Chartbook on Care Coordination

• This chartbook includes:
  • Summary of trends across measures of Care Coordination from the QDR.
  • Figures illustrating select measures of Care Coordination.
• Introduction and Methods contains information about methods used in the chartbook.
• Appendixes include information about measures and data.
• A Data Query tool (http://nhqrnet.ahrq.gov/inhqrdr/data/query) provides access to all data tables.

Trends in Care Coordination Measures

• Few Care Coordination measures can be tracked over time.
• One Care Coordination measure improved quickly, defined as an average annual rate of change greater than 10% per year:
  • Hospital patients with heart failure who were given complete written discharge instructions.
• No Care Coordination measures:
  • Showed worsening quality.
  • Showed elimination or widening of disparities.

Care Coordination

• The vision is health care providers, patients, and caregivers all working together to "ensure that the patient gets the care and support he needs and wants, when and how he needs and wants it" (NQS, 2011).
• Conscious, patient-centered coordination of care improves the person's experience and leads to better long-term health outcomes, as demonstrated by fewer unnecessary hospitalizations, repeated tests, and conflicting prescriptions, as well as clearer discourse between providers and patients about the best course of treatment (NQS, 2013).

Provider Communication and Care Coordination

• Six essential elements of provider-patient communication include:
  • Having open discussion.
  • Gathering information.
  • Understanding the patient's perspective.
  • Sharing information.
  • Reaching agreement on problems and plans.
  • Providing closure (Dean, et al., 2014).

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Measures of Care Coordination

• In addition to summarizing information on care coordination from the QDR, this chartbook tracks individual measures of care coordination, overall and for populations defined by age, race, ethnicity, income, education, insurance, and number of chronic conditions.
• Measures of Care Coordination include:
  • Transitions of care.
  • Preventable emergency department visits.
  • Potentially avoidable hospitalizations.
  • Integration of medication information.
  • Use of electronic health records.

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