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Table 1 Themes and Representative Quotes for Sustainable Model of Care Coordination for Complex Patients

From: Sustainable care coordination: a qualitative study of primary care provider, administrator, and insurer perspectives

Themes Stakeholder Quotes
1.A defined scope, rationale, and key partnerships for building comprehensive programs
1.1 Care coordination Inclusion and exclusion criteria
A1: “There’s kind of a tension between whether we should be caring for the sickest of the sick …as we are thinking about with chronic disease where whether there is more of a place to be caring for what might be considered a rising risk population… There needs to be defined criteria and there needs to be a defined end point because…it would [be] nice for patients to be in the program forever…[but] you might be stuck in the cycle of not progressing. Then the rest of your patients might suffer from that by not being able to get into the program.”
I1: “We have to make sure we can segment our population and understand how to identify the right people for case management or care coordination... The appropriateness of identifying people for care coordination.
1.2. Care coordination as a vehicle to bring together medical and community resources for complex patients P2: “Ideally things get straightened away and people can graduate but these patients are complex for a reason and they might have relapses for different things so I think always having a pretty accurate assessment is a good idea for a lot of them anyway.”
A10: “The thing that we also struggle with is the complexity of the psychosocial conditions that the patients present with…I would envision that it would be a multidisciplinary team...If it’s more psychosocial in nature, then a social worker is probably more appropriate. It would be a model in which there were multiple participants. So the care coordinator, there would be mental health support, there would be medical support, there would be social work involved, pharmacy. That [multi-disciplinary] team, while there are distinct roles and responsibilities, would also know how to work collaboratively with each other in the areas where things might overlap. An example, there’s things that are different about the RN and social work role, but there’s places where it [their roles] might overlap.”
I1: “There has to be a comprehensiveness of buy in. If you are creating a care team approach within a care delivery system, everybody has to buy in to… we’re doing team-based care. If you don’t have that type of accountability, and you don’t have folks that truly believe in team-based care, it’s not going to work. It’s going to fail…Making sure everyone is on the team so to speak… that’s the biggest critical success factor.”
P14: “Ideally have an effective team that can address all of the patient’s chronic health issues without diluting the expertise needed to manage it.”
2. Effective Information Exchange
2.1. Strong Interpersonal level-interactions among stake holders- and with patients
P11: “The hospital may have a nurse navigator that is helping take care of the patient in the hospital, but the communication back to us isn’t very good. The nursing home may have a social worker but the stuff they are doing there communicating back to us doesn’t happen. There are holes in our system that as a provider, as a team, if you said had I only known that, I would have done something different.”
A5: “I think co-location of the care coordinating group or team and the medical home team. In a perfect world, you would want them co-located because that facilitates communication. In smaller clinics or in rural areas, that’s not going to be feasible so we would somehow need to leverage technology to make sure that there is enough contact between those groups.”
I3: “Good communication between the medical staff and the case manager, and good information flow between the specialists and the case manager.”
I12: “With all medical care, there has to be a longitudinal, trusting relationship that occurs between the care team and the patient.”
2.2. The need for data and access to an interoperable health information system I4: “There needs to be very intense efforts…to engage the client in care coordination... It’s [care coordination] required that the appropriate amount of trust and effort is built in order to get the client to engage.”
A4: “There needs to be a place to keep this [care management] information so that people can readily access it when the patient makes contact with the care team.”
A10: “There needs to be a plan of care and that plan of care needs to be accessible not only by the primary care team but every other member of the team whether it’s within the same health care system… the inpatient units need to be accessing it [plan of care], everybody needs to know how to use it. People need to be able to contribute to it [the plan of care]to help everybody be on the same page. In the perfect world we’d be able to also do that same thing with any other community entity user, external agencies that the patient is working with as well so we are all working off that same platform.”
P9: “If we can set up web access so you can do face-to-face coordination but through the internet, if they are available for phone systems or something like that, like Skype. I think sometimes it’s too easy for folks to just spend a few minutes on the phone and if we can actually see a patient face-to-face, even if it’s over a camera…that’s just an extra step…using communication that’s available and technology as well to help us.”
I7: “From a technology standpoint, one of the biggest challenges is getting systems to talk to each other. Having an electronic medical record be able to communicate with a claims system. That’s the concept of big data… Making sure that the health system and the health plan and the community resources are connected and talking to each other on behalf of the patient so that information that is shared, recommendations that are given, are consistent and supportive of each other so at the end of the day the patient is well served.”
3. Trained and Available Workforce I11: “If it’s [the care coordinator is] a nurse, she has got to be very skilled and knowledgeable and passionate about not only the medical side but the patient interaction and advocating and understanding what the social connection resources are required to get that patient through.”
P8: “Getting well-trained individuals. Getting individuals who stick with it [care coordination] for years and so as they further develop their expertise as a care manager as opposed to finding an easier, more fulfilling job somewhere else.”
P1: “Having somebody that has the understanding of those [disease] conditions…is going to be much more beneficial than perhaps other clinical conditions. There has to be an understanding of what are the major morbidities and comorbidities in the area and have peer coordinators that have a good background on those conditions… You need to have a reasonable ratio of patients to care coordinators so the care coordinator herself or himself doesn’t feel burned out and it becomes the weakest link in the process.”
P6: “You need to show some stability in the personnel that provides care management. Nothing puts off patients or referring physicians if you see a carousel of people involved with your patients. There needs to be stability in the program and the personnel providing the program.”
I12: “So somebody that is able to interact with patients wherever they’re at or at whatever level they need to understand basic concepts, like motivational interviewing, to effect behavior change if that’s the issue and also have a grasp of what other adjunct services are available so if that means engaging county social workers or whatever other programs are out there, that they understand at least how to work through people that are out there that know how to do that sort of thing.”
A12: “If you start to introduce lower levels of education and individuals into care coordination, then you need to have a clear scope of practice so that they are not tip toeing into areas that may not be appropriate… Individuals who are not licensed or not an RN really should not be making clinical assessments or giving clinical advice because that’s way outside their scope. Nor should they be doing any kind of therapy or counseling. But what we see is that individuals who are not RNs don’t know that… Clear boundaries, clear parameters of what is okay and what is not okay.”
4. Need for a business model and financially justifiable program A5: We need to make a substantive difference in utilization of health care. If we can’t do that, we can’t pay for this[care coordination] and if we can’t pay for this, it’s [care coordination is] not going to exist. Nobody wants to talk about that [who pays for care coordination services]. That’s like taboo to talk about that but at the end of the day, this thing [care coordination] isn’t going to fly if it doesn’t make economic sense.
I11: “They try to tack it [care coordination] onto something else, they under-source it, they don’t have sustainable funding for it as a pilot, and there are a lot of other competing interests especially in a primary care provider’s office where they’ve got 150 things that are the most important thing to measure and manage and that’s never going to work.”
A11: “I think there has to be an aligned financial model and an aligned practice model for that [care coordination] to work well... This [There] was a grant-funded study that covered part of the cost to introduce these care coordinators into our system but in a fee-for-service kind of reimbursement mode there’s not a lot of incentives or a strong business case for doing some of this work… If you have an aligned financial model where the institution, the provider and the patient all have aligned incentives to do these [care management] things, that’s key.
A1: “I say 50% of our enrolled patients drop out because of that [finances]. They have to stop cost sharing. It [care coordination] is either a part of a wellness benefit to improve wellness or it’s not. If it’s not, don’t expect people to be care managed because they will opt out. They[policy makers] have to stop cost sharing.”
P4: “Someone has to pay for it [care coordination services]. The insurers have to pay for it. We can’t do it if we do not have the resources; primary care is not going to be able to do it all. It has to be paid for.”
P13: “Obviously cost on the side of the patient because they[patients] are being recommended to do things that involve more medications or visits.”
P13: “Also on the side of the health care organization, the cost of the personnel and time it takes [coordinate care].”
5. Evaluation and Improvement of Care Coordination Programs A10: “We would have a way to have solid metrics too that could help measure success that would be focused around the triple aim. The satisfaction of the patients, providers, nursing staff, everybody that’s working as a part of that support team, and then of course cost and clinical outcome data as well.”
A2: “We need some better data. That’s what a lot of us hope and COMPASS overall will be able to provide data that if you build it, they [patients] will come. If you do this well, you will either attract more patients, which will help sustain your organization. Or the data will prove that, indeed, investing in care management services has an outcome that we can measure. I don’t think that’s there yet.”
I7: “Having an electronic medical record be able to communicate with a claims system. That’s the concept of big data. Bringing claims information and EMR data together to be able to evaluate, to analyze, to stratify and really use that to kind of try and do prescriptive care coordination that’s specific to a particular patient and really prospective as opposed to retrospective.”
I12: “From a patient perspective I think you want to ask those quality of life questions: ‘am I able to do the things I want to do, am I happy, do I feel like I’m at the best health that I could possibly be.’ So patient reported outcomes. And then there are utilization outcomes so total cost of care, and those other preventable episodes of care…. And then of course the big dots, life expectancy, mortality rates...”
P3: “Research certainly is an important part. To be able to successfully implement it [care coordination program] you have to periodically be able to evaluate the process, evaluate outcomes, make changes. Those pretty much in terms of how it [the program] can be successful and of course be able to structure or formulate an effective model. The model itself is a major factor to decide whether this care coordination will be effective or not.
P5: “A rigorous method to assess need, to intervene to make choices what may be appropriate, to intervene or work with the patient on and then assessing effectiveness and then returning to taking that assessment back in and deciding whether we proceed forward or not…I sometimes feel like we talk about a lot of things but we haven’t found an effective way to move patients forward.”
6. Patient and family engagement P13: “If patients are in a mental health crisis and can’t access that care, they are unlikely to be managing their chronic disease, physical disease as well, or to be in contact with a care coordinator.”
P14: “Some hesitancy based on patient’s perspective being at this point that’s a non-traditional approach to chronic care so they [patient] may not be keen to do it[care coordination] so that may be an issue.”
A9: “Patients have to be willing participants as well…we certainly found patients that are very eligible but really don’t want to participate…is patients who really need help but are not interested. How to engage patients is a barrier…. Patients to be willing to participate in their care as well by making themselves available for care coordination.”
I9: “First they [patients] have to be agreeable to engage in it [care coordination program]. If they are not going to be compliant or they’re not interested, we wouldn’t engage them in case management. Sometimes the member may refuse, and the family members are participating. So we work with family members. Somebody on the other side has to be participating.
A10: “I think part of the problem we sometimes see is we end up creating a co-dependency with patients when they have a care coordinator instead of doing the very thing we are trying... We should be teaching them[patients] how to self-manage and everything we do should be preparing them for discharge so they can learn how to do things within the system as part of the skill set that they are leaving with and if we are always doing it for them, or they are always relying on the care coordinator, they are not ever having to do that [care management] on their own.”
  1. P Primary Care Provider, A Administrators, I Insurers