Monitoring Resource Utilization in a Health Care Coordination Program

Area of Science:

• Health Services Research
• Health Informatics
• Care Coordination

Background:

• Effective health care coordination is crucial for managing complex patient needs, particularly for those with chronic conditions.
• Existing frameworks for care coordination require systematic documentation to measure resource utilization and patient engagement.

Purpose of the Study:

• To develop and implement a health care coordination intervention and documentation system using the Agency for Healthcare Research and Quality (AHRQ) Care Coordination Atlas framework.
• To analyze the time and touch data collected through the developed system for Medicare and Medicaid patients.

Main Methods:

• Development of a documentation system based on AHRQ domains for a Centers for Medicare & Medicaid-funded project (Leveraging Information Technology to Guide High-Tech, High-Touch Care - LIGHT).
• Allocation of 8,593 Medicare, Medicaid, or dual-eligible patients into four tiers based on chronic conditions and utilization.
• Deployment of 25 registered nurse care managers (NCMs) across 10 clinics at an academic medical center.

Main Results:

• The majority of NCM activities (79% time, 61% touches) focused on communication, assessing needs/goals, and facilitating transitions.
• Higher patient tiers (Tier 3 and 4) received significantly more NCM time per member compared to lower tiers.
• Tier 2 patients, despite not requiring routine protocol touches, consumed 48% of NCM time (57 minutes/member).

Conclusions:

• The AHRQ Care Coordination Atlas provided a systematic approach to developing a documentation system for measuring NCM time and touches.
• Utilizing a structured framework enhances strategic thinking in care coordination, with implications for improving overall care delivery.
• Documenting the type and duration of care coordination activities is essential for reimbursement, payer communication, and guiding practice decisions.