Write an executive summary of a recent (within the past 2 years) article from the CTU Online Library related to healthcare policy processes that is center

1Hempel S, et al. BMJ Open 2023;13:e060232. doi:10.1136/bmjopen-2021-060232

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Care coordination across healthcare systems: development of a research agenda, implications for practice, and recommendations for policy based on a modified Delphi panel

Susanne Hempel ,1 David Ganz,2,3 Sonali Saluja,4 Maria Bolshakova,1 Timothy Kim,5 Carolyn Turvey,6,7,8 Kristina Cordasco,9 Aashna Basu,3,10 Tonya Page,11 Reshma Mahmood,12 Aneesa Motala,1 Jenny Barnard,9 Michelle Wong ,9 Ning Fu ,1,13 Isomi M Miake- Lye14,15

To cite: Hempel S, Ganz D, Saluja S, et al. Care coordination across healthcare systems: development of a research agenda, implications for practice, and recommendations for policy based on a modified Delphi panel. BMJ Open 2023;13:e060232. doi:10.1136/ bmjopen-2021-060232

► Prepublication history and additional supplemental material for this paper are available online. To view these files, please visit the journal online (http://dx.doi.org/10.1136/ bmjopen-2021-060232).

Received 16 March 2022 Accepted 03 April 2023

For numbered affiliations see end of article.

Correspondence to Dr Ning Fu; ningfu27@ hotmail. com

Original research

© Author(s) (or their employer(s)) 2023. Re- use permitted under CC BY- NC. No commercial re- use. See rights and permissions. Published by BMJ.

ABSTRACT Objective For large, integrated healthcare delivery systems, coordinating patient care across delivery systems with providers external to the system presents challenges. We explored the domains and requirements for care coordination by professionals across healthcare systems and developed an agenda for research, practice and policy. Design The modified Delphi approach convened a 2- day stakeholder panel with moderated virtual discussions, preceded and followed by online surveys. Setting The work addresses care coordination across healthcare systems. We introduced common care scenarios and differentiated recommendations for a large (main) healthcare organisation and external healthcare professionals that contribute additional care. Participants The panel composition included health service providers, decision makers, patients and care community, and researchers. Discussions were informed by a rapid review of tested approaches to fostering collaboration, facilitating care coordination and improving communication across healthcare systems. Outcome measures The study planned to formulate a research agenda, implications for practice and recommendations for policy. Results For research recommendations, we found consensus for developing measures of shared care, exploring healthcare professionals’ needs in different care scenarios and evaluating patient experiences. Agreed practice recommendations included educating external professionals about issues specific to the patients in the main healthcare system, educating professionals within the main healthcare system about the roles and responsibilities of all involved parties, and helping patients better understand the pros and cons of within- system and out- of- system care. Policy recommendations included supporting time for professionals with high overlap in patients to engage regularly and sustaining support for care coordination for high- need patients. Conclusions Recommendations from the stakeholder panel created an agenda to foster further research,

practice and policy innovations in cross- system care coordination.

INTRODUCTION Care coordination has received much prac- tical and research attention, and its role in integrating clinical services is of critical importance to ensure safe and effective patient care.1 The care coordination litera- ture derived from integrated delivery systems often focuses on coordination within a single healthcare system, such as improving inter- action between primary care and specialty

STRENGTHS AND LIMITATIONS OF THIS STUDY ⇒ Coordinating patient care across different healthcare delivery systems presents considerable challeng- es for healthcare professionals, and we convened a 2- day stakeholder panel, preceded and followed by surveys and informed by literature, to formulate concrete recommendations for research, practice and policy supporting healthcare organisations.

⇒ Some of the practice and policy recommendations may be aspirational for some organisations; howev- er, panellists took limited organisational resources into account throughout the process and prioritised recommendations to identify the most important steps to meaningfully improve and support care co- ordination across healthcare systems.

⇒ While we used a structured and framework- driven approach to stakeholder selection and convened a large panel with a broad range of stakeholders, undoubtedly, some perspectives of the complex care coordination between systems will have been missed, and we hope that future research will further investigate care coordination established across healthcare systems and different care deliv- ery organisations.

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care providers. Efforts within systems include shared soft- ware and business processes to foster interdepartmental coordination. However, as demonstrated by network analyses that capture patient sharing between healthcare providers, care coordination across healthcare systems is an increasingly common clinical scenario.2 Such coordi- nation may include management of chronic conditions by primary care with periodic input from external special- ists.3 Other common areas of collaboration between healthcare delivery systems are cancer care4 and palliative care.5

Care coordination across healthcare systems cannot always use the same approaches as those used within a single system and instead may include introducing new software designed to facilitate coordination, such as web- based communication tools that can be accessed by healthcare professionals from all systems.6 These online tools create a secure, virtual space for care professionals and sometimes include patients and caregivers in the communication. Results across evaluation studies are mixed, with some authors concluding that tool imple- mentation is feasible but sometimes of limited use to healthcare professionals. An evaluation of an accountable care organisation concluded that formal clinical integra- tion may be insufficient to improve patient outcomes.7

We engaged stakeholders in an expert panel process to articulate an agenda for improving care coordination across healthcare delivery systems, from the vantage point of a large integrated healthcare system needing to coor- dinate care with external healthcare entities that do not share administrative or medical infrastructure. We formu- lated concrete recommendations for research, practice and policy.

METHODS We developed a detailed workplan that guided a 1- year process. The modified Delphi stakeholder panel used online surveys and video- assisted, moderated discussions and was informed by a rapid literature review.

Rapid review A rapid review aimed to identify examples of care coor- dination approaches between healthcare systems and organisations to learn more about tested communication tools and strategies. There is no accepted nomenclature for care coordination, and the existing literature is domi- nated by coordination approaches within healthcare systems; hence, we applied a strategic search to identify relevant studies. We used four key publications selected by project staff to represent different aspects of care coordi- nation research (clinical integration, implementation of technological advances, social network analysis of provider relationships and interpersonal relationships between providers) as seed articles for a forward search.1 2 6 7 We screened studies included in 127 systematic reviews on care coordination to obtain a broad range of care coordination approaches.3–5 8–131 The reviews addressed

common chronic conditions managed in primary as well as specialty care, cancer care, palliative care, comorbidity and complexity, personnel specialising in care coordina- tion, frameworks and strategies to promote coordination, technology supporting coordination, settings for tempo- rary care such as emergency departments and care models applied to specific populations. The online supplemental appendix describes the methods and results of the rapid review in detail. We used the rapid review to prepare for the stakeholder panel meetings, made the results of the review available to stakeholders and summarised the find- ings during the panel meetings.

Analytical model The project team designed an analytical model that anchored the care coordination discussions with three scenarios and that introduced the idea of a main inte- grated organisation with external healthcare profes- sionals providing additional care outside of the primary network. Throughout the study, we used the Veterans Health Administration (VHA) as an example of a main healthcare delivery organisation that has significantly expanded its network of external providers over the years, allowing patients to use selected external healthcare providers to reduce waiting times and otherwise address patient needs, in particular since the introduction of the Maintaining Internal Systems and Strengthening Inte- grated Outside Networks Act.132 However, the panel’s goals were to advance care coordination across systems, an objective relevant not just to VHA but also to private- sector integrated delivery systems whose patients may receive out- of- system care (eg, for emergencies or when the main system contracts with an external organisation to deliver care).133

Our analytical framework is depicted using three scenarios in figure 1. The scenarios capture the multi- level aspect of care coordination, which includes patients, healthcare professionals, and the main healthcare delivery system or organisation. For simplicity, coordi- nation is depicted as occurring across two systems, with the understanding that, for complex situations, coordina- tion may need to occur across more than two entities. We also developed a glossary of key terms for panellists, also shown in the online supplemental appendix. The three care coordination scenarios include

► Scenario 1: intense care coordination—coordinating the care of individual, high- need patients who require frequent and high levels of care across different healthcare delivery systems.

► Scenario 2: ad hoc care coordination—an unexpected need to communicate across healthcare delivery systems (eg, abnormal lab value is identified by one professional that should be communicated to the other healthcare professional).

► Scenario 3: high overlap in patients—coordinating care between two healthcare professionals in different healthcare delivery systems who share a large number of patients.

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We hypothesised that the scenarios may warrant different approaches to care coordination; for example, there may be differences in the amount of investment into care coordination improvement and technology.

Stakeholder panel We reviewed stakeholder engagement models and adopted a model appropriate for public health, which includes four types of stakeholders: health services providers, decision makers, community representatives and research represen- tatives.134 Within stakeholder categories, we approached potential representatives and ensured that the panel was multidisciplinary and represented different levels within organisations. The online supplemental appendix table documents all 16 participating panellists.

Consensus finding The consensus- finding procedure adhered to principles of consensus methods for medical and health services research: anonymity (private ranking or voting to avoid dominance issues in the group), iteration (multiple rounds to allow individuals to change their opinions after discussions), controlled feedback (feedback of the group response after each rating round) and statistical group response (provision of summary measures of the group response).135 We used an online prepanel survey to elicit input from panellists to prepare the panel meeting. Fifteen panellists provided prepanel input (response rate 94%). The survey addressed available communication methods (formal and approved methods in the organ- isation as well as workarounds not sanctioned by the organisation but used to ensure communication with the external care professional), experience with approaches to foster informal interaction between healthcare profes- sionals to support coordination, unintended conse- quences of care coordinated between multiple healthcare professionals, and the different aspects and layers of care coordination. All survey questions were open to all panel- lists, as all panellists were felt to have sufficient insight into care coordination processes (eg, patient representatives,

although not engaging in ‘provider to provider’ commu- nication, stated their preference for how they preferred their providers to communicate with one another). The panellists also received the results of the rapid review, and we made key resources available on a secure site for all team members and panellists. Results of the survey were presented during the panel in aggregate format, including points of agreement and disagreement across panellists.

We convened two panel meetings of 5 hours each. Although originally planned as an in- person meeting, both meetings were held online due to COVID- 19 restric- tions. The two meetings were held in the same week, on the first and last days of the week. The first panel meeting included presentations and discussions, while the second panel meeting asked panellists to vote on themes identi- fied in the first meeting. The first panel meeting provided panellists with some background on the topic; an intro- duction of all team members and panellists; the status of the Veterans Health Administration Health Information Exchange, a system designed to support care coordina- tion across VHA and (external) community providers; the findings of the rapid literature review; a presentation of the three coordination scenarios; results from inter- views conducted within VHA with a specific focus on rural health; feedback from the prepanel survey; and a summary of the panel goals.

Three formal rounds of discussions in the first panel meeting focused on strategies for informal relationship- building among providers from different healthcare systems; communication methods; and the present state of care coordination across systems, focusing on what is working and what is not working for care coordination with current methods and approaches, from the panel- lists’ perspectives. Five discussion rounds on the second panel meeting day addressed the domains of care coor- dination, unintended consequences of (poor) coordina- tion, the future research agenda, implications for practice and recommendations for policy. Discussions were

Figure 1 Analytical framework.

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moderated by experienced moderators who ensured that a variety of perspectives were heard and panellists stayed on topic. Following an approach used for RAND appro- priateness panels, no attempt was made to force the panel to consensus. Instead, the discussions explored all view- points and tried to clarify terms and concepts. We used online technology to provide instant feedback. The panel meetings were attended by the panellists as well as five observers and two external presenters who added to the discussions.

A postpanel survey consolidated the findings of the panel meeting. Eleven panellists (69%) completed the postpanel survey. The survey was completed by each panellist individually to avoid situational groupthink and to consolidate the panel findings independently. To orient panellists, we used VHA as an example of a main healthcare system and termed professionals and community providers delivering outside care external healthcare providers. However, the input was geared towards making recommendations that are not specific to a selected organisation but that are applicable to different healthcare delivery systems that share care. The survey included recommendations for research, practice and policy drafted by the review team following the panel discussions. The survey used a 5- point rating scale throughout that assessed the importance of the presented items, ranging from not important (1) to very important (5). We used a cut- off of a mean value of 4.5 across panellists to select items as important. For the method of communication, one- way analysis of variance was performed to test for differences in means between the three coordination scenarios.

RESULTS Data were collected in the prepanel meeting survey, during the meeting and the postpanel meeting. Here we present the final results, that is, those that are based on the last consolidating round of panel input, preceded by a round of prepanel ratings and video- assisted discussions during the panel meetings.

Dimensions of care coordination We asked panellists about the importance of 16 dimen- sions of care coordination, all based on published liter- ature, suggestions from individual panellists and panel discussions. Panellists rated the method of communication, the organisational mechanism, the urgency of communication, the scope of coordination, the interpersonal aspect of coordi- nation and organisational culture (the healthcare system support for coordination) as key aspects of coordination (see figure 2).

Communication methods The most commonly used method of communication between healthcare professionals to achieve coordination was phone calls (87%). A large proportion of the panellists used secure messaging (53%), email (47%), in- person commu- nication (40%) and shared software (40%). The use of a web platform for care coordination (33%), call centre (33%), fax (27%), and letter/mail (27%) was also selected multiple times (table 1).

Panellists’ preferences for interprofessional communi- cation included phone, in- person, direct communication, email, secure messaging, text, shared online portal, video, shared web- based services, commercial collaboration soft- ware (Microsoft Teams), commercial communication software (Epic messaging), and a platform that allows

Figure 2 Care coordination domains. Domain content (mean (SD)) on a scale from 1 to 5.

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uploading of information and other electronic health information exchange capabilities. Some panellists indi- cated that the preferred method depended on the type of information, the situation or the purpose. Among all 22 communication modalities, there were no significant differences in mean preference ranking between the three scenarios; that is, we found no evidence that the communication method differed systematically by the three scenarios (intense care coordination, ad hoc care coordi- nation and high overlap in patients). One panellist preferred phone calls for ‘real- time issues’, and another panellist responded that some conversations warrant face- to- face interaction; otherwise, calls and emails work. One panel- list indicated it depends on the urgency of the need, and urgent issues required calls; otherwise, email would work. Panellists indicated it depends on whether the purpose is communication, coordination or collaboration. For collaboration, a platform that allows uploading informa- tion is needed (ideally with video or phone interface); for other purposes, phone calls are fine.

Furthermore, we asked about healthcare professionals’ use of strategies of communication and coordination that are not approved in their healthcare delivery system. Examples of these ‘workarounds’ were texting and using email. This included using day- to- day communication tools such as smartphones, for example, to check with another provider whether a patient had followed through and had made an appointment as suggested, or to check whether results of tests were coming on time for an upcoming appointment. Reasons for using workarounds were typically ease of use of the standard tools in time- pressing matters and the availability to communicate quickly without additional sign- in procedures when there were no confidentiality concerns because no details had to be shared.

Support to foster collaboration Twenty per cent of panellists indicated that there was only minimal or no support in their respective organisa- tions for external communication, care coordination and

Table 1 Frequency and preference for communication methods used in care coordination

Modality Frequency of use (%)

Preference ranking scenario 1 (intense coordination)

Preference ranking scenario 2 (urgent, unplanned communication)

Preference ranking scenario 3 (high overlap)

Phone call 87 4.10 4.30 4.18

Secure messaging 53 4.60 4.50 4.60

Email 47 4.10 4.00 3.91

In- person communication 40 4.20 4.20 4.00

Shared software 40 4.40 4.40 4.36

Web platform for care coordination 33 4.30 4.50 4.36

Call centre 33 3.30 3.30 3.00

Fax 27 2.67 2.60 2.55

Letter/mail 27 2.80 2.50 2.55

Email list 20 3.90 3.90 3.82

Pager 13 2.60 2.70 2.36

Text messaging (personal phone) 20 2.30 2.60 2.45

Text messaging (work phone) 13 4.00 3.80 3.64

Smart phone app 7 4.30 4.10 4.00

Messenger (third party) 13 3.11 3.00 2.82

Patient- held records 20 2.60 2.60 2.64

Video coordination (organisational system)

13 3.90 3.70 3.55

Commercial video (Zoom) 7 3.70 3.30 3.36

Duplicate health record 20 3.40 3.00 2.64

Other, query- based exchange in health information exchange system

7 3.80 3.50 4.00

Other, Veterans Health Information Exchange

7 4.00 3.40 3.91

Other, Microsoft Teams 7 3.78 3.80 3.91

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collaboration such as web portals, and pager and phone arrangements to make healthcare professionals acces- sible to partners in other health systems.

Participants reported very few informal initiatives for cross- system communication, that is, occasions charac- terised by informal interaction and relationship- building without focus on a particular patient or a specific care issue to solve. Similarly, only few studies identified in the rapid literature review described relevant initia- tives. Where studies mentioned initiatives, these were most often informal gatherings such as meet- and- greet lunches136–139 or training and didactic sessions for topics of shared interest.140–143 Other studies relied on a shared care facility promoting communication due to proximity.144–148

Unintended consequences While the literature cited many examples of the positive effects of care coordination, panellists also noted some unintended consequences. We differentiated between potential unintended consequences for patients and for healthcare professionals, and asked panellists to consider both perspectives. For professionals, panellists addressed burden, role confusion, miscommunication of health infor- mation leading to inaccurate care plans, patients pitting healthcare professionals against one another and healthcare professionals pitting patients against another professional.

For patients, panellists rated ambiguity of whom to contact for care needs, uncertainty of care processes, mixed messages from different professionals, delays in care (eg, professionals may wait to discuss care plans with each other first), miscommunication leading to misunder- standings, enhanced communication and collaboration disliked by patients (eg, patients not appreciating being the subject of discussion among providers), and confidenti- ality concerns. Although all items were rated as somewhat

important, none met the prespecified threshold, indi- cating that the item is ‘very important’.

Recommendations A key aim of the stakeholder panel was to identify targets for research, practice and policy. Panellists rated a large number of potential recommendations shown in the online supplemental appendix. The recommendations were based on the reviewed literature and the panel discussions on the first panel meeting day.

Figure 3 documents the 10 research recommendations selected by the panel. Recommendations for research centred around needed data on and measures of shared care and workflow, the role of patients in care coor- dination and explorations into better understanding healthcare provider needs. Throughout the study, recom- mendations stressed that needs may well be different for different care scenarios (eg, frequency of likely coordina- tion needs). Specifically, identified research recommenda- tions targeted the development of measures of shared care between professionals in the main healthcare delivery system and the external healthcare professionals such as the proportion or absolute numbers of patients shared between two care providers. Further research is needed that identifies coordination scenarios in which the additional expense and time associated with team care are warranted. Studies should evaluate patient experiences of care coordina- tion across separate healthcare delivery systems. We also need more information on the proper and improper uses of patient engagement to coordinate care, that is, to deter- mine how much we should expect patients to participate in care coordination versus how much should be owned by the providers/systems caring for the patient. Studies are further needed to understand the external profes- sionals’ needs and preferences better in relation to inter- facing with the main healthcare delivery system’s services.

Figure 3 Recommendations.

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Furthermore, organisations should evaluate roles/responsi- bilities of the main healthcare delivery system’s clinicians, administrators, external care and third- party administra- tors, for example, look for gaps or overlap. To advance care coordination, we need to conduct ongoing, real- time evaluation of changes to care coordination processes being implemented in the field, given that care coordination and available tools is a fast- moving field. The panel also agreed that it is imperative that studies produce replicable care coordination data and data validation, such as organisations tracking referrals and follow- up. Furthermore, organi- sations should evaluate their workflow practices to ensure closed- loop communication. Finally, the panel agreed that evaluating the comparative effectiveness of interventions to improve care coordination is a research priority.

The panel also made eight recommendations that should be implemented in routine practice (see figure 3). Recommendations addressed education of healthcare professionals in the main healthcare system as well as educating the external providers. Specifically, panellists agreed that it is critical to educate main and external healthcare professionals how to use the latest communica- tion technology, including electronic health information exchanges. Panellists