Abstract The U.S. healthcare system is changing, spurred on by increasing use of information technologies, changes in legislation and policy, and consumer demand for more convenient, timely, and patient-centered care. However, the current healthcare system is not prepared to maximize the benefits of these changes to optimize health outcomes for patients with chronic conditions, leaving many to fall through the cracks. New models of care coordination that align clinical activities are needed so that patients receive the right care at the right time. The goal of this commentary is to outline a research agenda for care coordination, drawing upon lessons learned from the VA healthcare system in which care coordination is enhanced through the application of health policy, population health/technology, and implementation science. BACKGROUND At least half of all U.S. adults have at least one or more chronic health conditions, and over a quarter have two or more chronic conditions . As the U.S. population ages, chronic physical and mental health conditions will be associated with even greater health care costs and premature morbidity and mortality. Currently, chronic conditions contribute to the top ten causes of hospital admissions in publicly funded health insurance (e.g., Medicare, Medicaid, and VA-funded care) and over 80 per cent of total healthcare spending . Moreover, evidence suggests that life expectancy decreases with each additional chronic condition . A large proportion of individuals with Medicare and Medicaid insurance (“dual-eligibles”) have multiple chronic conditions, and this vulnerable group is a key priority for care coordination under the 2010 U.S. Patient Protection and Affordable Care Act . Recent attention has focused on the needs of “high-need, high-cost” patients, defined as those whose multiple chronic conditions are complicated by functional limitations or social needs that make it hard for them to care for themselves. This population, estimated at 5 per cent, accounts for up to 50 per cent of national health care spending . Despite the prevalence and costs of chronic conditions, few patients receive adequate health care. Only half of U.S. residents receive effective care for chronic conditions overall , and for individuals with mental health conditions, less than half receive minimally adequate treatment . In addition, evidence suggests that up to one third of hospital readmissions are preventable , suggesting room for improvement in coordination and timeliness of care . The high prevalence and high burden of chronic conditions including physical and mental illnesses are further exacerbated by lack of care coordination. Defined by the Agency for Healthcare Research and Quality as the “deliberate organization of patient care activities among two or more participants . . . to facilitate the appropriate delivery of health care services,” effective care coordination has the potential to improve quality of care, reduce costs, and ultimately improve quality of life for individuals with chronic conditions [10, page v]. Effective practices in care coordination, especially for chronic physical and mental health conditions, are not optimized in routine practice, however [11–12]. Conversely, fragmentation is the norm across different care settings including primary care, mental health services, geriatric care, substance use, social services, and other systems, leading to missed treatment opportunities or overuse of inappropriate care that can lead to medical errors. Fragmentation also leads to patients and their family members having to act as their own care coordinators and navigate a complex system to get needed care . A recent longitudinal cohort study involving close to 8,000 Veteran patients found that having more than four different prescribing clinicians was a stronger predictor of emergency room visits or hospitalization than having more than three chronic conditions . Hence, new models of care need to be implemented and sustained to mitigate barriers to coordination of services and from health care to the home. This commentary outlines a research agenda for care coordination, primarily drawing upon lessons learned from the U.S. Department of Veterans Affairs Veterans Health Administration (VA) care management, case management, and similar services (Table 1). The focus of this commentary will be on coordination of care within and between healthcare organizations, to inform the further implementation of best practices and policies nationwide. Table 1 VA definitions of care coordination and similar services Care coordination An “administrative process that facilitates integration of health care services and navigation through complex health care systems” typically involving care across different sites, providers, and community resources Care management “A systems approach to the implementation and facilitation of longitudinal care coordination” with an emphasis on linkage to needed clinical care and other resources with a focus on wellness that emphasizes a plan of care for each patient Case management “Case management emphasizes a collaborative process that assesses, advocates, plans, implements, coordinates, monitors, and evaluates health care options and (other) services in order to meet the needs of an individual patient” Care coordination An “administrative process that facilitates integration of health care services and navigation through complex health care systems” typically involving care across different sites, providers, and community resources Care management “A systems approach to the implementation and facilitation of longitudinal care coordination” with an emphasis on linkage to needed clinical care and other resources with a focus on wellness that emphasizes a plan of care for each patient Case management “Case management emphasizes a collaborative process that assesses, advocates, plans, implements, coordinates, monitors, and evaluates health care options and (other) services in order to meet the needs of an individual patient” From VHA Directive 1010 (November 2016) on Transition and Care Management if Ill or Injured Service members and New Veterans. Available at https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=4297 . View Large Table 1 VA definitions of care coordination and similar services Care coordination An “administrative process that facilitates integration of health care services and navigation through complex health care systems” typically involving care across different sites, providers, and community resources Care management “A systems approach to the implementation and facilitation of longitudinal care coordination” with an emphasis on linkage to needed clinical care and other resources with a focus on wellness that emphasizes a plan of care for each patient Case management “Case management emphasizes a collaborative process that assesses, advocates, plans, implements, coordinates, monitors, and evaluates health care options and (other) services in order to meet the needs of an individual patient” Care coordination An “administrative process that facilitates integration of health care services and navigation through complex health care systems” typically involving care across different sites, providers, and community resources Care management “A systems approach to the implementation and facilitation of longitudinal care coordination” with an emphasis on linkage to needed clinical care and other resources with a focus on wellness that emphasizes a plan of care for each patient Case management “Case management emphasizes a collaborative process that assesses, advocates, plans, implements, coordinates, monitors, and evaluates health care options and (other) services in order to meet the needs of an individual patient” From VHA Directive 1010 (November 2016) on Transition and Care Management if Ill or Injured Service members and New Veterans. Available at https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=4297 . View Large CARE COORDINATION FOR HEALTH SYSTEMS Singer et al.  provides a comprehensive framework for care coordination, involving interactions across professionals (doctor to doctor or doctor to nurse, social workers, care navigators, and other staff), coordination across facilities, across support systems (community and families), and between visits (continuity over time). An essential element of optimal care coordination is effective communication between patients, their families, and providers, as well as between providers and the health systems that employ them, to translate clinical knowledge into services across complex healthcare systems. Ideally, effective communication involves appropriate treatment that considers patient needs and preferences, and increases care efficiency by enabling providers to practice at the “top of their license” to deliver comprehensive services. Two important roles within effective care coordination are as follows: (a) care managers, who typically communicate health status and care concerns between patients and their principal providers, deliver wellness education, and develop a comprehensive care that optimizes health promotion and disease prevention and (b) case managers, who typically focus on the broader needs of patients with complex medical and social conditions especially for those that require more intense, individualized support. Care managers and case managers use similar techniques (e.g., assessment, treatment planning, and services referral), but have distinctive roles and population foci. For example, care management typically involves longitudinal monitoring of symptoms and further consultation with a specialist for further treatment, as well as provision of patient self-management support [15–16]. Case management involves coordination of social services as well as life skills training for persons in need of additional assistance for nonmedical issues . Nonetheless, these roles can markedly differ in professional training and licensure requirements. For example, care managers who are typically nurses come from a different training background than case managers, who are typically social workers. There are also differences in reimbursement eligibility for care management and case management services [18–19]. CARE COORDINATION MODELS Essential to role definitions of care managers and case managers is defining effective care coordination models in routine practice. A recent meta-analysis  found that effective care coordination for cancer led us to more appropriate services use (cancer detection, treatment, and end-of-life care) and decreased overall costs. The most common and effective cancer care coordination models involved nurses or social workers, which has also been observed in other settings and conditions . Notably, the Chronic or Collaborative Care Model (CCM) [22–24] has been widely applied to promote proactive care management, self-management support, and community resource linkages in the context of an enhanced information system-based communication. The CCM has been shown to improve outcomes for people with chronic physical conditions such as diabetes or congestive heart failure  as well as for chronic mental health conditions  with little to no net health care costs. The CCM also forms the foundation of the Patient-Centered Medical Home model , especially in the VA where it has been implemented to facilitate coordination of multiple chronic conditions [28–30] and primary and mental health care services . Other effective practices similar to the CCM that aim to improve coordination of care include care transition models, defined as coordination of care after hospitalization discharge, and share similar characteristics as collaborative care models but focus on navigating hospital to home transitions through patient and family education and communicating with providers . The VA has also pioneered the implementation of home-based primary care models for older individuals who suffer from chronic conditions , as well as vulnerable populations including Veterans who are homeless . Notably, home-based primary care models [33–34] led us to lower costs in VA, in part due to fewer exacerbations, ER visits, and hospitalizations. Additional programs that focus on coordinating needs of more complex patients tend to integrate nonmedical services such as social or legal support and rely more on interdisciplinary teams to deliver comprehensive services. For example, the Geriatric Resources for Assessment and Care of Elders program (GRACE) and the Program of All-Inclusive Care of the Elderly (PACE) were developed for older patients and have had variable effects on reducing critical service encounters such as hospitalizations . BARRIERS TO CARE COORDINATION However, the CCM and similar models have not been fully implemented or sustained in routine care due to organizational and financial barriers to their uptake. Bundled payments that support hiring of care managers have yet to be fully implemented in the private sector and within publicly funded insurance programs (e.g., Medicare, Medicaid, and VA insurance) . Moreover, financial integration is not sufficient to achieve clinical integration of collaborative care models necessary to effectively coordinate care for patients with chronic illnesses. Even with the availability of care management reimbursement, the CCM and similar models may not be adequately implemented due to fragmentation of professional services across disciplines and differences in coding and billing rules across health system payers (e.g., mental health/substance use, primary care, and hospital). In addition, the lack of specified day-to-day clinical processes or pathways to enhance effective health care team functioning seep the CCM and other effective models from being sustained. Within integrated health systems such as VA, optimal implementation of collaborative care models is also elusive due to organizational barriers. For example, differences in job function statements that prevent nurses or social workers to function independently at the top of their license can impede the use of effective care management functions [36, 37]. There is also a tendency in integrated health systems to implement disease-specific care coordination models without considering multiple chronic conditions. Cross-diagnosis care management core competencies and credentialing are also lacking in integrated systems, leading to many patients having several care coordinators or care managers assigned to them for each condition. Many of the models also lack specific interventions delivered by the care manager to promote patient-centered care, self-management support, or shared decision-making that are vital for not only promoting treatment adherence but overall improved quality of life. Another key barrier is that in the USA, most patients receive care within solo or small group practices  that do not have the capacity to implement care management processes to facilitate care coordination across services . These settings may also lack the infrastructure such as integrated electronic medical records that enable clinical pathways or adequate access to community resources that facilitate communication between different types of providers . Care management processes delivered at the health plan level are currently being studied  but are not routinely used in practice. Thus, patients with multiple chronic conditions often fall through the cracks. Older patients with multiple chronic conditions are especially vulnerable in that the management of less acute but nonetheless serious chronic illnesses such as hypertension or dyslipidemia can be compromised . Other adverse consequences of poor coordination and lack of effective care models include missed diagnoses or treatment opportunities, missed handoffs to specialty care services, or overuse of low-value services. In addition, lack of patient-centered care can result in misunderstandings of treatments and nonadherence. Patient-level barriers to effective care coordination including self-management (self-activation) and social determinants (e.g., family situation, mental health, financial situation, home care needs, lack of transportation, and housing) also need to be addressed. FUTURE RESEARCH DIRECTIONS A future research agenda to promote effective care coordination can be gleaned from the VA’s experience in the implementation of national care models, primarily for special populations, primary care, mental health, and geriatric services. Most recently, VA is in the process of evolving as a payer of health services in addition to being a provider of services, bringing forth challenges as well as opportunities for coordination of services within and outside the VA. Key areas ripe for further research in care coordination include evidence-based health policy, population health, technology, and implementation science (Fig. 1). Fig 1 View largeDownload slide Key researchdomains tooptimizecoordination inhealthsystems. Fig 1 View largeDownload slide Key researchdomains tooptimizecoordination inhealthsystems. Health policy The U.S. Department of Veterans Affairs has invested in many initiatives to improve care coordination over the past few decades in part due to the disproportionate number of Veterans suffering from multiple chronic conditions that are also complicated by mental disorders and vulnerability (e.g., homelessness). A secondary analysis of the top 5 per cent of Veterans with the highest costs (who together account for 50 per cent of all VA health costs) found that 76 per cent had three or more chronic conditions, 47 per cent has a mental health condition, and 14 per cent were homeless . Several important national initiatives in the VA have implications for care coordination and offer opportunities for research into ways to optimize coordination. The first was a national implementation of the VA’s patient-centered medical home model known as PACT (Patient Aligned Care Teams) which emphasized proactive, team-based care with augmented care management through nurse care managers and tools to identify high-risk patients. An important component of the medical home model is the role of the care team as the coordinator for services outside of primary care, including mental health, social services, health promotion, and transitions between hospital and home. Early experience found that the beneficial effects of PACT on satisfaction, ER visits, and ambulatory care sensitive hospitalizations was highly correlated with the degree of implementation of core elements of PACT . The second major transformation involves expanded access to non-VA care to better address access problems in VA. This change was enabled by the Veterans Choice Act of 2014  and the more recent CARE Bill which will support the evolution of the Veterans Health Administration (VHA)’s to a role as a payor in addition to provider of health care for millions of Veterans nationwide. By 2018, it is expected that over a third of VA patients will be receiving care outside the VA clinic walls. However, the impact of these policy initiatives has not been assessed, and in some cases, is complicated by the lack of a strong, contemporaneous comparison group, as well as a lack of understanding on the day-to-day clinical practice. For example, although new policies have promoted the use of “medical home” models, their operationalization at the clinic level may vary widely. Policies also provide little guidance on standardizing care management core competencies across disciplines (e.g., primary care, mental health, and geriatrics), or clinical pathways and HIT tools that support patient self-management in addition to treatment best practices. The U.S. Evidence-based Policymaking Commission Act (US Public Law, 2016) strongly recommends the use of randomized designs and comprehensive data to evaluate new practices and policies in health care systems. A key advantage to randomization designs of different policy initiatives  is that they provide the best opportunity to differentiate a true effect from secular trends, informing greater return on the resources invested. The Veteran-directed home and community-based services study is a VA-randomized evaluation which will assess the impact of a caregiver-focused model on Veterans’ and Caregivers’ quality of life and outcomes . With the establishment of the Office of Community Care, VA is updating its care models to include more integration with non-VA providers via community care networks and use of home-based care. Key areas for research include the implementation of appropriate clinical processes and plans for deciding when a Veteran should seek care outside the VA, as well as tools that facilitate VA and non-VA provider communication beyond data-sharing. In addition, policies that promote standards and training for care managers working across health systems will be essential. Policies that promote effective family and caregiver involvement are also ripe areas for further research. Effective models of involving informal caregivers are needed that not only provide training to caregivers but facilitate other forms of support to enhance provider communication and best practices. Healthcare information technology and effective care coordination There are several opportunities for healthcare information technology (HIT) to improve coordination of care for multiple chronic conditions, especially with the growth of telehealth and mobile health devices. In general, these technologies are optimized when they are augmented to actively facilitate division of workload. They also help disseminate tailored patient education and support information exchange between providers. A variety of HIT interventions available in VA have the potential to improve care coordination by enhancing options for real-time and asynchronous communication between patients and clinicians and between different members of the health care team. These include secure messaging (e-mail) between patients and their health care team, video-connection into the home using smart phones and tablets, Open Notes which makes all notes in the VA electronic record available to the patient, and e-consults which allow for rapid consultation with specialty care. These HIT interventions can also help establish a patient-driven personal health plan that could support a common set of goals based on each patient’s priorities [48–50]. Secure messaging use between VA patients and providers has shown positive associations with improved glycosylated hemoglobin (HbA1c) levels among patients with diabetes [48, 50]. Although patients and providers have been receptive to secure messaging and similar HIT, additional investments in information technology infrastructure are needed to expand HIT for broader use. Clinical practice guideline decision support tools have also been developed and applied in the VA to assist in care coordination, notably for medication management [51–53]. These tools have the potential to make care plans more transparent to patients and providers and, in some cases, have been shown to improve communication between providers and patients . Telehealth is also an essential tool for care coordination. In a recent article, Secretary Shulkin envisioned telehealth as a path to improve access to care for Veterans by enabling them to see their medical providers from anywhere, including community care, and even within their own homes. More than 700,000 Veterans receive telehealth services in VA, more than any other system, and about half of these Veterans are from rural areas . The VA’s ability to pioneer use of telehealth services across state lines is also due to its extensive experience in using telehealth for the past four decades, and to coordinate care for a variety of conditions ranging from PTSD to HIV care. Notably, VA’s Quality Enhancement Research Initiative (QUERI) center on e-Health has assessed the implementation of Annie, an automated telehealth program to help with patient care transitions that also incorporates self-management best practices. Moreover, QUERI, whose mission is to more rapidly implement effective practices into routine care nationally, had led the way in integrating telehealth into coordinated physical and mental health care. For example, the QUERI Team-based Care center used telehealth to improve implementation of the collaborative care model for Veterans with bipolar disorder . A critical research priority is understanding how to maximize the communication potential provided by electronic health records and electronic communication to promote effective coordination. This will require greater understanding in how to apply technology to clarify roles and responsibilities among members of the clinical team; support patients’ and caregivers’ understanding of their roles and responsibilities; avoid missed hand-offs; and promote shared understanding and aligned goals. Electronic integration does not by itself ensure clinical integration. Even with the advent of new technologies and smartphones, without streamlined clinical processes between providers or care management core competencies, fragmentation could result in inadequate coordination of services. Overall, HIT tools should be user-friendly to care managers and other providers and include automated clinical decision support tools and measures wherever possible. User-centered design principles are also critical, especially for integration with electronic medical records. Alignment of clinical decision support tools and reconciliation of multiple tools in the same system are developing areas in HIT that will need continued investigation as growth in tool development and integration increases . Implementation science Implementation science is the study of provider and health system behavior change in the context of organizational constraints (e.g., lack of funding to hire more providers). Implementation strategies are needed to promote best practices in care coordination. Although effective care models have been shown to work, many have only been tested in settings that are in selective patient populations in research protocols, or delivered by providers paid for on a research study. Once the grant funding ends, the model ceases to sustain itself. Care coordination models also need to be adapted to accommodate technology innovations as well as barriers such as distance as in the case of telehealth. Therefore, strategies that train and work with existing providers in care coordination are needed to promote sustainability. Hence, many strategies to improve implementation of care models focus on training and supporting existing providers by enhancing team functioning. Notable strategies that focus on these areas include facilitation, which has been shown to improve the uptake of care coordination models in mental health [56–58] and evidence-based quality improvement . Other promising approaches currently being evaluated in the VA include a patient-centered medical home interprofessional learning program and behavioral health interdisciplinary programs . More research is needed in implementation science to help speed the translation of effective care coordination models into routine practice. This will ultimately help sustain the impact of the CCM and similar care coordination models in the long term . For effective CCM and similar models to improve access, timeliness, and efficiency of Veteran care in VA settings and in community care, implementation strategies will be required for smaller, lower-resourced sites which do not have the economies of scale to cover start-up costs of care coordination. For example, not all clinics have access to PhD psychologists to deliver mental health services, so efforts to enable nurses and social workers to coordinate mental health care will be warranted. In addition, reimbursement models for care coordination pathways especially for Veterans receiving community care will need to be established. To implement adequate reimbursement, there need to be clear definitions of core components of effective care coordination and which services are billable or covered under a bundled payment to community-based providers. Finally, it will be important to provide sufficient technical support to integrate coordinated care clinical pathways within routine clinical care, especially when different providers and community care are involved. A critical issue that will affect sustainability and spread is understanding the business case and returns on investments from better care coordination. Many of the models explored to improve coordination involve enhanced services and personnel; yet, evidence is still lacking that the benefits of better coordination (better outcomes, more efficient care, and avoidance of unnecessary care) will be sufficient to pay for these investments. CONCLUSIONS As the U.S. population ages, and the average patient accumulates a growing list of health problems and clinical providers, coordination is a 21st Century research priority. Effective models such as the Collaborative Care Model exist but need to be further operationalized through policy, implementation, and technology-based strategies to empower clinicians to function effectively as a team and provide the right care at the right time to any patient. The VA provides notable examples of CCM-based care coordination models but implementation strategies will be needed to sustain their return on investment. Reimbursement strategies for paying for effective care coordination will be necessary and tied to patient clinical outcomes and care experiences. Compliance with Ethical Standards Conflict of Interest: Dr. Kilbourne has received research grants from the National Institutes Health, the Agency for Healthcare Research and Quality, the Centers for Medicare and Medicaid Services, and royalties from New Harbinger (<$200 per year). Dr. Hynes has received research grants from the Patient Centered Outcomes Research Initiative. Drs. O’Toole and Atkins declare that they have no conflicts of interest. Authors’ Contributions: AMK developed the review scope and wrote the initial draft of the manuscript. DH provided input on the information technology and care coordination content as well as feedback on paper drafts. TO provided literature and relevant background on the care coordination policies as well as critically reviewed subsequent drafts. DA provided input on the research priorities as well as clinical impacts of care coordination. All authors read and approved the final manuscript. Informed consent: As this was an article reviewing published studies, no research data or analysis were presented and no human subjects were involved to require informed consent. Primary Data: The findings/views reported have not been previously published and that the manuscript is not being simultaneously submitted elsewhere. 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Translational Behavioral Medicine – Oxford University Press
Published: May 23, 2018
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