Define the care coordination model
Patient Care Coordination Assignment Paper

Currently, most hospitals and health systems focus on patient engagement because of their mission to deliver patient-eccentric care. These efforts are pursued despite the neutral or even negative economic consequences to these organizations, which operate within the fragmented, fee-for-service payment system. For example, care coordination attendant to patient engagement efforts will, at times, reduce demand for services and, thereby, reduce fee-for-service payments to providers.Patient Care Coordination Assignment Paper

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As public and private sector health care purchasers shift payment models towards value and as demographic changes result in more chronically ill patients entering the health care system, patient engagement efforts will become increasingly important to the financial sustainability and clinical success of these hospitals and health systems.

New patient engagement efforts shift focus from the inpatient core of hospitals to ambulatory care settings and to the integration of care into the homes and communities of patients. To succeed at these efforts, organizations must build longitudinal partnerships with patients to drive ongoing management of chronic conditions and utilization of preventive care services to drive long-term quality and cost outcomes.

Why Patient Engagement Now?

In response to increasing growth in health care spending, public and private health care purchasers are introducing new payment models to promote higher-value care in the U.S. health care system. Traditional fee-for-service payment methodologies pay providers for each health care service delivered, regardless of efficiency. The fee-for-service system encourages higher-acuity specialty utilization to the exclusion of other critical health system activities such as care coordination or care collaboration. Thus, the fee-for-service payment model contributes to a fragmented health care delivery system resulting in duplicative care, preventable utilization, escalation of care to higher-acuity settings, and ultimately, poorer patient outcomes.

For most patients in the U.S. health care system, navigating the maze of uncoordinated, fragmented medical care and social services has become a norm. The diverse array of providers and institutions have left patients as the main conduit of information between clinicians they see. As health systems strategize on how to respond to market demands of the post-ACA environment, care coordination is not only key to demystifying a complex health system for patients, but also a way for providers to achieve the most touted principles of the Triple Aim: improving population health, reducing overall costs and improving patient satisfactions.Patient Care Coordination Assignment Paper

Health systems that are designing and developing care coordination program should consider the following:

Define the care coordination model: Care coordination is a fluid term with different meanings for different provider types and organizations. Having a strong population health management strategy at a system-level, complimented by a care coordination model tailored to individual organizations, provides for appropriate care across settings. Successful care coordination models have defined core principles that can be shared and understood at all levels across a health system.
Develop a model that is focused on consumer friendly, patient-centered care: Consumer friendly, patient-centered care encompasses medical and non-medical needs of the individual. Providers are armed with the resources they need in order to work directly with the patient and their caregiver to develop a plan that meets their medical and social needs. The personalized approach allows providers to flag patient problems regarding their care to intervene earlier and prevent problems from getting worse, thus keeping the patient healthier and reducing overall cost.
Provide continuity of medical and non-medical services: Care that is truly coordinated addresses the entire individual, which includes medical needs as well as non-medical services such as assistance with food and housing. Such a model draws on multiple aspects of a system of care (health plans, nursing homes, hospitals, social services agencies, etc.) that directly impact a patient’s health.
Implement tools for delivering care: Effective care coordination requires health systems to implement appropriate clinical and organizational supports that enable providers to work across health care settings. Communication of timely and accurate information between providers, patients and caregivers is critical to provide high quality, patient-centered care. The use of standardized electronic health records (EHRs) to track patient care, identify care opportunities, and communicate with other provider types is a requirement for effective care coordination across settings. Furthermore, patients having access to their own medical record enables enhanced patient engagement and compliance.
Focus on improving transitions of care: With health systems increasingly at risk for readmission rates, improving transitions of care has become a focal point in care coordination models. Through the use of EHRs and health information exchange across various settings, providers have the opportunity to enhance communications during transitions of care. Health systems should also work on aligning financial incentives and establishing accountability particularly among hospitals, SNFs, primary care and specialty physicians.
Conduct health assessments to understand more about your patient population: Conducting periodic health assessments of your patients provides an opportunity for primary care providers to get a snapshot on the health status and risks of empaneled patients. Obtaining a health assessment not only provides an opportunity for providers to understand medical and non-medical needs of their patients, it also allows providers to take advantage of available incentives from payers or accrediting agencies.
Patient Care Coordination Assignment Paper

Develop and refine stratification methodologies in order to provide tailored case management to those most at-risk: As value-based care delivery and risk-based contracting become increasingly common, risk stratification is now more important than ever. In order to change cost structures and improve outcomes, interventions must be designed to target high-risk, high-cost patients. All interventions, no matter how effective, are predicated on accurately identifying and stratifying those patients.
Provide team-based care through the use of interdisciplinary care team: Interdisciplinary care teams (ICTs) address the full range of patient needs, integrating healthcare and non-medical services. A basic care team includes a member, PCP and PCP support staff. Patients with higher acuity may have a larger ICT that also includes a health plan representative, mental health or substance abuse providers and other social services or community-based organizations. Through the use of an ICT, different types of staff work together and share expertise, knowledge and skill to solve complex problems that cannot be solved by one discipline alone.
coordinated care
Effective population health management benefits patients, physicians, health care organizations, the entire health care system, and the nation at large. Here’s how:

Patients receive better coordinated care – and enjoy better health – because they are reminded of procedures needed to manage their condition or disease. They also save their portion of the cost for more expensive procedures not required because of timely care.
Patient Care Coordination Assignment Paper

Physicians are better informed and their patients are more engaged, resulting in better outcomes in care. Physicians also more easily satisfy quality measures that focus on engaging patients and providing timely, appropriate, coordinated care.
Health care organizations are more profitable – whatever their payment model(s) – because gaps in care are filled, patient volume increases and the cost of delivering care can be more accurately quantified.
The health care system benefits from increased preventative care, which helps avoid more expensive procedures and leads to higher quality, more efficient, coordinated care across health care organizations.
The nation benefits from reduced health care costs, better management of diseases, and a generally healthier population.
What is population health management?
It’s not just a fashionable trend; it’s a holistic approach that could change the way we think about health care delivery. Health care organizations looking to succeed in the shifting reimbursement landscape should focus on four crucial population management tasks:Patient Care Coordination Assignment Paper

Identify and engage patients in need of care.
Align physicians, care teams and care coordination.
Create seamless transitions in care.
Optimize revenue and efficiency.
In the following section of this Population Management Knowledge Hub, we’ll examine each of these tasks.

In recent years, there has been a dramatic increase in the push for various organizational interventions aimed at improving the coordination of healthcare delivery services. Two examples of such interventions are care coordination teams (CCTs), which are used in hospitals to coordinate patient flow across care units; and Accountable Care Organizations (ACOs), which are used to coordinate care delivery across healthcare organizations. Despite the widespread adoption of, and continued push for these interventions, there is very little systematic and rigorous research investigating their impacts on operational performance, such that to date, how beneficial they are remains an open question. Research findings in this area have been inconclusive, and there is a lack of theory to explain or reconcile these inconclusive results. This dissertation, which consists of two essays, addresses these shortcomings. The first essay focuses on the value of CCTs to hospitals. Using theories of organizational coordination, we develop hypotheses describing the influence of CCT structure on the efficiency and effectiveness of patient flow processes, and how team-patient coordination causally mediates this direct effect. We test this hypothesis in a field study of CCTs using quasi-experimental methods. The second essay focuses on the recent emergence of ACOs as an organizational form that can promote care coordination across healthcare organizations. Drawing on the contingency theory of organization, we propose and test the hypothesis that input uncertainty, knowledge insufficiency, and prevalence influence hospitals decision to participate in ACOs, as well as its effect on cost and quality performance. The theoretical contribution of this dissertation focuses on clarifying how these organizational interventions work to affect performance. The practical contribution focuses on identifying specific elements of the intervention that are most beneficial to hospitals, and conditions under which these interventions work best.Patient Care Coordination Assignment Paper

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As Medicaid spending continues to overwhelm state budgets, the medical home model of care offers one method of transforming the health care delivery system. Medical homes can reduce costs while improving quality and efficiency through an innovative approach to delivering comprehensive patient-centered preventive and primary care.

Also known as the patient-centered medical home (PCMH), this model is designed around patient needs and aims to improve access to care (e.g. through extended office hours and increased communication between providers and patients via email and telephone), increase care coordination and enhance overall quality, while simultaneously reducing costs.

The medical home relies on a team of providers—such as physicians, nurses, nutritionists, pharmacists, and social workers—to meet a patient’s health care needs. Studies have shown that the medical home model’s attention to the whole-person and integration of all aspects of health care offer potential to improve physical health, behavioral health, access to community-based social services and management of chronic conditions.

Although general agreement exists about the basic tenets of the medical home, the model is still evolving. Not all medical homes look alike or use the same strategies to reduce costs, improve quality and coordinate care. Accreditation offers formal recognition and a stamp of approval to those that successfully meet specific standards and requirements, facilitating payment from both public and private payers. Medical home accreditation is available from national accreditation organizations, as well as a few states that have developed their own standards. Although certain health care providers (such as community health centers) already embody many elements of the PCMH, many are seeking formal recognition as patient-centered medical homes. This is due in part to the fact that medical practices that participate in medical home pilot programs often qualify for enhanced reimbursement rates, or receive other financial incentives for coordinating care.

Key to medical home success are health information technology (HIT) and payment reform. Because the medical home can be a physical or a virtual network of providers and services, HIT facilitates communication and information sharing among providers. For example, medical homes use electronic health records, which give providers instant access to patient information regardless of location. Payment reform is another important element. The medical home model offers financial incentives for providers to focus on the quality of patient outcomes rather than the volume of services they provide. Medical homes assume a wide variety of forms. A couple of examples outlined below include community health centers and medical homes to manage chronic disease and behavioral health.Patient Care Coordination Assignment Paper

Legislators play a key role in creating and supporting this health care delivery model. As of April 2013, 43 states had policies promoting the medical home model for certain Medicaid or CHIP beneficiaries. States have created pilot projects, reformed payment structures, invested in health information technology, restructured Medicaid provider systems, and included the medical home model in service delivery.

The 2010 Patient Protection and Affordable Care Act (PPACA) contains various provisions that support implementation of the medical home model including new payment policies, Medicaid demonstrations, and the creation of Accountable Care Organizations – which are similar to medical homes, on a larger scale.

Becoming a centralized hub for care allows PCPs to foster strong patient engagement relationships, coordinate service, and manage chronic diseases as they move beyond the scope of traditional medicine.

By delivering quality care in all of these three aspects, providers can ensure better patient engagement and more patient-centered care, which in turn will ideally lead to higher levels of patient wellness.Patient Care Coordination Assignment Paper

The epicenter of care coordination

Patients view primary care as exactly that: the central place where they receive their healthcare. Because of this, primary care providers need to zero in on care coordination as a way to ensure patient satisfaction with the primary care and as a way to ensure that patient care is comprehensive when they visit specialists.

A 2015 Accenture survey investigated patient preferences with primary care coordination, showing that a majority of patients want their care managed at one central point. Eighty-seven percent of respondents reported such, and a near equal number of respondents reported that their primary care providers should be the epicenter of all of this care coordination.

Patient-centered care coordination is not just limited to how primary care providers and specialists can manage an individual patient. This concept also extends to how providers can coordinate care with the patient, engaging them in their own care.

According to Marcia Cheadle, RN, Senior Director of Clinical Applications at Inland Northwest Health Services, patients need to be integrated as a member of the care team. This means that they participate in care coordination efforts.

“By having more patient involvement, that activation of the patients in their care journey, their longitudinal healthcare journey, we’re really looking to leave behind that unilateral decision-making, that white coat paralysis that happens to all of us when go in to see the doctor,” Cheadle said.

Cheadle says patients can be brought into the care team through digital technologies, mainly patient portals. By giving patient access to their health data, they stake a bolder claim in their healthcare. Additionally, they can contribute their own patient-generated health data, adding to the repository of information a primary care provider may have.

Primary method for early disease detection

As primary care providers generally tend to patients overall wellness, their practices are ideal for detecting illness early on, hopefully mitigating those illnesses before they become catastrophic.

Primary care providers must deliver patient-centered care as a means to better detect patients illnesses in early stages. According to Mark Wagar, President of Heritage Medical Systems, this is the main goal of primary care.Patient Care Coordination Assignment Paper

“It’s not enough to be really good when somebody falls in your door,” Wagar asserted. “It’s in fact as important, if not more important, to be able to figure out how to work with them to improve their general health status so that they have fewer events where they fall in the door.”

Patient engagement is vital for providers to really determine what may be ailing a patient, and then conduct further tests to potentially uncover a chronic disease.

Engagement goes beyond the realm of patient-provider communication in the primary care site, however. According to Peter Goldbach, MD, Chief Medical Officer of Redlining and Health Dialog, being able to early detect chronic diseases starts with getting the patient in the door. An innovative approach to this is through primary care delivery in retail clinics.

“Retail clinics make good healthcare more accessible as well as affordable for a broad group of Americans, which means people get the care they need a return to health faster,” he noted.

Retail clinics also help patients who have already been diagnosed with a chronic disease receive care coaching in convenient locations.

“We’re going to be moving toward a provision of chronic care because if you think about a lot of what’s been written about chronic care and how we’re looking to improve it and keep care coordinated, a lot of that centers on patient-centered medical homes,” Goldbach said.

“The way I think it’ll play out is that ACOs will embrace retail as the right solution for them. It’ll allow them a larger primary care footprint, it’ll allow them to deliver care more efficiently.”

Moving beyond the scope of traditional medicine

Unlike specialist care, primary care practices enable physicians to go beyond one specific ailment. When a patient visits their primary care doctor, they not only care for the patient’s overall wellness, but also probe into other aspects of the patient’s life that could affect that wellness.

While providers can certainly deliver quality technical healthcare, it’s the going beyond that which allows providers to deliver better care in the future.Patient Care Coordination Assignment Paper

“Certainly we have all the necessary delivery systems to take care of you when you come to us in a physician’s office or in an urgent situation… where you have determined that you need something, you’re really sick, you’re injured, we have all that,” Wagar stated.

“That’s the traditional healthcare system. It’s the engagement with you when you’re not presenting technically as a patient today that is the key.”

Primary care providers can go beyond the traditional scope of medicine to understand what about a patient’s personal life may bar them from actually attending their doctor’s appointments. From there, providers can mitigate these issues. All of these actions go specifically with accountable care organizations, which by definition deliver highly patient-eccentric care.Patient Care Coordination Assignment Paper

“It’s a matter of adapting your outreach to what will work for [the patient],” Wagar explained. “Maybe if they live in an apartment building in an urban setting, maybe they have a couple of friends who are the best persons to talk with them and help us get information and figure out the best way to access them. If someone’s relatively isolated, get some kind of community care worker, a local person they trust to visit once in awhile.”

As the healthcare landscape changes to value patient-centered care over the volume of care delivered, primary care providers will need to recognize that they are the central place where this transition can begin.

By understanding the role that primary care plays in delivering patient-centered care, these physicians can better utilize care coordination and chronic disease management and detection strategies to move beyond the traditional scope of care.

Focus on transition of care from outpatient to inpatient and back to an outpatient setting should be a priority in the fragmented health care system. Inpatient care coordinators, along with an interdisciplinary team from varying settings along the care continuum, can be instrumental in ensuring smooth, safe, and quality transitions. This, in turn, provides an avenue to ensure that patients are educated, adherent, and involved in their own health along the continuum of diabetes care.

Are your hospitalized patients with diabetes receiving diabetes self-management education? What education are they receiving from various hospital staff members, and when? Are patients’ treatment regimens and medication histories being carefully passed along during transitions from one unit to another and ultimately to discharge? Is adequate and appropriate information being shared with patients, their family members, and their next care facility before discharge? Can your patients afford the prescriptions, supplies, and foods needed to follow their diabetes regimen as recommended after leaving the hospital? Who will follow up with patients to see if everything is going smoothly after they return home?

All of these questions are very real to anyone working with patients with new hyperglycemia or diabetes in an acute care setting. This article will discuss coordination of care as a possible solution to some of these issues.Patient Care Coordination Assignment Paper

What Is Care Coordination?
Care coordination, sometimes called case management, is the process of helping health care consumers navigate safely and effectively through the fragmented and confusing health care environment that exists today in the United States. According to the Case Management Society of America, “Case management is a collaborative process of assessment, planning, facilitation, and advocacy for options and services to meet an individual’s health needs through communication and available resources to promote quality cost-effective outcomes.”1 Many care management models grew out of insurance-focused programs. These models included case managers as the pivotal point of patient advocacy. Often, these functions of utilization review, precertification, utilization management, care coordination, case management, discharge planning, and disease management were accomplished by different individuals in a variety of settings, such as hospitals, managed care organizations, and independent companies. These individuals performed their functions within the four walls of their specific settings, professing cost-effective, quality outcomes; however, they never spoke to each other, and so their efforts sometimes overlapped, sometimes hindered each other, and sometimes left gaps no one was catching.Patient Care Coordination Assignment Paper

Today, as the care management process evolves, the utilization and disease management components have given way to a more integrated approach to care coordination. Integrated care coordination professionals facilitate quality, cost-effectiveness, health promotion, and patient satisfaction with and involvement in care by coordinating medical and behavioral care services within more aggressive time frames and often in “single care” settings with one focus. These locations where care coordinators practice are often one stop on a continuum of settings and services to meet the needs of health care consumers.

Because of the “single care” setting, a new model with a framework for transition of care has surfaced. These new programs focus on the full continuum of care in terms of settings and scope of services, with the care coordinator driving patient care throughout. Advanced care management professionals strive for a patient-centered approach to community health care, partnering with appropriate providers and optimal care sites to produce quality health and financial outcomes. Transition of care is a multidisciplinary, multidimensional, complete health continuum consumer experience. Health care consumers and the system are empowered to move toward wellness as opposed to illness, cost containment, and access to quality care.

Transition of care is receiving much national consideration. In 2006, multiple organizations joined together to form the National Transition of Care Coalition. The coalition’s website (www.ntocc.org) is full of information and solutions to transition of care issues.2 In one study, it was established that “patients and their caregivers who received tools and support from a nurse `transition coach’ were significantly less likely to experience rehospitalization, a finding that was sustained for at least 6 months.”3 “Transition coach” is another term for care coordinator and a great description of the role such professionals play. A patient-centered model of transition coaching provides the tools for patients to make the most informed and rational use of their health care resources by reducing uncoordinated care and multiple contacts while improving communication with providers.Patient Care Coordination Assignment Paper

Advanced care coordination is distinguished by:

A health care consumer mentality empowering and educating patients and families to manage their personal health

Enhanced communication and documentation throughout the health care system not only within individual care settings

Interdisciplinary collaborative teams

Coordinated care from health care providers’ offices to emergency departments to hospital units, to rehabilitation facilities, to home care and back to outpatient care if needed

In short, care coordination improves services, reduces costs by reducing duplication, and allows for sharing of resources among all of a given patient’s care providers.

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The Acute Care Setting
The Joint Commission has taken an active role regarding hyperglycemic control and safety within hospitals that seek accreditation or certification. The Joint Commission joined with the American Diabetes Association (ADA) to develop goals and standards for hospitals seeking certification. The goals and standards, if met, can help improve the outcomes of hyperglycemic patients and provide an opportunity for patients to receive excellent hospital care. The Joint Commission and ADA recommend that inpatient diabetes programs include the following crucial attributes.3

Patient Care Coordination Assignment Paper

Specific staff education requirements

Written blood glucose monitoring protocols

Plans for the treatment of hypoglycemia and hyperglycemia

Data collection on incidences of hypoglycemia

Patient diabetes self-management education

An identified program “champion” or program champion team

The care of inpatients with hyperglycemia is complex. As noted above, the Joint Commission has indicated that it is crucial to identify a program champion or champion team. In most cases, these champions are care coordinators, who ensure that patients receive organized, coordinated care both in the hospital and throughout their transition from one setting to another. Care coordinators are a great resource for continuity of care and the development of a collaborative team approach to ensure a high-quality, safe, and cost-effective hospitalization. Hospitalization should be viewed as an investment more than as a cost4 because it could help prevent additional morbidities and hospitalizations resulting from complications and lack of adequate patient self-care, both of which can greatly increase the costs of diabetes care. Therefore, hospitalization is an opportunity for assessment and education to improve diabetes care over the long run. Care coordinators and case managers are resources who can ensure that the treatment team is fully engaged in the care of these patients. Following are some of the key goals to be included in an inpatient care coordination plan.

Identify hyperglycemia and diabetic patients.
The identification of an individual with hyperglycemia may already be accomplished in any unit of a hospital, including the emergency department. The care coordination team must be mindful of any patient’s history of diabetes and of elevated blood glucose levels in any hospitalized patients, including those without a diagnosis of diabetes. Undiagnosed hyperglycemia is common and can occur at any time during hospitalization as a result of illness or treatment. Inpatient hyperglycemia does not necessarily indicate that a patient has diabetes. However, the care coordination team must be prepared for next steps5 and should collaborate closely with the hospital’s diabetes educator or nurse to identify patients with hyperglycemia and ensure best practices.Patient Care Coordination Assignment Paper

Create a collaborative team.
This interdisciplinary team should be composed of physicians, nurses, diabetes educators, dietitians, case or care managers, discharge planners, and pharmacists. This team should be involved in diabetes management throughout the inpatient continuum from the emergency department to critical care to general and pre- and postoperative care, and eventually to discharge and beyond.

Fully assess patients.
The patient assessment must include lifestyle, access to health care services, available support, culture, health literacy, knowledge of diabetes and treatment recommendations, and financial stability, which includes the ability to pay for blood glucose monitoring supplies, medications, and healthful foods.Patient Care Coordination Assignment Paper

Develop an individualized plan.
Patient care plans should include interventions by the entire collaborative team for the duration of the hospitalization. Continued management is a priority, with consistent planning by the full team. Include the patient and his or her family members or caregivers as members of the team, and adopt a patient-centered approach. Planning for and implementing protocols to control blood glucose is crucial, especially in intensive care units.Patient Care Coordination Assignment Paper

Educate.
Facilitate education by the collaborative team for patients, families, and hospital staff in areas of care for patients with hyperglycemia or diabetes. Create or obtain patient education materials that will deliver consistent messages from all staff. When distributing these education materials, be cognizant of the individual learner’s health literacy. In general, patient education materials should not exceed a fourth- or fifth-grade reading level. Assess patients thoroughly and then tailor education appropriately to match their learning style.6

Encourage a safe environment.
In 2005, the Joint Commission developed its Sentinel Events, which included National Patient Safety Goals. The eighth goal identified is medication reconciliation. The Joint Commission defines medication reconciliation as “accurately and completely reconciling medications across the continuum of care.”7 In its National Patient Safety Goals, the Commission identifies steps such as placing the medication list in highly visible locations in each patient’s chart, creating an interdisciplinary process of reconciling medications on admission and at any time of transfer or discharge, and communicating a list of medications to the next providers of care and the patient during transitions.

It is crucially important to include all of the medications the patient was taking before hospitalization, new medications started during hospitalization, and those ordered for use after discharge. One of the most complex hurdles for patients is determining which medications they should take once they are back at home. This confusion has the potential to create an unsafe environment if patients continue medications prescribed before hospitalization but which may no longer be necessary after hospitalization. Attention to such medication issues should be given regardless of the care setting a patient will be in after discharge.Patient Care Coordination Assignment Paper

Promote self-care.
Assist the team in promoting patient self-care across settings in a continuum adherence program. As mentioned above, this effort must include assessment of patients’ health literacy, medication knowledge, motivation to change, and social support system and reconciliation of medications used in the hospital with those used before and after hospitalization. Comorbidities, polypharmacy issues, and the stress of hospitalization or illness may create insurmountable barriers to self-care for many patients. Be prepared with information regarding medication changes, self-monitoring, and titrating medication doses according to blood glucose levels, meal content, and activity levels. Communicate this information to patients, family members, and other caregivers, as well as to the outpatient care coordination team.

Empower patients.
Encourage patients to be involved in their own care from hospital back to home and ongoing thereafter. Create an open environment in which they can ask questions. Listen for potential barriers and assist patients in removing any possible roadblocks to effective self-care.Patient Care Coordination Assignment Paper

Coordinate care.
Care must be coordinated by the collaborative team, facilitated by the care coordination staff, throughout the full hospital stay, from one transition to the next, including discharge. A discharge plan promoted on Day 1 of hospitalization, if not before, can help smooth and promote a safe and successful discharge. Securing insurance coverage for the hospital stay, as well as for necessary outpatient supplies, equipment, and medications, may require additional coordination, especially if alternative funding is needed.

Focus on continuity during transitions between inpatient and outpatient care.
An inpatient diabetes management task force of the American College of Endocrinology and the ADA recently developed a consensus statement on inpatient diabetes and glycemic control in which the importance of continuity of care between inpatient and outpatient settings was stressed.4 A consistent plan for glycemic management, both in the hospital and after discharge, will foster patients’ involvement in their own care.Patient Care Coordination Assignment Paper

As patients enter the hospital, having medical records available from their primary care setting can be enormously helpful for hospitalists or specialists who provide their inpatient care. Likewise, patient education and self-care efforts in the hospital can benefit outpatient care efforts later on. Discussion from the time of admission about the meaning and value of the A1C test will help patients understand this measure of their diabetes control, which will further enhance self-care in the long term. Patient motivation and readiness to accept the challenges of either a new diagnosis of diabetes or self-care for a long-standing diagnosis must be assessed and, if necessary, enhanced because lifestyle modification may be required for successful self-care. Often, patients’ medication and lifestyle adherence starts with attention to these issues during hospitalization.

Tools focusing on medication adherence are available through the Case Management Society of America. Case Management Adherence Guidelines8 have been developed for people with diabetes and can be found online at http://www.cmsa.org/portals/0/pdf/CMAG_Diabetes.pdf.Patient Care Coordination Assignment Paper

Hospitalists are actively pursuing protocols and routines that will enhance the successful transition of diabetes care along the inpatient continuum and throughout the transition from inpatient to outpatient settings, using an interdisciplinary team approach. The Society of Hospital Management’s Glycemic Control Task Force has produced a comprehensive workbook that is an excellent resource for developing transition-of-care plans from acute care to discharge to the community.9 This resource can be found online at http://www.hospitalmedicine.org/AM/Template.cfm?Section=Search_Advanced_Search&section=Glycemic_Control&template=/CM/ContentDisplay.cfm&ContentFileID=2934.

Care coordination involving an interdisciplinary team in the hospital setting is crucial to successfully meeting patients’ needs. Hospitalization, often a stressful time for patients, is only the beginning of the care-coordination process; ensuring smooth and cohesive transition of care should be a priority. Communication between caregivers before, during, and after hospitalization must include medications prescribed, medical records, education offered, assessment findings (especially health literacy), and patient and family willingness to change lifestyle factors. Having patients’ input into the care-coordination process is a key to success, which can be measured by a smooth transition throughout every stage of hospitalization and into outpatient care settings.Patient Care Coordination Assignment Paper