Collaborating to Improve the Coordination of Care


In June 2016, the Massachusetts eHealth Institute (MeHI) announced that Cape Cod Healthcare (CCHC) had been awarded a Connected Communities grant to improve the coordination of care for patients living in Cape Cod. CCHC collaborated with ECG to help manage the care coordination improvement project and facilitate interactions with the large, diverse group of stakeholders. CCHC, ECG, MeHI, and representatives from Mass HIway, worked with collaborating organizations to identify breakdowns in care and implement new processes to improve communication through technology. At the start of the project, CCHC facilities used paper-based processes to exchange clinical discharges and lacked the ability to track the receipt of exchanged information.

the challenge

ECG collaborated with the project stakeholders to establish a steering committee that included sponsors from CCHC’s clinical, IT, finance, and operations departments. The steering committee identified two use cases to be the focus of the project: use case one included sending electronic continuity of care documents (CCDAs) from CCHC to post-acute care collaborators (e.g., skilled nursing facilities, rehab centers) upon a patient’s discharge, while use case two included sending CCDAs from CCHC to PCPs or community health centers. Of the more than 30 organizations that were considered for the project, 15 ultimately decided to participate as collaborating partners.

the process

The grant from MeHI stipulated that grantees must organize work into four predetermined milestones. ECG was responsible for understanding these requirements and working with the necessary stakeholders to facilitate the completion of the activities and collection of documentation for each milestone. The four milestones for this care coordination improvement initiative included the following:

Milestone One

  • Assessed current-state workflows, policies, security, and IT capabilities
  • Developed standardized CCDAs, future-state workflows, and testing plans
  • Sent test electronic CCDAs through Mass HIway

Milestone Two

  • Instituted new processes to send/receive electronic CCDAs through Mass HIway
  • Evaluated opportunities for improving workflows/outcomes
  • Developed process improvement plans

Milestone Three

  • Implemented process improvement plans
  • Established metrics and developed custom reports to monitor performance

Milestone Four

  • Monitored transaction performance
  • Adjusted workflows and policies
  • Developed expansion plans

For each milestone, ECG organized a networking event at CCHC where representatives from MeHI, Mass HIway, and each of the collaborating partners would meet to review the project status, share lessons learned, receive education regarding industry trends or regulatory changes, and network with one another.

the outcome

The project goal was to transmit 80% of CCDAs electronically to the PAC organizations at the time of patient discharge. This was measured by calculating the number of CCDAs successfully sent from CCHC’s EHR (Cerner) to a collaborating organization via Mass HIway over the total number of outbound referrals sent to the same collaborating organization. Because this information came from two disparate data sources, it was incumbent upon CCHC to develop a custom report to measure the performance. Initially, only roughly 60% of CCDA were sent within the target parameters, but after making adjustments to workflows and how data was being measured, the overall 80% goal was achieved.

Perhaps the most valuable aspect of this report from an operations standpoint was that CCHC could now pinpoint which referrals did not have CCDAs electronically sent upon discharge and troubleshoot accordingly.

As a result of the project, CCHC is well positioned to expand these processes to many more PAC organizations across Cape Cod and improve performance with existing partners, with a long-term goal of transmitting 100% of CCDAs electronically to all referral partners.

ECG managed the overall project plan, including timeline, issues/risks, budget, and decision-making needs; worked closely with the collaborating organizations to ensure they completed the necessary tasks for each milestone; and prepared/submitted the necessary documentation for each milestone. As a result, CCHC was able to successfully meet the grant’s requirements to receive full funding, automate and track CCDAs sent to collaborating organizations, strengthen relationships with fellow care providers, and establish a foundation for more coordinated care and better clinical outcomes in the future.

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