# Presentation: 355062

## 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**

## 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)

## Literature Gap: The Chronic Care Model

**	****Community**
**Resources & Policies             Organization of Health Care**

**Health System**

| Self-Mgmt Support | Delivery System Design
 | Decision Support | Clinical Information Systems |
| --- | --- | --- | --- |
|  |  |  |  |
|  |  |  |  |

**Functional**** ****and Clinical Outcomes**

**Productive Interactions**

**Prepared PCP**

**Active Patient**

- -Wagner, 1992

**Notes:**
Physician-Patient(A dyadic “team”)
Importance of a primary care physician capable of performing care coordination function for a patient
Critical in care of seniors and chronic disease
Medical sociology has long understood and studied the relationship between physician and patient and changes throughout history and regulatory environments
Sociolinguistic study of physician-patient communication identifies patterns of effective speech
Organizational theory informs care coordination mechanisms through macro and micro pathways

## Relational Coordination

**Prepared  PCP**

** **
**Active Patient**

**Outcomes and Adherence**

- _Relational Coordination_
- _Communication_
- Frequent
- Timely
- Accurate
- Problem solving
- _Relationships_
- Shared goals
- Shared knowledge
- Mutual respect

**Trust**

- Productive Interactions

- -Gittell, 2002

- -Levin & Cross, 2004

**Notes:**
Extension to the design theories of coordination (Tushman and Nadler, 1978 and Galbraith 1995)
Relational Coordination is a communication and relationship-intensive form of coordination that improves performance in settings where tasks are highly interdependent and where levels of uncertainty and complexity are high (Gittell, 2002, 2004, 2006)
TRUST: tested a dyadic knowledge exchange model-useful knowledge to knowledge seeker under conditions of competence and benevolence-based trust.  Controlling for trust access gained to non-redundant information. Competence-based trust was especially important for the receipt of tacit knowledge.

Extension to the design theories of coordination (Tushman and Nadler, 1978 and Galbraith 1995)
Relational Coordination is a communication and relationship-intensive form of coordination that improves performance in settings where tasks are highly interdependent and where levels of uncertainty and complexity are high (Gittell, 2002, 2004, 2006)

Measures equally weighted dimensions: communication (frequent, timely, accurate and with problem-solving capacity) and relationships (shared goals, knowledge and mutual respect) (Gittell, 2002, 2004, 2006)

## 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?

## Study Population

- Patients 65 yrs 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

## Measures of Quality and Adherence to Treatment:Outcome Variables

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

## Fitted Model = HLM

**Outcome**kmit = 0 + 1PCP-PTRCkmit + 2PCP-PTTrustkmit 		    + 3Time + ..... +nPTCovkmit 			                +1kPCPCareCoordkmit +...+  nkPCPCovkmit  		 +1kmCCM1kmit +...+ 6kmCCM6kmit ... 			 + nkmClCovkmit +...+ i + m + k + kmit
- Where k = associated clinic
- 	m = associated PCP
- 	i = individual patient
- 	t = time

## Analytical Model:

- Chronic Care Model Components

**Improved Patient Outcomes and Adherence**

**Relational Coordination (PCP-Pt.)**

**Trust (PCP-Pt.)**

- Physician Care Coordination Activities

- Physician Characteristics

- Patient Characteristics

## 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