Pilot Program

Improving Team-Based Care Coordination Delivery and Documentation in the Health Record

Fed Pract. 2018 October;35(10):32-39

References

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Implementation Evaluation

The RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance)framework served as the basis for evaluation of CC Template implementation. The RE-AIM framework is well established and able to evaluate the implementation and potential successful spread of new programs.^23,24 Using RE-AIM, the authors planned to analyze data to explore the reach effectiveness, adoption, implementation, and maintenance of the CC Template use while providing complex care management for high-risk patients.

All data for the evaluation was extracted from the CDW by a data analyst and stored on a secure server. A statistical process control (SPC) chart was used to analyze the implementation process to assess variation in template use.

Results

After implementation, 35 weeks of CC Template pilot data were analyzed from June 1, 2015 to January 5, 2016. The PIM team completed 393 CC Templates over this collection period. After week 23, the CC template was linked to specific CC notes automatically. From weeks 23 to 35 an average of 20.3 CC Templates were completed per week by the team. The RE-AIM was used to assess the implementation of the CC Template.

Reach was determined by the number of patients enrolled in PIM with CC Template documentation. Of patients enrolled in Atlanta PIM, 90.1% had ≥ 1 CC encounter documented by the CC Template; 74.4% of Atlanta PIM patients had ≥ 1 CC encounter documented; 15.5% of patients had > 10 CC encounters documented; and 1 patient had > 25 CC encounters documented by the CC template.

Effectiveness for describing CC activities was captured through data from CC Template. The CC Template documentation by the PIM team showed that 79.4% of CC encounters were < 20 minutes, and 9.9% of encounters were > 61 minutes. Telephone communication was involved in 50.4% of CC encounters, and 24% required multiple modes of communication such as face-to-face, instant messenger, chart-based communication. Care coordination during hospitalization and discharge accounted for 5.9% of template use. Of the CC encounters documenting hospital transitions, 94.4% documented communication with the inpatient team, 58.3% documented coordination with social support, and only 11.1% documented communication with primary care teams. Improving communication with PACT teams after hospital discharge was identified as a future QI project based on these data. The PIM team initiated 83.2% of CC encounters.

Adoption was determined by the use of the CC Template by the team. All 5 team members used the CC template to document at least 1 CC encounter.

Implementation allowed for improvement based on feedback from the PIM team. Mean completion of CC Templates rose from 10.9 per week to 20.3 per week after automatically linking the CC Template to specific CC notes. (Figure 4)

Maintenance was monitored over the course of the pilot. Consistent use of the CC Template over 35 full work weeks of data collection was seen, and mean utilization per week nearly doubled in the latter half of the pilot period.

Because several elements were added to the CC Template over the course of the pilot period, our ability to analyze the data for descriptive statistics about the types of CC services, related diagnoses, collaborators, and PIM staff involved in CC encounters was limited.