NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.
McDonald KM, Sundaram V, Bravata DM, et al. Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies (Vol. 7: Care Coordination). Rockville (MD): Agency for Healthcare Research and Quality (US); 2007 Jun. (Technical Reviews, No. 9.7.)
Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies (Vol. 7: Care Coordination).
Show details“Like a sailing ship needs a navigator to avoid the rocks, patients need navigation to get all the way through the medical system as quickly as possible... We put Patient Navigators in place in Harlem Hospital in 1994, and we have found them to be very effective at getting people treated. We don't lose patients anymore.” Dr. Harold P. Freeman *
The U.S. health care delivery system suffers from pervasive deficiencies and remarkable variation in patient safety and healthcare quality.2–5 While numerous factors may explain continued poor performance and variation, one commonly accepted belief is that improvements in care coordination can help reduce fragmentation of patient care, lead to better quality, and potentially, lower costs. In Priority Areas for National Action: Transforming Health Care Quality, the Institute of Medicine (IOM) suggested that improvements in care coordination could result in significant benefits “across the continuum of care across the life span,” and called for national action on this “cross-cutting” topic.6
Clinical vignettes of patients receiving care in a well-coordinated system provide a striking contrast to those of patients navigating the more typical uncoordinated system.2, 7 Patients with complex health care needs, their families, and their providers often must traverse numerous professional, geographical, information system, and organizational boundaries to ensure that necessary care activities are performed adequately.8–13 Failing to overcome these barriers may disrupt the flow of critical information and heighten patient vulnerability to medical errors; duplication, omission, or delay of services; and poor outcomes. However, the evidence base connecting care coordination to its potential positive effects is sparse, and the definitions and key concepts underlying the topic are unresolved.7
1A. Report Scope and Organization
This report is the sixth in the series “Closing the Quality Gap” by our Stanford-UCSF Evidence-based Practice Center (EPC), and addresses the topic of care coordination. The other reports in the series have focused on specific clinical conditions (e.g., hypertension, diabetes, asthma), which lend themselves to a standardized approach for identifying and evaluating primary studies of quality improvement strategies. However, for the broader and more ambiguous topic of care coordination, our objective was to identify and fill in some of the major gaps in the evidence regarding the key definitions and concepts of care coordination and provide an overview of the effectiveness of care coordination interventions on the processes and outcomes of care for outpatients, typically for those with chronic medical conditions. We did not aim to identify and present all of the primary evidence related to this broad topic. Instead, we set out to provide an overview of ongoing efforts in health care coordination, summarize some of the evidence about the effectiveness of care coordination interventions, and present relevant frameworks for the development and evaluation of future interventions. This background and approach may be useful to a variety of decisionmakers: for example, designers of interventions who need to make decisions about what to include in a package of interventions aimed at improving care coordination, evaluators of interventions who need to assess comparative effectiveness of different approaches to improving coordination, and purchasers of interventions to reduce the adverse consequences of fragmentation of health care services.
As a result, this report is organized differently than the others in the series. We first describe ongoing efforts in care coordination and describe the relevant information needed by decisionmakers involved in improving care coordination (Chapter 2). We synthesized this information from personal contacts with professionals currently leading care coordination efforts and Internet searches—it was not intended to be exhaustive. Second, we describe contemporary definitions of care coordination and related concepts from which we developed a working definition for use in identifying relevant evidence (Chapter 3). Third, we present a review of systematic reviews of the effects of care coordination interventions for outpatients (and inpatients whose care was not solely limited to that setting) who, in most cases, have chronic medical conditions (Chapter 4). Fourth, we describe conceptual frameworks from different fields that explore care coordination needs, approaches to coordinating care, and patient outcomes (Chapter 5). For Chapters 3, 4, and 5, we performed extensive literature searches, although only the review presented in Chapter 4 is completely systematic since its purpose is to synthesize information from evaluations of care coordination interventions. Finally, we conclude with a discussion of the future research required to further understand and benefit from care coordination efforts (Chapter 6).
1B. Key Research Questions
The key questions addressed in each of the chapters of this report are listed here and summarized at the end of each chapter:
Background: Ongoing Efforts in Care Coordination and Gaps in the Evidence (Chapter 2)
Research Question 1: What aspects of care coordination are of greatest interest to healthcare decisionmakers?
Research Question 2: What are the key gaps in the care coordination evidence base?
Definitions of Care Coordination and Related Terms (Chapter 3)
Research Question 3: What definitions exist for care coordination?
Research Question 4: What definition could be formulated to apply to systematic reviews?
Review of Systematic Reviews of Care Coordination Interventions (Chapter 4)
Research Question 5: Which care coordination interventions have been evaluated by systematic reviewers and how were they defined?
Research Question 6: What is the evidence regarding the health benefits of these care coordination interventions as summarized in the systematic review(s)? In particular, is the effectiveness of care coordination interventions related to the setting in which care is being coordinated, the component of care being coordinated, or the type of disease or patients for whom care is being coordinated?
Research Question 7: Have the costs of care coordination interventions been evaluated in any of these systematic reviews, and if so what is known?
Conceptual Frameworks and Their Application to Evaluating Care Coordination Interventions (Chapter 5)
Research Question 8: What concepts are important to understand and relate to each other for evaluations of care coordination? What conceptual frameworks could be applied to support development and evaluation of strategies to improve care coordination?
Research Question 9: What measures have been used to assess care coordination?
Research Question 10: How do these frameworks relate to quality improvement strategies evaluated in the previous Closing the Quality Gap series reports?
1C. Peer Review
A draft of the Evidence Report was sent to a panel of 21 experts in quality improvement, researchers in the area of care coordination, and other professionals with an interest in care coordination (Appendix D *). We compiled their comments and made appropriate revisions to the final Report. The revision included updating the systematic review search, which resulted in 22 additional reviews analyzed.
Footnotes
- *
Quote from polo.com interview with Dr. Harold P. Freeman, past President of the American Cancer Society, explaining the need for patient navigation in a fragmented system with barriers to coordinated delivery of care, accessible to all people.1
- *
Appendixes cited in this report are provided electronically at http://www
.ahrq.gov/clinic/tp/caregaptp .htm
- Introduction - Closing the Quality Gap: A Critical Analysis of Quality Improveme...Introduction - Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies (Vol. 7: Care Coordination)
- GSM926493[Accession] (3)GEO DataSets
- GSE3586[Accession] (31)GEO DataSets
- MSRB1 methionine sulfoxide reductase B1 [Homo sapiens]MSRB1 methionine sulfoxide reductase B1 [Homo sapiens]Gene ID:51734Gene
- Gene Links for GEO Profiles (Select 115371563) (1)Gene
Your browsing activity is empty.
Activity recording is turned off.
See more...