Table 3 Interview responses about provider-level coordination activities

Response 1

Establish accountability or negotiate responsibility

Interview 1/ACH 1

“We developed a web based care management and care planning tracking system. The nurse practitioner (NP) and social worker (SW) go in and identify protocols that apply to the particular individual… So at the team conference with the pharmacist, mental health, and geriatrician, they all provide input … the NP and SW then use that tool as an ongoing way to track implementation and the weekly team conference provides a kind of accountability and problem solving. If something’s not getting done, how come?”

Response 2

Interpersonal communication

Interview 1/ACH 2

“We have a very close network, so if I’m sending a person to [Doctor A] in house calls, I’ll shoot him an email or give him a page. And similarly, [Doctor B] and I often communicate and not only about the good stuff but if something went wrong we are very accountable to each other and let each other know ‘this didn’t go as smoothly as it might have seemed,’ and that way we can always hope to better our programs for patient care.”

Response 3

Information transfer

Interview 1/SNF

“For patients who are coming from Hospital A and Hospital B, we do have a computer available in at least a couple of our facilities where we can log in and really extract information from the medical records. It is very time consuming, logging in some days is not that great or internet issues and all that… But I know my nurse practitioner regularly logs onto the computer and tries to extract important pieces of information. In terms of getting discharge summaries, it’s still a huge challenge. I would say that with [Hospital C] I only receive discharge summaries on probably 50 % of the patients. They tried to improve this and, even though the residents are doing them before the patient leaves, getting them on the ambulance with the patient just does not work out all the time.”

Response 4

Information transfer

Interview 2/IT

“[The pre-admission clinical evaluation] is captured electronically, but it’s sent as a pdf. It supports what’s affectionately sometimes called the swivel chair interface, you can swivel your chair from one screen to another screen as you read key stuff. So it’s not an ideal interface, but it’s also a very controlled interface. What we’ve had in the past when we’ve tried to just plug different systems together and taken some data from some e-referral solutions is we get data quality problems when we bring the data in. They don’t have the name right, they don’t have the address right, they don’t have the date of birth right, they don’t have the payer right, they don’t have the payer ID right.”

Response 5

Information transfer

Interview 2/SNF

“If information is missing when the patient comes in to the LPAC, we typically will go to our clinical liaison and ask them to get us the missing pieces from the short term acute care hospital. We’ve had discharge summaries missing or pieces of a medication record missing or a health care proxy, things like that. But we’ll typically reach right back out to that clinical liaison who has a relationship with the short term acute care hospital, and get that for us as soon as possible.”

Response 6

Facilitate transitions

Interview 3/HHA

“We go and look in a variety of systems: the system that most of the hospital discharge planners are using, our medication administration and order entry system, and we can also look in our outpatient system… you end up having clinical people, nurses doing a lot of clerical work because, how do you divide that workflow up? They’re the one combing through the chart to find it.”