interested in Clinical Integration
Framework to Improve Clinical Integration using Systemic Care Coordination Strategies
Conclusions
Future Research
Executive summary
3. Trend #1: Fragmented Delivery of Care
Trend #2: Healthcare Reform
Trend #3: Increased Consolidation Activity
Three Current trends Shaping the healthcare
environment
4. AIM: To bring providers together to manage care in a more standardized,
coordinated, effective, and efficient manner, leading to improvement in
quality for patients.
PRIMARY CHARACTERISTICS AS DEFINED BY THE
FEDERAL TRADE COMMISSION:
(1)Ability to achieve significant clinical and economic efficiencies
(2)Broad physician representation and physician intervention
(3)A well-developed care management program that uses
evidence-based guidelines
(4)A data management system that enables extensive data
collection, information sharing, and utilization review
clinical integration and quality
5. Care Coordination is defined as “the deliberate
organization of patient care activities between two or
more participants (including the patient) involved in a
patient’s care to facilitate the appropriate delivery of
health care services.”1
Mechanism by which clinical integration can be
improved through comprehensive interventions
Systemic care coordination strategies involve
collaboration between multiple disciplines within an
institution or between institutions
Care coordination
1
Source: Care Coordination, Quality Improvement: Structured Abstract. June 2007. Agency for Healthcare Research and
Quality, Rockville, MD. http://www.ahrq.gov/research/findings/evidence-based-reports/caregaptp.html
7. A systematic review of the available literature in the Business and Medical
databases was performed in April 2013. The specific databases searched
were MEDLINE via PubMed, ABI/Inform, Business Source Complete, and
CINAHL.
A search strategy and specific inclusion criteria were established a priori.
All databases were searched from 1990-2013. Search terms utilized were
“integration,” “care coordination,” “hospitals,” and “healthcare systems.”
The Boolean terms “AND” and “OR” were used to find intersection
between these terms
overview of methods
8. Studies were included that met the following criteria:
(1) study designs consisting of randomized controlled trials, cohort studies,
case-control studies, before-after studies, pseudo-experimental or non-
randomized trials, cross-sectional studies, and case studies
(2) intervention must fall under one of the five broad approaches of care
coordination as identified by the Agency for Healthcare Research and
Quality
(3) intervention must aim to further integrate setting where intervention is
being implemented
(4) intervention must be limited to hospital-wide settings, integrated health
systems or a hospital clinic setting that involves multi-disciplinary
collaboration
(5) intervention must be a systemic intervention
(6) studies were limited to 1990 to April 2013.
Inclusion criterion
9. results of search
77 studies were identified from
ABI/Inform, 185 studies from
MEDLINE via Pubmed, 193 from
CINAHL, and 136 from Business
Source Complete. A total of 592
records were identified through a
database search and 94 duplicates
were removed. A remaining 498
studies were then screened by title
and abstract. 441 studies were
excluded and 57 remaining full text
articles were then screened for
eligibility. Of the 57 full text articles
that were screened, 13 met the
inclusion criteria.
10. Numerous definitions for both clinical integration and
care coordination exist in the literature
Lack of consensus on appropriate measures of clinical
integration
Deficit of high-quality, empirical studies
measuring the effects of care coordination on clinical
integration
Review was performed by only one individual,
leaving room for potential error
limitations of search Strategy
11. Interventions all met one of the five broad categories of care
coordination interventions as defined by the Agency for
Healthcare Research and Quality
Outcomes of all studies included at least one of the four
components of clinical integration as defined by the Federal Trade
Commission
Five of the thirteen studies examined interventions
implemented across an integrated delivery system
Six studied single institution interventions
Two studies compared multiple settings
Characteristics of included studies
13. summary of results
All studies gave insight into the design and implementation
of care coordination interventions
Varied reporting of quantitative results across studies
Metrics reported included length of stay, hospital
utilizations, patient satisfaction, staff satisfaction, ED
presentations, and cost savings
Each study gave in-depth descriptions of care coordination
interventions, processes used to develop these
interventions, and recommendations
14. A standardized abstraction tool adapted from Downs and Black was utilized to
assess the methodological quality of each study
Many studies included were of low quality, had limited reporting of quantitative
results, and lacked generalizability
Difficult to find the best study design to assess the link between care coordination
and clinical integration due to the limited amount of existing studies as well as
the numerous metrics that can be utilized to assess this link
Reporting bias is a concern as specific positive outcomes were often reported but
adverse outcomes were not
Conflict of interest was also of concern, as only four studies specifically stated
that no conflict of interest was present
methodological quality
16. Eligible studies all incorporated at minimum one
component of the categories of care coordination
interventions and one component of the
characteristics of clinical integration as an aim
Certain components of both care coordination and
clinical integration were studied more than others
completeness of evidence
Unclear if the care coordination intervention was the only factor that affected
clinical integration in the study setting
The appropriate study design to study the link between systemic care
coordination interventions and improving clinical integration has not been
determined in the literature
17. Institutions are consolidating to meet new demands in the healthcare
environment and must become more efficient to remain competitive
Improving clinical integration through carefully implemented systemic
care coordination strategies can lead to higher quality and satisfaction
and has the potential to reduce costs
Care coordination strategies to improve clinical integration within a
hospital can be applied systematically across a delivery system
If an institution that is part of a system implements a strategy or
intervention and success is reasonably demonstrated, that institution can
expand or share that strategy within the system
clinical integration within and between institutions
18. Despite variations in quality and generalizability of
included studies, the synthesis revealed common
components of interventions regardless of study design
or setting:
Leadership
Communication
Data Collection and Meaningful Utilization
Flexibility
Process Improvement
Patient-Centered Emphasis
Common themes of care coordination
interventions
20. Establish leadership before implementation of intervention
Leadership can be senior management, clinical leaders, care
coordinators, or teams but must be clear to the staff
Responsibilities include setting institution and organizational goals,
creating an organizational structure, and ensuring appropriate
management of various components of the intervention
Oversight and monitoring of the
intervention is essential
Leadership
21. Frequent staff meetings that incorporate all levels of staff
High-touch communications strategy that emphasizes institutional goals and a
culture of learning and adaptability
Cross-department communication pathways established
Sharing best practices between institutions within an integrated delivery
system
Establish communication between
patient and individual or team that
serves as single point of care
communication
22. Data collection is essential to any quality improvement
initiative
Defined metrics should be established and data collection
should begin prior to any intervention
Data should be benchmarked with institutional and
national data
Real-time data collection allows for adaptive learning and
necessary adjustments to be implemented
Effective utilization of healthcare information technology to
ensure data is being collected efficiently
data collection & meaningful utilization
23. Flexibility is necessary in two contexts:
(1) Institutional Flexibility
(2) Point of Contact for Patient
flexibility
Institutions require adaptability with implementation of interventions, as no
two settings are entirely homogeneous
The point of contact for the patient must have the ability to span
departments to ensure proper management of patient care
Beneficial for care coordination staff or intervention leadership to give an
outside perspective on pathways and processes occurring in the institution
24. process improvement
Adaptive learning to adjust, enhance, and improve implemented
interventions
Incorporation of data collection, staff and patient feedback, evidence from
the literature, and existing clinical pathways to strive for improved
outcomes and efficiency
Process improvement measures should
be performed as problem areas are
defined and should be adapted as data
is collected
25. patient-centered emphasis
Goal of any intervention is ultimately to improve
outcomes and quality for patients
Comprehensive care management plans should be
designed for high-risk and high-utilizing patients
Patient feedback is informative for improvement and can provide insight
beyond the perspective of providers
Patient and caregiver satisfaction should be kept in mind with any intervention
designed to improve patient care and overall experience
Patient care pathway is integral to any systemic care coordination intervention
26. More high quality studies with empirical data should be performed
Studies should involve comprehensive systemic care coordination
interventions that encompass all of the broad categories as defined by the
AHRQ
Outcomes should be identified and defined before the intervention is
implemented and an adequate time period should be established for follow-
up
A standardized, validated, systematic, evidence-based tool needs to be
developed to effectively evaluate integration in order to compare different
hospitals and integrated delivery systems
Future research
27. Relationship between care coordination and clinical integration is important in
the context of healthcare reform and increased consolidation
These different components can be used to develop a comprehensive, systemic,
care coordination plan that has the potential to improve clinical integration within
an institution and between institutions
conclusions
There is no identical, repeatable care coordination
plan guaranteed to work in every institution
Further research and higher-level study should be
performed as coordinating care at a systemic level
shows great promise to improve the quality and
experience of healthcare delivery