Care Coordination Tough to Define, Measure

In the first part of an in-depth discussion with two nurse leaders, the emphasis is on the importance of clearly defining and measuring a major area for cost-cutting in hospitals—care coordination.

Care coordination is an increasingly important factor in improving quality and reducing hospital readmissions, but it remains tough to define, quantify, and measure. I recently caught up with two nurse leaders who are leading the way in making care coordination not only more clearly defined, but also more quantifiable:

• Gerri Lamb, PhD, RN, FAAN, Arizona State University nursing associate professor and editor of Care Coordination: The Game Changer—How Nursing is Revolutionizing Health Care
• Maureen Dailey, PhD, RN, CWOCN, ANA senior policy fellow and specialist in healthcare quality improvement and measurement development

The following is part one of our conversation. Look for part two next week.

See Also: Care Coordination a Cost-Cutting Quality Driver

HLM: Why is it important for care coordination to be measured and/or quantified?

Dailey: Care coordination, as Dr. Gerri Lamb often says, is a cost-cutting area that's so important to quality outcomes: clinical quality outcomes, and cost outcomes. In order to measure the quality of care coordination, it's very important that we have the right measures that reflect the quality of the care coordination from the team, including the largest group of healthcare professionals, the front-line providers: nurses.

To that, I'd like to mention that ANA has a series of care coordination documents; we have our ANA policy briefs, we have [an] ANA whitepaper on the value of nurses to care coordination, and we're very pleased to announce that the board in December approved the ANA's care coordination measurement framework.

In that document [is] a description of the framework's structural components, the measurement context that we're in, and a visual representation of the framework.

And what is the framework, essentially, to the front-line nurses and the safety leaders in the United States?

It's a rubric, a roadmap, if you will, to prioritize the best existing measures of care coordination, and very importantly, to help fill the current measurement gaps in care coordination to get to those robust measures that really gets to the heart of quality care coordination. The framework helps to identify the best concepts for development of new measures of care coordination.

Lamb: If I remember correctly, about 100 nurses participated in that framework. I think that it reflects the importance of care coordination to quality of care as well as patients and families and to the nursing community.

Dailey: It was actually over 200. It was a bi-level professional issues panel that was convened by ANA over six months, and there was a steering committee, [as well as input from experts like Gerri Lamb].

Lamb: As Maureen was saying, care coordination is a priority for the National Quality Strategy, so it's essential that we define it well and measure it for all the reasons that Maureen was talking about… so we know when it's happening, we can capture it, and we have the opportunity to improve it. Care coordination is so central to the patient experience, to families, so that a measurement becomes a really core piece to this.

We're able to say, yes, this is care coordination; it's being done well, and we have the opportunity to improve it. So the framework that Maureen was talking about becomes really important, because care coordination tends to be very abstract for people. They often know it when they see it, but it's difficult to define upfront.

We have many, many definitions of care coordination, and the one that we use most commonly from the Agency for Healthcare Research and Quality, is a combination of [dozens of] definitions. So [it's] really channeling from a rather abstract concept to what does this mean for patients and families, how does it impact outcomes? Measurement really is the bridge for that and thus becomes really important.

HLM: What kinds of feedback and additions did you make to the framework from talking with these nurses and nurse leaders that you consulted with?

Dailey: We identified missing concepts or domains and sub-domains… that made it a richer framework to better capture nurses contributions. One area is transition of care, that's a subset of care coordination, so that's a very rich area to capture nurses' contributions to care coordination.

And also there's a related concept… care coordination is very much related to another national quality strategy priority, which is person- and family-centered care, so identifying patient-centered goals. Many of the things cross over, they're related by different concepts.

Lamb: It's fairly common to have communication as one of the domains and there's lots of work going on in the area of capturing how well we're communicating across providers and across settings.

The pieces that the new framework and certainly the work that the National; Quality Forum is doing to look at measurement gaps, is now bringing in the areas that Maureen is talking to: How are patients and families involved in care coordination? What role do they play? How are they becoming part of the decision making? Which is all part of patient-centered care. 

Dailey: ANA has a National Database of Nursing Quality Indicators that over 2,000 hospitals participate in the United States, so it's evaluating the quality of hospital care. But we're very excited that we will be adding ambulatory care.

HLM: Let's move onto reimbursement. How will reimbursement make care coordination better and more common?

Dailey: Reimbursement for care coordination is occurring in a few ways. Reimbursement for reporting on quality of care, and transparent quality reporting, such as Hospital Compare, is pay-for reporting. [There are also] pay-for-quality care programs. So for instance, consumers, purchasers, payers, and other providers, nurses, can look on Hospital Compare and see what the readmission rates are; that's an outcome related to the quality of transitional care and care coordination from hospital to home.

And then there is a pay-for-quality program, the Readmission Reduction Program, which is one of the multiple programs by the Centers for Medicare & Medicaid Services that rewards hospitals with better outcomes of care.

And finally there are care coordination codes that are in discussion by CMS that will… allow for increased reimbursement for eligible providers. By eligible providers we mean advanced practice nurses such as nurse practitioners, nurse midwives, [and] physician assistants, and physicians.

Lamb: The new payment strategies that are under discussion right now, such as capitated payment [and] bundling, all provide new incentives for looking at integration of care. And care coordination at its foundation is all about integration. It's about effective connections between settings; it's passing the baton well.

Capitation and bundled payment begins to step away from more silo-based payments so that… I think it reinforces and incentivizes being able to work across settings and make sure that care is really connected between settings and providers.

In the 90s, I was part of a capitated community-based case management care coordination model, and the payment in that model really supported providers being able to work, I think, more fluidly across settings and providers…because there was a shared incentive, because everyone would benefit from making sure that care was closely linked from setting to setting and there were no fall-throughs between the cracks.

HLM: Are there reimbursement barriers and what are they?

Lamb: I think there are a variety of reimbursement barriers. Currently, when you begin to look at siloed payment where one setting may be incentivized to really capitalize on the use of those services and not necessarily the integration of services.

In the 1990s people used to talk about the right service in the right time at the right place. When you've got payment that is isolated to one particular service or setting it makes it much more difficult to be able to coordinate across settings and to use services appropriately.

Look for part two of our discussion next week in which we talk about the care coordination that's happening in hospitals today; the challenges for patients, families, and providers; and how to bridge the gaps between the two.