Here is a simple slidedeck of research done that examined which systemic care coordination practices should be maximized according to the literature to improve clinical integration within and between healthcare organizations.

1. Which systemic care coordination strategies should be
maximized to improve clinical integration in hospitals and
integrated healthcare delivery systems?
Soraya Ghebleh
May 29, 2013
The Dartmouth Institute for Health Policy and Clinical Practice

2.  Background
 Trends in Current Healthcare Environment
 Clinical Integration
 Systemic Care Coordination Strategies
 Conceptual Framework
 Methods and Search Strategy
 Overview
 Inclusion Criteria
 Search Results
 Limitations
 Results
 Characteristics of Included Studies
 Summary of Results
 Methodological Quality
 Synthesis
 Completeness and Applicability of the Evidence
 Common Themes of Care Coordination Interventions
 Recommendations
 Implications for Institutions Interested in Clinical Integration
 Framework to Improve Clinical Integration using Systemic Care Coordination Strategies
 Conclusions
 Future Research
Executive summary

3.  Trend #1: Fragmented Delivery of Care
 Trend #2: Healthcare Reform
 Trend #3: Increased Consolidation Activity
Three Current trends Shaping the healthcare
environment

4. AIM: To bring providers together to manage care in a more standardized,
coordinated, effective, and efficient manner, leading to improvement in
quality for patients.
PRIMARY CHARACTERISTICS AS DEFINED BY THE
FEDERAL TRADE COMMISSION:
(1)Ability to achieve significant clinical and economic efficiencies
(2)Broad physician representation and physician intervention
(3)A well-developed care management program that uses
evidence-based guidelines
(4)A data management system that enables extensive data
collection, information sharing, and utilization review
clinical integration and quality

5. Care Coordination is defined as “the deliberate
organization of patient care activities between two or
more participants (including the patient) involved in a
patient’s care to facilitate the appropriate delivery of
health care services.”1
Mechanism by which clinical integration can be
improved through comprehensive interventions
Systemic care coordination strategies involve
collaboration between multiple disciplines within an
institution or between institutions
Care coordination
1
Source: Care Coordination, Quality Improvement: Structured Abstract. June 2007. Agency for Healthcare Research and
Quality, Rockville, MD. http://www.ahrq.gov/research/findings/evidence-based-reports/caregaptp.html

6. Conceptual framework

7. A systematic review of the available literature in the Business and Medical
databases was performed in April 2013. The specific databases searched
were MEDLINE via PubMed, ABI/Inform, Business Source Complete, and
CINAHL.
A search strategy and specific inclusion criteria were established a priori.
All databases were searched from 1990-2013. Search terms utilized were
“integration,” “care coordination,” “hospitals,” and “healthcare systems.”
The Boolean terms “AND” and “OR” were used to find intersection
between these terms
overview of methods

8. Studies were included that met the following criteria:
(1) study designs consisting of randomized controlled trials, cohort studies,
case-control studies, before-after studies, pseudo-experimental or non-
randomized trials, cross-sectional studies, and case studies
(2) intervention must fall under one of the five broad approaches of care
coordination as identified by the Agency for Healthcare Research and
Quality
(3) intervention must aim to further integrate setting where intervention is
being implemented
(4) intervention must be limited to hospital-wide settings, integrated health
systems or a hospital clinic setting that involves multi-disciplinary
collaboration
(5) intervention must be a systemic intervention
(6) studies were limited to 1990 to April 2013.
Inclusion criterion

9. results of search
77 studies were identified from
ABI/Inform, 185 studies from
MEDLINE via Pubmed, 193 from
CINAHL, and 136 from Business
Source Complete. A total of 592
records were identified through a
database search and 94 duplicates
were removed. A remaining 498
studies were then screened by title
and abstract. 441 studies were
excluded and 57 remaining full text
articles were then screened for
eligibility. Of the 57 full text articles
that were screened, 13 met the
inclusion criteria.

10. Numerous definitions for both clinical integration and
care coordination exist in the literature
Lack of consensus on appropriate measures of clinical
integration
Deficit of high-quality, empirical studies
measuring the effects of care coordination on clinical
integration
Review was performed by only one individual,
leaving room for potential error
limitations of search Strategy

11. Interventions all met one of the five broad categories of care
coordination interventions as defined by the Agency for
Healthcare Research and Quality
Outcomes of all studies included at least one of the four
components of clinical integration as defined by the Federal Trade
Commission
Five of the thirteen studies examined interventions
implemented across an integrated delivery system
Six studied single institution interventions
Two studies compared multiple settings
Characteristics of included studies

12. characteristics of included studies

13. summary of results
All studies gave insight into the design and implementation
of care coordination interventions
Varied reporting of quantitative results across studies
Metrics reported included length of stay, hospital
utilizations, patient satisfaction, staff satisfaction, ED
presentations, and cost savings
Each study gave in-depth descriptions of care coordination
interventions, processes used to develop these
interventions, and recommendations

14.  A standardized abstraction tool adapted from Downs and Black was utilized to
assess the methodological quality of each study
 Many studies included were of low quality, had limited reporting of quantitative
results, and lacked generalizability
 Difficult to find the best study design to assess the link between care coordination
and clinical integration due to the limited amount of existing studies as well as
the numerous metrics that can be utilized to assess this link
 Reporting bias is a concern as specific positive outcomes were often reported but
adverse outcomes were not
 Conflict of interest was also of concern, as only four studies specifically stated
that no conflict of interest was present
methodological quality

15. Methodological quality
 High Risk
 Low Risk
 Unclear
 N/A

16.  Eligible studies all incorporated at minimum one
component of the categories of care coordination
interventions and one component of the
characteristics of clinical integration as an aim
 Certain components of both care coordination and
clinical integration were studied more than others
completeness of evidence
 Unclear if the care coordination intervention was the only factor that affected
clinical integration in the study setting
 The appropriate study design to study the link between systemic care
coordination interventions and improving clinical integration has not been
determined in the literature

17. Institutions are consolidating to meet new demands in the healthcare
environment and must become more efficient to remain competitive
Improving clinical integration through carefully implemented systemic
care coordination strategies can lead to higher quality and satisfaction
and has the potential to reduce costs
Care coordination strategies to improve clinical integration within a
hospital can be applied systematically across a delivery system
If an institution that is part of a system implements a strategy or
intervention and success is reasonably demonstrated, that institution can
expand or share that strategy within the system
clinical integration within and between institutions

18. Despite variations in quality and generalizability of
included studies, the synthesis revealed common
components of interventions regardless of study design
or setting:
 Leadership
 Communication
 Data Collection and Meaningful Utilization
 Flexibility
 Process Improvement
 Patient-Centered Emphasis
Common themes of care coordination
interventions

19. Guidelines for improving clinical integration through systemic
care coordination strategies

20. Establish leadership before implementation of intervention
Leadership can be senior management, clinical leaders, care
coordinators, or teams but must be clear to the staff
Responsibilities include setting institution and organizational goals,
creating an organizational structure, and ensuring appropriate
management of various components of the intervention
Oversight and monitoring of the
intervention is essential
Leadership

21. Frequent staff meetings that incorporate all levels of staff
High-touch communications strategy that emphasizes institutional goals and a
culture of learning and adaptability
Cross-department communication pathways established
Sharing best practices between institutions within an integrated delivery
system
Establish communication between
patient and individual or team that
serves as single point of care
communication

22.  Data collection is essential to any quality improvement
initiative
 Defined metrics should be established and data collection
should begin prior to any intervention
 Data should be benchmarked with institutional and
national data
 Real-time data collection allows for adaptive learning and
necessary adjustments to be implemented
 Effective utilization of healthcare information technology to
ensure data is being collected efficiently
data collection & meaningful utilization

23. Flexibility is necessary in two contexts:
 (1) Institutional Flexibility
 (2) Point of Contact for Patient
flexibility
Institutions require adaptability with implementation of interventions, as no
two settings are entirely homogeneous
The point of contact for the patient must have the ability to span
departments to ensure proper management of patient care
Beneficial for care coordination staff or intervention leadership to give an
outside perspective on pathways and processes occurring in the institution

24. process improvement
Adaptive learning to adjust, enhance, and improve implemented
interventions
Incorporation of data collection, staff and patient feedback, evidence from
the literature, and existing clinical pathways to strive for improved
outcomes and efficiency
Process improvement measures should
be performed as problem areas are
defined and should be adapted as data
is collected

25. patient-centered emphasis
Goal of any intervention is ultimately to improve
outcomes and quality for patients
Comprehensive care management plans should be
designed for high-risk and high-utilizing patients
 Patient feedback is informative for improvement and can provide insight
beyond the perspective of providers
 Patient and caregiver satisfaction should be kept in mind with any intervention
designed to improve patient care and overall experience
 Patient care pathway is integral to any systemic care coordination intervention

26. More high quality studies with empirical data should be performed
Studies should involve comprehensive systemic care coordination
interventions that encompass all of the broad categories as defined by the
AHRQ
Outcomes should be identified and defined before the intervention is
implemented and an adequate time period should be established for follow-
up
A standardized, validated, systematic, evidence-based tool needs to be
developed to effectively evaluate integration in order to compare different
hospitals and integrated delivery systems
Future research

27.  Relationship between care coordination and clinical integration is important in
the context of healthcare reform and increased consolidation
 These different components can be used to develop a comprehensive, systemic,
care coordination plan that has the potential to improve clinical integration within
an institution and between institutions
conclusions
 There is no identical, repeatable care coordination
plan guaranteed to work in every institution
 Further research and higher-level study should be
performed as coordinating care at a systemic level
shows great promise to improve the quality and
experience of healthcare delivery