Care coordination for senior patients with multiple chronic diseases: Examining the association between organizational factors and patient outcomes.

摘要

The Institute of Medicine has identified care coordination as a national priority to improve the quality of care. Care coordination is critical for senior patients who are challenged by our fragmented healthcare delivery system. Many senior patients have multiple chronic conditions, receive care from numerous providers across different care settings, and take multiple prescriptions. The primary care physician (PCP) is in a unique position to coordinate care and the Chronic Care Model (CCM) purports to optimally support the PCP.;The CCM posits that the redesign of physician practice organizations will result in effective physician-patient interactions and subsequently improved patient outcomes. Physician-patient relational coordination and trust, which are not included in the CCM, may play a significant role in facilitating these productive interactions between physicians and patients envisioned by the CCM framework. Therefore, the theories of RC and trust within the CCM framework guide this research.;This study evaluated quantitatively the association between the Chronic Care Model components and PCP relational coordination and trust, and nationally recognized quality measures using patient and organization data from a single, multispecialty medical group with an Independent Practice Association division. The main research questions examined in this study were the following: (1) do the CCM components predict quality outcomes, (2) do PCP relational coordination and trust predict quality outcomes and (3) do RC and trust moderate patient risk covariates such as low levels of education, etc.?;The patient population was composed of managed care Medicare beneficiaries with diabetes and at least one additional chronic condition receiving care from this organization between 2004 and 2007. Longitudinal analyses were conducted using four years of medical claims and physician satisfaction data from the study organization, incorporating proxy variables (PCP communication and coordination scores) for relational coordination (RC) and trust. Cross-sectional analyses utilized primary data assessing CCM, RC and trust that were linked with respondents' 2007 claims data. The cross-sectional analyses also examined two additional outcome variables---"end of life" discussions with PCP and overall PCP satisfaction---derived from the patient survey.;In all fitted Hierarchical Generalized Linear Models (HGLM) using longitudinal data and examining the log odds of the diabetes quality measures, PCP communication and coordination (combined as the proxy variable for RC) was a significant predictor. In the fitted HGLM using the cross-sectional survey-linked data, PCP RC moderated the negative impact on the diabetes quality composite measure from low education of the patient (p=0.04). Both RC and trust were significantly associated with the probability of patients having "end of life" discussions with their PCP (p=0.03). Lastly, the logisitic model fit with the CCM component scores from 24 clinics, 81 PCPs and 408 patients found the overall chronic care model score and the score for self-management support significant (p = 0.07 and 0.03 respectively). In this fitted model the combined variable for high RC and trust did not reach statistical significance although the coefficient was positive. Additionally, statistically significant correlations were found between the proxy variable of PCP coordination/communication examined as a key predictor in the longitudinal analyses, and RC and trust examined as key predictors in the cross-sectional analyses.;In summary, this study found a strong association between high levels of PCP communication/coordination and diabetes quality composite measures in a senior population with significant disease burden. Moreover, the study found that PCP relational coordination and trust play an important role in "end of life" discussions with patients. Finally, the study supports previous research which highlights the importance of the self-management component within the CCM.;Given the growing prevalence of multiple chronic conditions among the elderly, this study provides evidence to support reimbursement for care coordination within primary care. The study also supports the current emphasis on the expansion of patient-centered medical homes within an infrastructure of the Chronic Care Model. Finally, the role of PCP partnership including RC and trust is critical to meaningful discussions with patients in primary care settings when patient preferences and options can be fully explored and prior to an emergent medical crisis.