Table 4 Interview responses about patient-level coordination activities

Response 7

Assess needs and goals

Interview 6/ACH

“In addition, there’s some functionalities in [our EHR]…What are the patient’s goals of care? and you can enter it into a field that is automatically pulled in. So it might say, ‘The patient wants to get to their son’s graduation,’ or, ‘They’re not ready to quit smoking, but they’re ready to do this,’ so we’re not asking the patient all the time.”

Response 8

Create a proactive plan of care

Interview 3/ACH

“Every day the patient gets an itinerary of exactly what will happen to them that day in their plan of care and a spot to write their questions and their concerns about what’s happening and that is addressed during those care coordination rounds every day.”

Response 9

Monitor, follow up, and respond to change

Interview 5/ACH

“We have a certain e-mail trigger that, when any of our patients who are identified with medically complex child service, anytime they hit the institution, there’s an automatic e-mail sent to that inbox.”

Response 10

Support self-management goals

Interview 4/HHA

“We’re also doing chronic care management training with our clinicians. That has a lot of things like telephone triaging, really looking at the patient and determining their specific goals. One of their goals may be to stay out of the hospital. There’s a lot of those things, however none of it is really software driven, meaning the software doesn’t have the logic to help with the decision making to help the clinician with any specific care plan or interventions or anything like that.”