The Effect of Implementing a Care Coordination Program on Team Dynamics and the Patient Experience

A primary care redesign program embedding care coordinators into practices slightly improves the patient experience and does not disrupt team dynamics.
Published Online: August 21, 2017
Paul Di Capua, MD, MBA, MSHPM; Robin Clarke, MD, MSHS; Chi-Hong Tseng, PhD; Holly Wilhalme, MS; Renee Sednew, MPH; Kathryn M. McDonald, MM, PhD; Samuel A. Skootsky, MD; and Neil Wenger, MD, MPH
ABSTRACT

Objectives:
Care coordination programs are frequently implemented in the redesign of primary care systems, focused on improving patient outcomes and reducing utilization. However, redesign can be disruptive, affect patient experiences, and undermine elements in the patient-centered medical home, such as team-based care.

Study Design: Case-controlled study with difference-in-differences (DID) and cross-sectional analyses.

Methods: The phased implementation of a care coordination program permitted evaluation of a natural experiment to compare measures of patient experience and teamwork in practices with and without care coordinators. Patient experience scores were compared before and after the introduction of care coordinators, using DID analyses. Cross-sectional data were used to compare teamwork, based on the relational coordination survey, and physician-perceived barriers to coordinated care between clinics with and without care coordinators.

Results: We evaluated survey responses from 459 staff and physicians and 13,441 patients in 26 primary care practices. Practices with care coordinators did not have significantly different relational coordination scores compared with practices without care coordinators, and physicians in these practices did not report reduced barriers to coordinated care. After implementation of the program, patients in practices with care coordinators reported a more positive experience with staff over time (DID, 2.6 percentage points; P = .0009).

Conclusions: A flexible program that incorporates care coordinators into the existing care team was minimally disruptive to existing team dynamics, and the embedded care coordinators were associated with a small increase in patient ratings that reflected a more positive experience with staff.

Am J Manag Care. 2017;23(8):494-500
Take-Away Points

A care coordinator program was implemented as part of primary care redesign. This study examined the intervention’s effects on patients’ experiences and team dynamics.
  • Teamwork scores in practices with care coordinators were not significantly different than scores in practices without care coordinators.
  • Overall patient experience with staff in practices with care coordinators improved significantly after program implementation, although the care coordinators worked with only a fraction of patients.
  • Our findings suggest that embedded care coordinators improved the primary care experience for patients; they integrated themselves in the care teams without disruption of the existing team’s function.
Healthcare systems transitioning toward value-based models of healthcare delivery often focus on redesigning primary care as a means of achieving better access and quality at a lower cost.1-3 The patient-centered medical home, a common model that aims to revamp the role of primary care, emphasizes population health and integration across the care continuum.4,5 Coordination of care is one of the key tenets of the patient-centered medical home, and practices adopting the model frequently implement a care coordination program as part of their practice transformation. These programs, which typically empanel high-risk patients based on prior utilization or comorbidities,6,7 can result in significant reductions in acute care utilization.8-10 

The health system for the University of California, Los Angeles (UCLA Health) implemented an innovative care coordination program as part of its primary care redesign. The intervention embeds nonlicensed care coordinators (CCs) in primary care practices to work with physicians in real time. Program details including coordinators’ backgrounds, the program’s training processes, and operations are described elsewhere.10 Although other components of the redesign focused on technology or ancillary services across all practices, the introduction of the care coordination program was the most significant and potentially disruptive change in the operations of the existing primary care system, and it was applied differentially to practices over time. The CCs focus on patients discharged from an acute care episode, high-complexity patients, and patients referred by physicians, totaling approximately 10% of patients in a primary care physicians’ panel. The primary purpose of the CCs was to improve care and reduce utilization for the most complex patients. Practices in the health system with CCs have been shown to be associated with a 20% reduction in emergency department visits compared with practices without CCs in the health system.10 

However, practice redesign is disruptive, and the mixed results of primary care transformation efforts11,12 suggest that one size does not fit all.13 As a result, it is important to understand how CCs and other “transformative” interventions impact patients’ experiences and the overall structure and function of the team.

Team-based care, another central tenet of the medical home, facilitates primary care’s expanded role as a medical home.6,14-16 At a minimum, practice redesign should support the team’s ability to provide cohesive care. Relational coordination has emerged as a dominant method of measuring how various actors in a healthcare setting work together17 and focuses on the relationships between team participants fulfilling specified roles.18

Practice redesign efforts must also consider the impact on patients’ experiences as a health-related outcome. Furthermore, patient experience scores are a common feature of quality metrics used in various accountable care payment models, directly affecting the redesign’s return on investment. The scores also indirectly reflect the success of primary care redesign: patients with better experiences are more adherent to physician recommendations, more loyal to their physicians, and more engaged in their care, all desirable outcomes in value-based models of care.19,20 Finally, publicly reported patient experience scores can affect a health system’s reputation.

In this study, we sought to expand the understanding of CC interventions by evaluating the downstream effects on patients and other members of the care team. Because this program affected only a small number of patients, we hypothesized that the overall set of patients in practices with CCs would report no change in access to care, care coordination, and their overall rating of their experience compared with patients in practices without CCs. Regarding team dynamics, we hypothesized that CCs would not change the relational coordination within a practice and that physicians in practices with CCs would perceive a lower burden of coordinating care for their patients.

METHODS

A phased implementation of the UCLA Health Care Coordinator Program within UCLA Health allowed for a natural experiment comparing practices with CCs already embedded (CC practices) with the practices that had not yet introduced CCs (non-CC practices). Because the health system continuously collects patient experience data for all practices, we used a difference-in-differences (DID) approach to compare preintervention and postintervention patient experience between the 2 cohorts. Data on relational coordination and physician-perceived barriers to care were collected only in the postintervention period and were compared between CC practices and non-CC practices.

Description of Health System and Primary Care Practices

UCLA Health is an urban academic system that had 26 primary care practices caring for adult patients at the time of the study encompassing internal medicine, family medicine, and geriatrics. Primary care practices within UCLA Health are primarily traditional community-based practices with full time physicians; 4 practices also have trainees. The first CCs were introduced into 5 practices in May 2012, and another 9 were introduced in November 2012; half of all practices had CCs by December 2012. The other half of primary care practices incorporated CCs starting in March 2014. The rollout of the primary care redesign was set up to represent the wide range of practices within the UCLA Health System: practices belonged to 1 of 4 “pods” corresponding to the management structure of the ambulatory care network. Each pod had semi-autonomous management. The first practices to receive CCs were selected by UCLA Health System leadership to encompass a representative sample from each pod and to include sites with, and without, trainees. 

The CCs were embedded members of the primary care team, working with all physicians within their assigned practice, and were tasked with addressing nonmedical barriers to care. Our prior work showed that the majority of the work of the CCs related to transitions of care, including such physician-directed tasks as scheduling appointments, providing self-management support services, and monitoring and following up with patients between visits.10 As a result, a CC served as a dependable point person for a subset of patients in order to complete tasks that were typically done by a variety of receptionists and clerks, or not performed at all. 

Patient experience survey. The health system used the Clinician and Group Survey by Consumer Assessment of Healthcare Providers and Systems 12-Month Survey to measure and track patient experience.21 The survey evaluated 6 categories of each patient’s experience, detailed in eAppendix A (eAppendices available at ajmc.com). Four categories used multiple questions to form composite measures: quality of patient–doctor interaction, access to care, care coordination, and courteous and helpful office staff (defined as clerks and receptionists). The last 2 categories covered 2 global rating questions: 1) overall rating of the doctor and 2) whether the respondent would be willing to recommend the doctor to their family and friends.

Patient experience data were split into 2 periods: the preintervention period ranged from May 2011 through February 2012 and the postintervention period ranged from May 2013 through February 2014. Because the last CC in the intervention group was introduced in December 2012, this allowed a minimum of 4 months for CCs to become established team members of their primary care practice. Two CC practices were excluded because they were in a transition period between CCs at the time of the study, and the newly hired CCs had not had time to form relationships with their colleagues.

Relational coordination and physician burden surveys. Relational coordination is a tool initially developed in the airline industry22 that was, subsequently validated in multiple healthcare settings.18,23,24 It is defined as a mutually reinforcing web of communication and relationships carried out for the purpose of task integration.18 In primary care, higher relational coordination has been associated with higher-quality chronic care delivery,25,26 and improvement in relational coordination predicts improvements in chronic care delivery.27 The measure is computed by having respondents rate the quality of working relationships with their colleagues based on 3 relational dimensions (shared goals, shared knowledge, and mutual respect) and 4 dimensions of communication: frequency, accuracy, timeliness, and whether the communication seeks to solve problems or assign blame (see eAppendix B for details).

In order to assess physician-perceived burdens of coordinating care, we asked primary care physicians within the health system and not directly involved in this research to describe the tasks that do not require clinical training or licensure but are needed for patients to receive well-coordinated care. We overlaid these responses with tasks documented by CCs as part of their workflow to identify areas in which CCs might reduce the physician burden of care coordination. Five questions assessed physicians’ perceived burden of nonmedical care coordination tasks; each was scored on a 5-point scale where 5 was the lowest perceived burden.

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