Program Implementation Approaches to Build and Sustain Health Care Coordination for Type 2 Diabetes

Abstract

This article adds new insights into strategies promoting effective care coordination. The strategies that grantees implemented throughout the program align with ACA requirements, underscoring their relevance to the changing U.S. health care environment and the likelihood of further support for program sustainability.

Barriers and Facilitators in Implementing Non-Face-to-Face Chronic Care Management in an Elderly Population with Diabetes: A Qualitative Study of Physician and Health System Perspectives

“…The current study found that providers valued CCM as a key component of care that supports patient self-management of their chronic conditions. Sharing of electronic health data as a necessary facilitator of CCM was a consistent finding for this study and in the wider literature [ 17 , 18 , 23 , 24 ] on CCM. In contrast to this study which focused on NFF encounters in primary care, another qualitative study on care management focused the importance and the limitations of EHR in the coordination of care across practices [ 24 ].…”

“…A study by Lewis and colleagues found that care management enhanced patient empowerment and addressed local barriers and individual needs with coordination of resources from a variety of settings [ 7 ], whereas the present results indicated that coordination of multiple programs addressing diabetes and its complications may hinder accessing the benefits of care management due to complex systems. Another qualitative study focusing on care coordination for insulin initiation in patients with diabetes explored different clinician perceptions of roles as they pertained to developing relationships with clear communication, trust, and respect [ 18 ]. Our results indicated that physicians and health system staff are often overwhelmed by the large volume of patients, but also concerned that patients feel they are receiving care from someone that they know and trust, as opposed to someone from another region of the country.…”

“…Given that chronic care management is intended to improve both health service delivery and patient quality of life, research into facilitators of chronic care management has grown in recent years. This has resulted in the identification of several domains of interest: health information systems development [ 17 , 18 , 19 ], organized channels of communication [ 6 , 20 , 21 ], collaboration with specialists such as endocrinologists [ 22 , 23 , 24 ], relationship building with patients to improve engagement [ 6 , 25 ], involvement of community health workers and/or educators [ 20 , 26 , 27 ], telemedicine such as remote screenings [ 28 , 29 , 30 ], medication management [ 21 , 31 ], and establishment of clinic-community collaborations [ 6 , 18 ]. Potential barriers to implementing CCM programs include challenges addressing social needs of the patient that impact their self-management ability [ 6 ] and establishing provider buy-in for new processes and procedures [ 18 ].…”

Examining the effect of the individual characteristics of implementers and the interaction of multiple relationships on the structure of psychosocial intervention teams

“…Program success depends on the proper coordination among the implementers [14]. Recent studies highlight the importance to deeply understand the interaction patterns connecting the implementers.…”

Care coordination to target patient complexity and reduce disparities in primary care

“…Many models conceptualize patient complexity as number of diseases and calculation of complexity is not necessarily tied to care coordination processes (Boult et al, ; Huntley, Johnson, Purdy, Valderas, & Salisbury, ). Other models target users of high‐cost hospital services (LaPointe, ), focus on one disease such as diabetes (Fitzgerald et al, ), do not address social determinants, or fail to integrate physical and mental health services (Woltmann et al, ). Evaluation of these models and the way they quantify patient complexity is still in the early stages (Izumi et al, ).…”