Care Coordination: If we don’t measure it, does it exist?
It has been said (perhaps first by William Bruce Cameron), “Not everything that can be counted, counts, and not everything that counts can be counted.” When it comes to state policy for health system performance improvement, a more accurate axiom might be, “What gets measured gets done”. Leaders rely on evidence that a health care policy, process or program is meeting its goals—containing costs, producing better health outcomes and/or improving quality of care. Anecdotal evidence can be powerful, but data also are an influential tool in policymaking. Through research for a forthcoming report on NASHP’s ABCD III project, it became clear there are many state and federal delivery reform and performance improvement initiatives expecting or requiring care coordination, but we aren’t measuring care coordination across primary medical and community (non-medical) settings. How do we know if it’s happening?
The joint principles of the patient-centered medical home (PCMH) describe care coordination as the organization of a patient’s care across all health care settings and the (non-medical) community to ensure timely and culturally/linguistically appropriate delivery of care. Richard Antonelli and others have defined care coordination for children as a patient- and family-centered, team-based, and assessment-driven activity designed to meet children’s needs. Communication among providers is key to care coordination.
A number of initiatives underway across the country rely upon or promote care coordination:
- State Medicaid and multi-payer PCMH programs;
- State health home programs;
- Child health quality demonstration programs funded as part of the Children’s Health Insurance Program Reauthorization Act;
- The Center for Medicare and Medicaid Innovation (CMMI)’s State Innovation Models initiative;
- CMMI-led accountable care organization (ACO) programs; and
- CMMI’s Comprehensive Primary Care Initiative, just to name a few.
Clearly, we as a country are committed to improving care coordination—we are providing additional financial and other support to providers and states to do it—but do we know it exists, let alone is improving?
An array of entities have created guidelines for evaluating care coordination, with measures around hospital readmission, hospital discharge planning, and care transitions between inpatient and outpatient settings. However, a rather unsettling report last year by the National Quality Forum (NQF) notes that existing measures focus on patient experience and do not look at whether providers communicate critical information, involve community partners in care planning or delivery, or coordinate care for vulnerable populations. We can measure coordination when it involves hospitals, but we don’t know whether care coordination in primary care settings, between primary medical care and community (non-medical) service providers is happening. I would add that we don’t fully understand whether care coordination in these settings occurs for children.
NASHP’s Assuring Better Child Health and Development (ABCD) III project focused on improving care coordination between primary care providers and community service providers of young children—exploring some of the very gaps identified by NQF. For the past three years, partners in Arkansas, Illinois, Minnesota, Oklahoma, and Oregon worked to implement improvement strategies and measure pediatric care coordination.
These states measured receipt of referral feedback information or “closed feedback loops” between primary care providers and Part C Early Intervention providers in pilot communities to assess care coordination. The states found they needed to create new mechanisms to measure this communication—data spanned multiple systems and provider types. At baseline or mid-project, states determined that care coordination (via closed feedback loops) was occurring 53-64% of the time. At project’s end, it occurred 66-88% of the time, indicating that targeted interventions help support improvement in care coordination.
ABCD III suggests that care coordination occurs to some extent even if we are not measuring it. It also demonstrates that this type of care coordination can be measured, is important to measure to improve and meet project goals, and confirms the daunting, complicated nature of measurement. But if we are investing in and rewarding care coordination, we need to be able to verify if and how well or often it occurs. For accountability purposes, we need to verify it in ways other than solely provider or patient self-report. The ABCD III states took critical first steps toward measuring care coordination across medical and community providers, and thanks to their hard work, we now can take the next steps.