TABLE 4

Theme 3: Structures, Processes, Decisions that Enabled Implementation of Proactive Care Coordination Activities

Structures, Processes, DecisionsExplanatory QuotesSpecific Care Coordination Activity or Activities Enabled
External funding for care coordinator positions and protection of care coordinators’ time“I don’t know that we would really have a care coordinator in our office if we hadn’t had 4 years of the national grant paying for her services, you know, supplementing her salary to show us how valuable it could be. Because at the end of the 4 years, then it was a 7-person, 6-person decision. “Okay, are you willing to keep this as a full-time position and pay?” This is … now, we’re going to have to pay this salary. And it was unanimous.” (Physician in a practice that elected to support the care coordinator position after grant funding expired)Previsit phone calls, care plans, organizing materials, streamlining communication
“I tried for years to do both [care coordination and triage nurse], but I’d be out there, patients were calling; I’d be in here, they’re calling. Everybody was unhappy. So then that was the decision—we’re going to commit to this or we’re not because I can’t work both halves.” (Care coordinator describing the tension between urgent practice needs and care coordination activities)
Creative problem solving by medical home teams, and practice environments that encouraged organizational improvements“And it’s . . . Dr. K [physician champion] will have a great idea and then she’ll meet with us, run it by us . . . and we’re ultimately behind the scenes, planning of all her stuff. . . . It’s always about teamwork and we . . . I think we utilize our strengths very well. We know who’s extremely compassionate, versus extremely knowledgeable, versus extremely whatever else.” (Care coordinator, describing the medical home team dynamics)Organizing family-oriented materials, streamlining referral/communication processes
“[Before,] we didn’t even have a physician referral sheet; they would just grab a piece of paper, write the doctor’s name on it, and we’d look up their phone number. That’s like reinventing the wheel each and every single time. But that’s how it was done. I worked around trying to develop some of the tools that we use today and we take for granted.” (Care coordinator, describing how she identifies recurring issues for improvement)
“But, just . . . the group of doctors that we meet with, once a month. Just kind of say, “Here’s what we’re working on. Here’s what people are saying. Here’s what.” You know, just to kind of meet with them . . . just empowers.” (Care coordinator, describing how she communicates ideas for improvement)
“I think . . . we continue to do quality improvement projects and different things because I think that really, kind of, keeps us focused that way. So when opportunities come along to do something like the youth in transition project and things like that—it’s made me look at my own newborn screening processes and what have you. Those, I think, kind of keep us energized.” (Physician champion)
Visible improvements in everyone’s efficiency“I think a huge big deal was when we started running on time. Consistently.” (Physician colleague of the medical home physician champion)Previsit phone calls, flagging charts for longer visit times to more patients
“I think everyone, kind of, realizes how much it helps and makes our lives easier from the doctor’s standpoint. That we will have someone in this position, I think, always.” (Physician champion)
EMR enhancements“Gosh, that was one of the, the big things that we had with creating our new care plan, which pulls as a report in our system—that was, huge involvement with that. We have a meeting where there would be people who worked with the computer system, would come to that and then there was nurses, providers, care coordinators, everybody kind of coming together to figure out how we could create a tool that would work for us.” (Care coordinator in a practice that recently implemented an EMR)Tracking referrals, care plans
Commitment to attaining medical home recognitionWithin the past year, this whole program has taken off so much more, and I think that what allowed it to do that was having the [medical home] certification process. . . . I think it makes it a lot easier for everybody to get onboard when you have something to work from. (Physician in a practice receiving enhanced reimbursement from a state-level medical home program)Previsit calls, care plans, referral tracking