Care coordination: Identifying and connecting the most appropriate care to the patients

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Care coordination, which has been defined as “the deliberate organization of patient care activities to facilitate the appropriate delivery of health care services” (McDonald et al., 2007), is recognized as central to patient‐centered high‐value care (Institute of Medicine, 2001; Liaw, Moore, Iko, & Bazemore, 2015). Coordinated care that is organized around patient‐specific need(s) and context is critical in the complex and fragmented healthcare system, particularly for high‐risk and/or high‐cost populations.
Over the last decade, care coordination models and programs have been developed and implemented in different populations and care settings. The Transitional Care model developed by Naylor (Naylor & Keating, 2008; Naylor et al., 2004, 2009) and the Care Transition program developed by Coleman (Coleman, Parry, Chalmers, & Min, 2006; Parry, Coleman, Smith, Frank, & Kramer, 2003; Parry, Min, Chugh, Chalmers, & Coleman, 2009) are examples of care coordination models for older adults who are transitioning from hospital to home. Antonelli, McAllister, and Popp (2009) developed a framework for care coordination for the pediatric population. The Agency for Healthcare Research and Quality (AHRQ) has funded multiple projects to develop and test effective care management models to coordinate care for their populations (Farrell et al., 2015). In these frameworks, the composition of teams that care coordinators work with and the financial and practice models of care coordination vary by setting. This variation by program influences the roles and practice of care coordinators (Fagnan et al., 2011; Joo & Huber, 2013; Tahan, Watson, & Sminkey, 2015).
Although conceptual descriptions of competence in care coordination exist (American Academy of Ambulatory Care Nursing, 2015; American Nurses Association, 2012; Lamb, 2014) and training programs for care coordination for nurses are burgeoning (e.g.,; based on the models and demonstration projects described above, the role of care coordinator is still relatively new and evolving. In fact, little is known about the nuances of care coordination practice as it is enacted within the context of healthcare teams, what roles care coordinators play on teams, and what knowledge and skills they require to effectively coordinate care in real‐world contexts.
In addition, performance measures to evaluate effectiveness of care coordination are limited (American Nurses Association, 2015; Farrell et al., 2015). To date, the quality of care coordination is primarily evaluated by patient outcomes including health service utilization and patient/family satisfaction (McDonald et al., 2014; Schultz, Pineda, Lonhart, Davies, & McDonald, 2013; Vedel & Khanassov, 2015). Commonly used outcome measures, such as hospital readmission rate, may suggest care coordination failure but may not capture the nuances of care coordination that prevent care breakdown or hospital readmission. High patient satisfaction rates may be an indicator of successful care coordination but cannot explain why it was successful.
To develop sensitive measures that enable capturing the real impact of care coordination, it is necessary to understand the ways in which it is performed in context, especially when it is done well. In other words, obtaining concrete and contextualized descriptions of care coordination practice is the first step to identifying the essential attributes of measurable quality care coordination. The purpose of this study was to uncover what care coordination practice entails and to describe the knowledge and skills required in care coordination practice to promote patient‐centered high‐value care.
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