Enhancing Complex Care through an Integrated Care Coordination Information System

Most chronic and preventive longitudinal care needs are addressed in primary care practices, yet payments and practice structure are based on visits and procedures that may contribute to unnecessary utilization of health care services. For older adults with multiple chronic illnesses, the longitudinal coordination needs that are not accounted for under current payment structures may represent the majority of care needed to improve outcomes, such as reducing hospitalizations due to fragmented care and complex care plans.        

This project tested the hypothesis that incentives for team-based care coordination would better address unnecessary utilization than do traditional quality measure-based pay for performance. It evaluated the impact of an integrated care coordination information system (ICCIS) on the outcomes and satisfaction of patients with chronic and complex illnesses. A cluster-randomized study was conducted at six ambulatory clinics in both rural and urban settings.          

The specific aims of this project were to:

• Implement the Care Management Plus and TITLE Enhancing Complex care through an Integrated Care Coordination Information System model.
• Perform a cluster randomized, controlled trial in six clinics on the ability to use the IT functions to monitor and deliver care to high-risk patients through a care coordination (Arm 1) or a quality performance model (Arm 2).
• Assess the implementation.
• Understand and disseminate the outcome, benefits, challenges, and unintended consequences from use of these functions for patients and the system.         

Clinics received training in care management, coordination, and other principles of medical homes, a designated care manager, and the ICCIS. The ICCIS provided interactive quality reports, tracked and reminded providers about services, and facilitated population management based on risk. The six clinics were randomized into two arms: care coordination clinics that received care coordination payments for activities related to assessment, education, goal setting, motivational interviewing, and communication; and quality clinics that received incentive payments for documented improvement of five self-selected standard National Quality Forum-approved quality measures. The evaluation included tracking of quality measures, conducting before-and-after surveys of patients and their care experiences, and measuring changes in utilization.       

Care coordination clinics used the system to perform 1.8 times as many care coordination activities as the quality clinics. The quality clinics improved their quality measures 14.2 percent versus 8.9 percent for the coordination clinics. Experience of care did not change except for a 9 percent absolute increase in ease of making appointments in the coordination arm. Six-month preliminary results for hospitalization bed-days showed a greater decline in the care coordination group, while emergency department visits were lower in the complex illnesses.