Enhancing Complex Care through an Integrated Care Coordination Information System (Oregon)

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Summary:

Most chronic and preventive longitudinal care needs are addressed in primary care practices, yet payments and practice structure are based on visits and procedures that may contribute to unnecessary utilization of health care services. For older adults with multiple chronic illnesses, the longitudinal coordination needs that are not accounted for under current payment structures may represent the majority of care needed to improve outcomes, such as reducing hospitalizations due to fragmented care and complex care plans.        

This project tested the hypothesis that incentives for team-based care coordination would better address unnecessary utilization than do traditional quality measure-based pay for performance. It evaluated the impact of an integrated care coordination information system (ICCIS) on the outcomes and satisfaction of patients with chronic and complex illnesses. A cluster-randomized study was conducted at six ambulatory clinics in both rural and urban settings.          

The specific aims of this project were to:

  • Implement the Care Management Plus and TITLE Enhancing Complex care through an Integrated Care Coordination Information System model.
  • Perform a cluster randomized, controlled trial in six clinics on the ability to use the IT functions to monitor and deliver care to high-risk patients through a care coordination (Arm 1) or a quality performance model (Arm 2).
  • Assess the implementation.
  • Understand and disseminate the outcome, benefits, challenges, and unintended consequences from use of these functions for patients and the system.         

Clinics received training in care management, coordination, and other principles of medical homes, a designated care manager, and the ICCIS. The ICCIS provided interactive quality reports, tracked and reminded providers about services, and facilitated population management based on risk. The six clinics were randomized into two arms: care coordination clinics that received care coordination payments for activities related to assessment, education, goal setting, motivational interviewing, and communication; and quality clinics that received incentive payments for documented improvement of five self-selected standard National Quality Forum-approved quality measures. The evaluation included tracking of quality measures, conducting before-and-after surveys of patients and their care experiences, and measuring changes in utilization.       

Care coordination clinics used the system to perform 1.8 times as many care coordination activities as the quality clinics. The quality clinics improved their quality measures 14.2 percent versus 8.9 percent for the coordination clinics. Experience of care did not change except for a 9 percent absolute increase in ease of making appointments in the coordination arm. Six-month preliminary results for hospitalization bed-days showed a greater decline in the care coordination group, while emergency department visits were lower in the complex illnesses. 

Enhancing Complex Care Through an Integrated Care Coordination Information System - 2012

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    RFA: HS08-002: Ambulatory Safety and Quality Program: Improving Management of Individuals with Complex Healthcare Needs Through Health Information Technology (MCP)
  • Grant Number: 
    R18 HS 017832
  • Project Period: 
    September 2008 – September 2012
  • AHRQ Funding Amount: 
    $1,155,147
  • PDF Version: 
    (PDF, 304.38 KB)

Summary: Patients with chronic illnesses are at risk for complications due to a lack of coordination and quality in a fragmented health care system. This project investigated whether care for patients with complex needs can be improved by implementing an integrated care coordination information system (ICCIS) and Care Management Plus developed by the Oregon Health and Science University. The ICCIS incorporates population management techniques, patient-centered goals, quality measures, and clinical
reminders to support clinical care teams and patient self-management. The three study objectives were to: 1) understand whether ICCIS can be implemented among diverse clinics using certified electronic health records (EHRs) and existing standards; 2) assess whether the functions in the ICCIS can be used by the clinics; and 3) evaluate whether these system changes lead to improved patient outcomes.

Using a randomized controlled trial, Dr. Dorr and his team examined whether six participating clinics (three inner-city, three rural) were able to use health information technology (IT) to monitor and deliver care for high-risk patients with a care coordination model (Arm 1), or quality performance model (Arm 2). The team evaluated how well care coordination functions were used at the clinics. Measures included indicators of patient engagement, clinic-level quality of care, clinic-level process, and patient health outcomes. A post-study survey and an interview guide were developed and tested. The survey was administered in person to clinicians and office managers at each of the six sites. The surveys and interviews were analyzed to quantitatively and qualitatively assess issues such as the aspects of care management that were most useful, awareness of reimbursement related to care management, and level of user-friendliness of the system design.

Specific Aims:

  • Implement the Care Management Plus and ICCIS models. (Achieved)
  • Perform a cluster randomized controlled trial in six clinics on the ability to use the IT functions to monitor and deliver care to high-risk patients through a care coordination (Arm 1) or a quality performance model (Arm 2). (Achieved)
  • Assess the implementation. (Achieved)
  • Understand and disseminate the outcomes, benefits, challenges, and unintended consequences from use of these functions for patients and the system. (Achieved)

2012 Activities: The focus of 2012 was analysis of the study data. The project used a 1-year no-cost extension to complete the project. As last self-reported in the AHRQ Research Reporting System, project progress was on track and budget spending was on target. This project ended in September 2012.

Impact and Findings: Of the 87,710 patients followed by the six clinics, 26,395 were seen twice during the study period and were therefore eligible for the study. Among eligible patients, 31 percent were preselected as having a high risk of hospitalization. Baseline characteristics of the high-risk group did not vary across clinics. Of those eligible, 3,075 were enrolled and actively followed by care managers. In the care coordination arm, clinics received reimbursement for completing care management activities. For this arm, the number of completed care management activities was 1.8 times higher than for the quality improvement arm. In the quality improvement arm, quality measures improved by 14.2 percent as compared to 8.9 percent in the care coordination arm. Overall, the quality improvement arm achieved more consecutive improvements than the care coordination arm. Of the two study arms, fee-for-service care coordination reimbursement was more effective.

Dr. Dorr reports that end-user feedback was very positive and that five of the six clinics will use the ICCIS beyond the end of the project. The large clinics demonstrated the most dramatic, broad-based changes, while some of the smaller clinics found it difficult to have one staff member fully dedicated to the care management role. Additionally, the project has generated a lot of interest from other clinics, many of which have approached Dr. Dorr to express their interest in using the ICCIS.

Target Population: Adults, Chronic Care*, Elderly*

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to improve health care decisionmaking through the use of integrated data and knowledge management.

Business Goal: Implementation and Use

* This target population is one of AHRQ's priority populations.

Enhancing Complex Care through an Integrated Care Coordination Information System - 2011

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    RFA: HS08-002: Ambulatory Safety and Quality Program: Improving Management of Individuals with Complex Healthcare Needs through Health Information Technology (MCP)
  • Grant Number: 
    R18 HS 017832
  • Project Period: 
    September 2008 - September 2012
  • AHRQ Funding Amount: 
    $1,155,147
  • PDF Version: 
    (PDF, 202.99 KB)

Summary: Patients with chronic illnesses are at risk for complications due to a lack of coordination and quality in a fragmented health care system. This project is investigating whether care for patients with complex needs can be improved by implementing an integrated care coordination information system (ICCIS) developed by the Oregon Health and Science University. ICCIS incorporates population management techniques, patient-centered goals, quality measures, and clinical reminders to support clinical care teams and patient self-management. The three study objectives are to: 1) understand whether ICCIS can be implemented among diverse clinics using certified electronic health records (EHRs) and existing standards; 2) assess whether the functions in the ICCIS can be used by the clinics; and 3) evaluate whether these system changes lead to improved patient outcomes.

Using a randomized, controlled trial, Dr. Dorr and his team are examining whether six participating clinics (three inner-city, three rural) can use health information technology (IT) to monitor and deliver care for high-risk patients with a care coordination model (Arm 1), or quality performance model (Arm 2). The team is evaluating how well care coordination functions are used at the clinics. Measures include indicators of patient engagement, clinic-level quality of care, clinic-level process, and patient health outcomes.

Specific Aims:

  • Implement the Care Management Plus and ICCIS models. (Achieved)
  • Perform a cluster randomized, controlled trial in six clinics on the ability to use the IT functions to monitor and deliver care to high-risk patients through a care coordination (Arm 1) or a quality performance model (Arm 2). (Ongoing)
  • Assess the implementation. (Ongoing)
  • Understand and disseminate the outcome, benefits, challenges, and unintended consequences from use of these functions for patients and the system. (Ongoing)

2011 Activities: Developing the second version of ICCIS was the project team's major focus in 2011. The following system refinements were implemented in ICCIS Version Two: 1) passwords were synched across several systems to simplify password management; 2) patients without a clinic visit in 3 years are now automatically inactivated to improve the accuracy of reporting; 3) the rule base that generates appointments with care managers was modified to allow care managers enhanced flexibility for task coordination; and 4) software was modified to allow ICCIS to better integrate with information systems in other clinics. From the end-user perspective, Version Two of ICCIS increased the speed of loading quality measure reports from approximately 90 to 10 seconds. As a result, clinician work flow improved, and the reports are easier to use on a regular basis or on an as needed basis. The changes also improved the usability of the interface and integration of data sources, which minimizes double entry between the EHR and ICCIS.

The collection of patient-level data from ICCIS continued in 2011. A post-study survey and an interview guide were developed and tested. The survey was administered in-person to clinicians and office managers at each of the six sites. Followup interviews with the same clinic staff are nearly complete. The surveys and interviews will be analyzed to quantitatively and qualitatively assess issues such as the aspects of care management that were most useful, awareness of reimbursement related to care management, and level of user-friendliness of the system design.

The project is using a 1-year no-cost extension to complete the project. As last self-reported in the AHRQ Research Reporting System, project progress and activities are on track and project budget spending is on target.

Preliminary Impact and Findings: Of the 65,615 patients followed by the six clinics, 13,852 were seen twice during the study period and were therefore eligible for the study. Among eligible patients, 51 percent were over the age of 50, and 15 percent were preselected as having a high risk of hospitalization. Baseline characteristics of the high-risk group did not vary across clinics. Of those eligible, 2,087 were enrolled and actively followed by care managers. In the care coordination arm, clinics received reimbursement for completing care management activities. For this arm, the number of completed care management activities was three times higher than for the quality improvement arm. In the quality improvement arm, clinics received reimbursement for meeting quality measure benchmarks. Overall, this arm demonstrated a doubling of achieved quality measures and achieved more consecutive improvements than the care coordination arm. Of the two study arms, fee-for-service care coordination reimbursement was more effective.

Dr. Dorr reports that end-user feedback was very positive and that five of the six clinics will continue to use ICCIS beyond the end of the project. Additionally, the project has generated a lot of interest from other clinics, many of which have approached Dr. Dorr to express their interest in using ICCIS.

Target Population: Adults, Chronic Care*

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to improve health care decisionmaking through the use of integrated data and knowledge management.

Business Goal: Implementation and Use

* This target population is one of AHRQ's priority populations.

Enhancing Complex Care through an Integrated Care Coordination Information System - 2010

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    RFA: HS08-002: Ambulatory Safety and Quality Program: Improving Management of Individuals with Complex Healthcare Needs through Health Information Technology (MCP)
  • Grant Number: 
    R18 HS 017832
  • Project Period: 
    September 2008 – September 2011
  • AHRQ Funding Amount: 
    $1,155,147
  • PDF Version: 
    (PDF, 311.65 KB)


Target Population: Adults, Chronic Care*

Summary: Patients with chronic illnesses are at risk for complications due to a lack of coordination and quality in a fragmented health care system. This project is investigating whether care for patients with complex needs can be improved by implementing an Oregon Health and Science University-developed integrated care coordination information system (ICCIS) that incorporates population management techniques, patient-centered goals, quality measures, and clinical reminders to support clinical care teams and patient self-management. The three study objectives are: 1) to understand if ICCIS can be implemented among diverse clinics using certified electronic health records (EHRs) and existing standards: 2) to assess if the functions in the ICCIS can be used by the clinics: and 3) to evaluate if these system changes lead to improved patient outcomes.

A randomized controlled trial examines whether six participating clinics can use health information technology (IT) to monitor and deliver care for high-risk patients with a care coordination model (Arm 1) or quality performance model (Arm 2). Three inner-city locations and three rural clinics are participating in the study. Dr. Dorr and his team are evaluating how well care coordination functions are used at the clinics. Measures include indicators of patient engagement, clinic-level quality of care, clinic-level process, and patient health outcomes.

Specific Aims:
  • Implement the Care Management Plus and ICCIS models. (Ongoing)
  • Perform a cluster randomized controlled trial in six clinics on the ability to use the IT functions to monitor and deliver care to high-risk patients through a care coordination (Arm 1), or a quality performance model (Arm 2). (Ongoing)
  • Assess the implementation.(Upcoming)
  • Understand and disseminate the outcome, benefits, challenges, and unintended consequences from use of these functions for patients and the system. (Ongoing)

2010 Activities: The team completed a joint analysis of transcribed interviews to determine which combination of features would make the ideal product. Preferred system functions and features were divided into three groups: features to be added before the trial start-date, features to be added during the trial, and features for future versions of the software. The features that were designated for development before the trial start-date were developed and implemented. Quality measures were selected and defined. A protocol was developed for how and where to extract the data from the EHRs into ICCIS for quality-measure tracking. System features include: notifications that alert providers to past emergency room visits and hospitalizations and upcoming patient office visits; a dashboard that allows comparison of adherence to quality measures between physicians, care teams, and clinics; and a reporting functionality that fosters the care team model.

Staff at all six clinics were trained in care management according to the protocol. The clinics were randomized to the care coordination model or the quality performance model. Baseline information on costs, utilization, and patient panels was collected and patient satisfaction survey data is ongoing.

Grantee’s Most Recent Self-Reported Quarterly Status (as of December 2010): The project is mostly on track. The system has been implemented, an assessment was conducted, and the trial began. Project spending is on target.

Preliminary Impact and Findings: Baseline data collected from four of the six clinics indicate that 54,406 patients were eligible to be enrolled in care management. Among eligible patients, 37.3 percent had at least one chronic condition and 22.9 percent had two or more chronic conditions. Of those eligible, 3,254 were enrolled and actively followed by care managers. Of these, 87.4 percent had at least one chronic condition and 70.6 percent had two or more chronic conditions. Seventeen percent of enrolled patients had very high risk chronic illness compared with 6 percent in the non-referred population. In terms of the quality improvement measures, of the five quality improvement measures tracked in the four clinics over three quarters, improvements in quality were detected 97 percent of the time (29 improvements out of 30 measurements). Data for the two other clinics will be available in 2011.

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to improve health care decisionmaking through the use of integrated data and knowledge management.

Business Goal: Implementation and Use

*AHRQ Priority Population.

Enhancing Complex Care through an Integrated Care Coordination Information System - Final Report

Citation:
Dorr D. Enhancing Complex Care through an Integrated Care Coordination Information System - Final Report. (Prepared by Oregon Health and Science University under Grant No. R18 HS017832). Rockville, MD: Agency for Healthcare Research and Quality, 2012. (PDF, 499.76 KB)

The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services. (Persons using assistive technology may not be able to fully access information in this report. For assistance, please contact Corey Mackison)
Principal Investigator: 
Document Type: 

Care Management (CMP) Discussion Guide. Oregon Health and Science University. Version 4.0.

Citation:
Dorr DA & Behkami N. Care Management (CMP) Discussion Guide. Oregon Health and Science University. Version 4.0. (PDF, 237.57 KB)

(Persons using assistive technology may not be able to fully access information in this report. For assistance, please contact Corey Mackison)
Principal Investigator: 
This project does not have any related resource.

Integrated Care Coordination Information System Interview Guide

This is an interview guide designed to be conducted with nurses in an ambulatory setting. The tool includes questions to assess user's perceptions of electronic health records.

Year of Survey: 
Created prior to 2012
Survey Link: 
Integrated Care Coordination Information System Interview Guide (PDF, 780.74 KB)
Document Type: 
Research Method: 
Population: 
Care Setting: 
Copyright Status: 
Permission has been obtained from the survey developers for unrestricted use of this survey; it may be modified or used as is without additional permission from the authors.
Location: 

Care Management (CMP) Discussion Guide

This is an interview guide designed to be conducted with nurses, physicians, and office staff in an ambulatory setting. The tool includes questions to assess the current state of electronic health records.

Year of Survey: 
2008
Survey Link: 
Care Management (CMP) Discussion Guide (PDF, 188.54 KB) (Persons using assistive technology may not be able to fully access information in this report. For assistance, please contact Corey Mackison)
Document Type: 
Care Setting: 
Copyright Status: 
Permission has been obtained from the survey developers for unrestricted use of this survey; it may be modified or used as is without additional permission from the authors.
Location: 
This project does not have any related project spotlight.
This project does not have any related survey.
This project does not have any related story.
This project does not have any related emerging lesson.