Table 4.
Group interview results organized by AHRQ Care Coordination Broad Approach and subthemes
| AHRQ Broad Approach | Subtheme | Quote representing subtheme |
|---|---|---|
| 1. Teamwork Focused on Coordination | Interdisciplinary involvement in care plan development current state | ‘The nurse practitioner and social worker start the plan in the web-based care management tracking system, and then they bring an initial [POC] to the team conference, where the patient is present and discussed, and then they fine tune and add to the drafted care plan. So at the team conference with the pharmacist, mental health [practitioner], and geriatrician, they all [provide] input at that point in time. Typically throughout the week, the geriatrician, mental health, and pharmacist do not access the POC. But the nurse practitioner and social worker then use that tool as an ongoing way to track implementation.’ |
| Patient involvement in care plan current state | ‘When we have our interdisciplinary team meeting we do invite patients and families to attend their particular rounding if they're able to do so and we are required to document patient family involvement in the plan, review it with them after the team meeting because the goals often will change [during the meeting], the discharge date or disposition often will change, so that patient involvement and engagement in that plan is absolutely a part of our work flow.’ | |
| Patient involvement in care plan ideal future state | ‘It could be great if we could somehow project it [the care plan] in the patient's room on the TV screen so they could actually see it and read it. A lot of adults learn better that way, visually, and kind of see what their goals were and have that opportunity to really engage and say no, I don't really think I can ambulate fifty feet by Friday, how about we start with thirty, or maybe, I think I can do a hundred feet can we push it up?’ | |
| Use of CCD to support team communication of care plan across setting | ‘Our care settings are outside of the incentive scope of Meaningful Use and HITECH, so we're not being paid to install systems that for example can handle a continuity of care document. But we recognize that that's important so we're working with our internally developed apps and with our purchased applications to have that capability and if the development plans hold up to have it by year end of this year, so that we will be able to receive a CCD when someone's admitted from an acute care setting, and to provide a CCD when they leave our organization and go on to the next care setting. Our expectation is that for starters this is going to be supplemental to the information that they're getting today, but as we learn both technically what we need to do and as we get feedback from upstream and downstream providers about what's necessary and what's technically doable, we expect that that data set will get richer over time.’ ‘We'll learn how good or not good that is and our intention is to work on it until we get it right. In some ways there's nothing that substitutes for a really good verbal communication and so it may be that, you know, two people at a distance looking at the same electronic [CCD] document and then talking about what's there and not there, and one having provided the care and the other one about to be providing the care with the patient. Hopefully that will be a robust and rich exchange that will really support a good handoff.’ |
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| 2. Health Care Home (HCH) | Challenges related to lack of interoperability (emergency department to HCH) | ‘But the other piece that you were asking as far as communicating with the medical home, this is a big challenge for the emergency room with our current medical documentation in that when we discharge patients from the emergency room we don't routinely call their primary care providers and the office of the primary care provider receives a very rudimentary fax that basically just says your patient was here. Often they have little knowledge of what went on in the emergency room, what our thought process was, what we did for the patient, and it's a rare circumstance that they get a lot of information, and most providers don't have access to our medical records.’ |
| 3. Care Management | Siloed nature of care plans | ‘There is not one home for any unified care plan. There are many sub-care plans. There are many care plans with homes, but there is not one unified care plan across the system.’ |
| Potential benefits of care plan reconciliation and sharing | ‘For instance, let's say there was a diabetic and maybe they are able to do a percentage of their insulin, maybe they can draw it up but they can't inject or something of that nature… We may get a verbal communication about it. But it would be nice to know that they've met this goal and if [so], the next goal. And then we can say, “What's the teaching that we need to do on the home care side or maybe at the SNF level or whatever to then pick it up from there so they actually meet their ultimate goal.”’ | |
| Care plan current state best practice | ‘Current state is the family has a paper copy of their care plan; they are instructed to take it with them to any medical facility they visit. What future state would be is for them to identify ‘I have a care plan’ and that whoever, the pediatrician or the emergency room would be able to access that electronically.’ | |
| 4. Medication Management | Care plan reconciliation related to medication management | ‘So medication reconciliation is a huge part of the plan of care and coordination of care… So you have the tool to make sure the list is correct going in. It translates to the plan of care in patient-friendly language, and while that's not perfect yet, it's much better… So a lot of the use of electronic medical records to coordinate care, to make sure from the patient's perspective they have one list, and it's accurate, and they understand the changes.’ |
| 5. Health IT-Enabled Coordination | Limitations of current state health IT tools | ‘We're also doing chronic care management training with our clinicians. [This includes] 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.’ |
| Use of patient portal | [Using the patient portal] The patient can say ‘These are my concerns coming in for my next visit,’ the provider can put some information in there, so it really is the beginning of this ongoing plan of care that hopefully will become seamless and be able to be integrated at some point in time into the inpatient record, if the patient is admitted due to whatever their concerns are, but it also allows us to have a seamless transition back, to have follow-up conversation on the portal.; | |
| Innovative solutions | ‘We've identified the need [for an LCP] we have a lot of innovation going on; for example—we'll use the problem list as a potential LCP. The problem is diabetes and it would list the goals of care. In addition there is some functionality in [the vendor-based EHR system], it says, “What are the patient's goals of care and background” and you can enter it into a field that is automatically pulled in.’ |
AHRQ, Agency for Healthcare Research and Quality; CCD, Continuity of Care Document; EHR, electronic health record; IT, information technology; LCP, longitudinal care plan; POC, plan of care; SNF, skilled nursing facility.