Developing Protocols for Care Coordination

Protocols for care coordination are guidelines designed to streamline processes commonly used during care coordination activities.
Resource Type: 
  • Guide
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    REFERENCES

     

    American College of Physicians. The Patient-Centered Medical Home Neighbor: The Interface of the Patient-Centered Medical Home with Specialty/Subspecialty Practices. Philadelphia: American College of Physicians; 2010: Policy Paper. (Available from American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106.)

    https://www.acponline.org/system/files/documents/acp_policy/policies/pcmh_interface_subspecialty_practices_2010.pdf

    Cardwell D, Richmeier, S. (2011).  Patient-Centered Medical Home Care Coordination Workbook: Part of the Transformation Series. MGMA and TransforMED publishers

    Care Coordination.  AHRQ.  https://www.ahrq.gov/professionals/prevention-chronic-care/improve/coordination/index.html  Accessed 05 Dec 2017

    Care Coordination Implementation Guide.  Reducing Care Fragmentation in Primary Care. (2013).  Safety Net Medical Home Initiative.  http://www.safetynetmedicalhome.org/sites/default/files/Implementation-Guide-Care-Coordination.pdf.  Accessed 05 Dec 2017.

    Clinical Referral Protocol Guide: Definitions and Templates for Referrals with the Accountable Care Collaborative (2014).  Developed by RCCOs across the state of Colorado. http://ichpcolorado.com/providers/pdfs/Clinical-Referral-Protocols-Guide.pdf

    Coordinating Care in the Medical Neighborhood: Critical  Components and Available Mechanisms..  PCMH Resource Center.  AHRQ https://pcmh.ahrq.gov/page/coordinating-care-medical-neighborhood-critical-components-and-available-mechanisms

    Greiner A. White space or black hole: What can we do to improve care transitions. American Board of Internal Medicine Issue Brief #6. 2007. Accessed at www.abimfoundation.org/~/ media/Files/Publications/F06-05-2007_6.ashx accessed 13 December 2017

    Institute for Healthcare Improvement / National Patient Safety Foundation. Closing the Loop: A Guide to Safer Ambulatory Referrals in the EHR Era. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2017. (Available at www.ihi.org)

    Mehrotra, Ateev, Christopher B Forrest, and Caroline Y Lin. “Dropping the Baton: Specialty Referrals in the United States.” The Milbank Quarterly 89.1 (2011): 39–68. PMC. Web. 13 Dec. 2017.

    Primary Care Team Guide. A program of the Primary Care Team Leap.

    http://www.improvingprimarycare.org/work/referral-management.  Accessed 06 Dec 2017

    Royer, Richard, (May, 2015).  Transforming Care Coordination.  Hospitals and Health Networks.    https://www.hhnmag.com/articles/3067-employees-raise-a-half-million-dollars-to-build-rural-replacement-building

    Snow, V., et al.  Transitions of Care Consensus Policy Statement: American College of Physicians, Society of General Internal Medicine, Society of Hospital Medicine, American Geriatrics Society, American College of Emergency Physicians, Society of Academic Emergency Medicine. J Hosp Med. 2009 Jul;4(6):364-70. doi: 10.1002/jhm.510.

    Transitions of Care Measures. (2008).  NTOCC Measures Workgroup. www.NTOCC.org

    REFERENCES

    Introduction

    Protocols for care coordination are guidelines designed to streamline processes commonly used during care coordination activities. Protocols define a common set of procedures for all providers, staff, patients and referral sources that result in:

    • Appropriate and timely care coordination activities, 
    • Effective communication and coordination among providers, staff, patients, and referral sources,
    • Improved flow of necessary patient and care information,
    • Patient-centered care, enhanced care access and increased quality and safety,
    • Better health outcomes,
    • Reduced duplication of healthcare services.

    Steps for Developing Protocols for Care Coordination:

    Assemble a Team

    Developing protocols for Care Coordination activities begins with assembling a team of staff members include a provider, nurse, MA, office personnel. Include people who touch the information process both to and from the referral sources.

    Define Common Care Coordination Processes

    This team will develop a list of the common processes and work flows encountered in care coordination. Consider the following processes as you prepare your list:

    Decision Making:

    Provider

    • Determines when and to whom to make a patient referral
    • Determines course of action based on referral recommendations
    • Use of Evidence Based Guidelines
    • Use of Collaborative Care Agreement

    Care Team

    • Use of agreed upon Clinical Pathways to assist in care delivery
    • Use of established protocols to assure process completion

    Communication:

    Face to Face

    • Appropriate and timely care coordination activities, 
    • Effective communication and coordination among providers, staff, patients, and referral sources,
    • Improved flow of necessary patient and care information,
    • Patient-centered care, enhanced care access and increased quality and safety,
    • Better health outcomes,
    • Reduced duplication of healthcare services.

    Electronic

    • Appropriate and timely care coordination activities, 
    • Effective communication and coordination among providers, staff, patients, and referral sources,
    • Improved flow of necessary patient and care information,
    • Patient-centered care, enhanced care access and increased quality and safety,
    • Better health outcomes,
    • Reduced duplication of healthcare services.

    Telephonic

    • Appropriate and timely care coordination activities, 
    • Effective communication and coordination among providers, staff, patients, and referral sources,
    • Improved flow of necessary patient and care information,
    • Patient-centered care, enhanced care access and increased quality and safety,
    • Better health outcomes,
    • Reduced duplication of healthcare services.

    Paper/Manual

    • Appropriate and timely care coordination activities, 
    • Effective communication and coordination among providers, staff, patients, and referral sources,
    • Improved flow of necessary patient and care information,
    • Patient-centered care, enhanced care access and increased quality and safety,
    • Better health outcomes,
    • Reduced duplication of healthcare services.

    Patient Flow:

    • Assuring patient keeps the designated appointment
    • Assuring patient returns to PCP as indicated by the Collaborative Agreement

    Establish Standards for Follow-up

    Define and agree upon time-frame expectations for each step of the coordination process based on patient acuity. Determine when and how often follow-up interventions are needed to close the loop.
    Emergent:

    Within 24 hours

    Urgent:

    Within 1 week

    Priority:

    Within 2 weeks

    Routine:

    Within 8 weeks

    Elective:

    Before next visit

    Develop Workflow Map and Conduct FMEA

    Having identified the key processes involved in care coordination and the timing of their completion, develop a process workflow map of the referral process (See Managing Referrals for more information.Consider possible failures in this workflow using a Failure Modes Effects Analysis (FMEA) for each step of the process, and develop contingency plans. (See FMEA for more information).
    A Failure Modes and Effects Analysis (FMEA) worksheet showing Process Step 1: "PCP Orders a Referral," with columns for potential failures, impact, causes, detection mechanism, and interventions. The worksheet outlines risks like missing or incorrect orders and suggests solutions like automation and real-time communication. Process Step 2 is listed but blank.

    Use the IHI model for a Closed Loop EHR referral Process as place to start your FMEA. The IHI Model recommends the following steps should be included in a closed loop EHR referral process. Those steps include:

    1. PCP orders referral
    2. PCP communicates to specialist
    3. Referral reviewed and authorized
    4. Appointment scheduled
    5. Consult occurs
    6. Specialist communicates plan to patient
    7. Specialist communicates plan to PCP
    8. PCP acknowledges receipt of plan
    A horizontal referral workflow diagram showing eight sequential steps: PCP orders referral → communicates to specialist → referral reviewed → appointment scheduled → consult occurs → specialist communicates plan to PCP → PCP acknowledges and communicates to patient.

    Adapted from Institute for Healthcare Improvement/National Patient Safety Foundation. Closing the Loop: A Guide to Safer Ambulatory Referrals in the EHR Era. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2017. (Available at www.ihi.org) 

    Write Role-based Protocols Based on Workflow

    Write office protocols identifying the workflow, the contingency plans and the responsible person for each step.

    • Provider’s responsibilities
    • MA/Nurse responsibilities
    • Office Staff responsibilities
    • Patient responsibilities
    • Referral Source responsibilities

    Review and Improve Care Coordination Process

    Periodically review and improve the process between the PCP and referral sources. Designate an interdisciplinary team representing all entities to agree on acceptable measures and tracking methods. Suggestions of areas to improve include:
    SIPOC diagram divided into three columns—Structure, Process, Outcome—listing key components such as accountable providers, care team processes, and patient health outcomes.
    Adapted from Transitions of Care Measures. (2008).  NTOCC Measures Workgroup..  www.NTOCC.org​

    *Care Team Processes

    • Care planning (including advance directives)
    • Medication reconciliation (this process includes patient and family)
    • Test tracking (laboratory, radiology, and other diagnostic procedures)
    • Tracking of referrals to other providers or settings of care
    • Admission and discharge planning
    • Follow-up appointment tracking
    • End-of-life decision making

    **Information Transfer & Communication

    • Timeliness, completeness, and accuracy of transferred information
    • Protocol of shared accountability in effective transfer of information

    ***Patient & Family Education and Engagement:

    • Patient and/or family preparation for transfer
    • Patient and/or family education for self-care management
    • Patient and/or family agreement with the care transition (active participation in making informed decisions)
    • Appropriate communication with a patient with limited English proficiency and health literacy.

    Once your care coordination protocols are defined conduct Quality Improvement analysis, such as Plan-Do-Study-Act, on areas needing improvement. (See Plan-Do-Study-Act PDSA for more information)

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