Care Coordination for Seniors with Multiple Chronic Diseases

Examining the Macro and Micro Level Relationships and Outcomes

NRSA Trainees Research Conference Slide Presentation (Text Version)

By Marian Ryan, RRT, MPH, CHES

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On June 2, 2007, Marian Ryan made a slide presentation on care coordination for seniors with multiple chronic diseases at the 13th Annual National Research Service Award (NRSA) Trainees Research Conference. This is the text version of the slide presentation. Select to access the (PowerPoint® File, 310 KB).

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Slide 1

Care Coordination for Seniors with Multiple Chronic Diseases: Examining the Macro and Micro Level Relationships and Outcomes

Marian Ryan, RRT, MPH, CHES
Schneider Institute for Health Policy
The Heller School for Social Policy and Management
Brandeis University

Slide 2

Improving Quality Via Care Coordination

• IOM Report makes an appeal for the redesign of our system of care to improve care coordination.
• Critical for Medicare beneficiaries.
  • More than half have two or more chronic conditions.
  • One fourth have mental function or cognitive impairments.
  • More than one fourth report health as fair or poor.
  • 43% report no help from doctor in coordinating their medical services.

(RWJ, 2001)

Slide 3

Literature Gap: The Chronic Care Model

A diagram includes one large and two small ovals depicting the literature gap:

The large oval includes components of Community Resources and Policies as well as Health System Organizations. They are: Self Management Support, Delivery System Design, Decision Support, and Clinical Information Systems. These components are shown to influence functional and clinical outcomes.

A small bottom left oval is entitled Active Patient and a small bottom right oval is entitled Prepared PCP (Primary Care Physicians). Two directional arrows emphasize the importance of productive interactions between the two groups as being important in functional and clinical outcomes.

Wagner, 1992

Slide 4

Literature Gap: The Chronic Care Model (Continued)

Diagram Shows Relational Coordination between an active patient and PCP in understanding Outcomes and Adherence

The square in the diagram includes dimensions of relational coordination that influence each other.

The two dimensions of Relational Coordination are Communication and Relationships. Communication elements include: frequent, timely, accurate, and problem solving aspects. Relationships include Shared Goals, Shared Knowledge and Mutual Respect.

Relational Coordination is then seen as influencing Trust presented in the form of a rectangle, which in turn influences productive interactions between an active patient and prepared PCP. These Productive Interactions in turn influence Outcomes and Adherence.

This slide shows the second half of a diagram showing the interactions between the community, health care organizations, patients, and physicians in providing chronic care.

Relational Coordination (Gittell, 2002)

Slide 5

Research Questions

• Does the Chronic Care Model improve quality outcomes and patient adherence for seniors with multiple chronic diseases?
• Does PCP care coordination improve outcomes and adherence to treatment?
• Does Relational Coordination and trust between the patient and primary care physician improve outcomes and adherence to treatment?
• Does Relational Coordination and trust mediate the impact of the Chronic Care Model on outcomes and adherence?

Slide 6

Study Population

• Patients 65 years of age and older with two or more chronic conditions served by large IPA in Southern CA
  • One of which must be diabetes (high prevalence/cost).
  • Exclusions: cancer, ESRD, HIV.
• Primary care physicians associated with patient sample.
• 41 practice sites throughout Los Angeles, CA.
  • Five independently operating regions.
  • One umbrella organization, physician owned and led.
  • Physicians make majority of care decision including referrals.

Slide 7

Measures of Quality and Adherence to Treatment: Outcome Variables

1. Receipt of HEDIS® Diabetes process measures.
2. Receipt of FOBT or colonoscopy.
3. Acceptable A1-c and LDL levels.
4. Inpatient admits, readmission rates, LOS.
5. SNF admissions and LOS.
6. Days on hospice.
7. Adherence to maintenance medication.

Slide 8

Fitted Model = HLM

Outcomekmit =	β0 + β1PCP-PTRCkmit + β2PCP-PTTrustkmit
	+ β3Time + ... +βnPTCovkmit
	+ β1kPCPCareCoordkmit + ... + βnkPCPCovkmit
	+ β1kmCCM1kmit + ... + β6kmCCM6kmit ..
	βnkmC1Covkmit + ... + αi + πm + γk + εkmit

Where k = associated clinic

m = associated PCP

i = individual patient

t = time

Slide 9

Analytical Model

This diagram presents a model of Chronic Care Components, depicted as a rectangle, which influences three dimensions:

• Physician Care Coordination Activities,
• Relational Coordination between the Patient and PCP, and
• Improved Patient Outcomes and Adherence.

Each of these three dimensions is presented in the format of a rectangle.  In addition, Physician Care Coordination Activities is depicted as influencing Relational Coordination between the Patient and PCP, which in turn influences Improved Patient Outcomes and Adherence.  Relational Coordination between the Patient and PCP is then seen as influencing and being influenced by trust between the patient and PCP.  At the bottom left corner of the diagram are two additional rectangles—one for Physician Characteristics and one for Patient Characteristics.  Physician Characteristics are shown to directly influence Physician Care Coordination Activities and Relational Coordination between the Patient and Physician.  Patient Characteristics are seen to directly influence Relational Coordination between the Patient and PCP and Trust between the Patient and PCP.

Slide 10

Policy Implications

• Inform ambulatory system redesigns.
• Provide evidence to support the financial compensation to physicians for care coordination.
• Inform changes to medical training programs.
• Has potential to examine micro factors in racial inequalities and work to reduce them.

Current as of October 2007

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Internet Citation:

Ryan, M. Care Coordination for Seniors with Multiple Chronic Diseases: Examining the Macro and Micro Level Relationships and Outcomes. Text Version of a Slide Presentation. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/fund/training/marryantxt.htm

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