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Care Coordinator Quality Metrics

Quality improvement in care coordination seeks to standardize processes and structure to reduce variation, achieve predictable results, and improve outcomes. The didactic series provides an introduction to the basic methodology including the “Plan, Do, Study, Act” model for improvement. Monthly quality indicator reports are generated to identify and monitor individual and program improvements. Coaching translates quality improvement theory into real world applications to support tailored individual nurse change talk and subsequent actions.

IC4 measures processes and outcomes to propel each nurse care coordinator's skill development. Key process measures address the frequency of contacts with enrolled families, periodicity of updates to plans of care, and plan of care distribution. Outcome measures focus on the care coordinator logging of targeted key activities, such as obtaining needed equipment and supplies, coordination between multiple health visits and procedures and completion of home and community based or supplemental security income applications or other family identified needs. Additional outcome measures include semi-annual family satisfaction and primary care team surveys. Family responses are collected electronically by the university team with a goal of 20 family responses per participating practice each cycle. Families receive nominal reimbursement in thanks for their participation. Practices received anonymous collated reports each cycle. Team survey responses are collected electronically, anonymously collated and reported back to practices each cycle.

Quality Indicators

  • Enrollment and maintenance of a full registry of 100 patients.
  • Documentation of a first month coordination outcome for each family enrolled.
  • Quarterly contact with each patient.
  • Shared Plan of Care updates semi-annually for each patient, with content accuracy demonstrated by coach audits scores on a monthly sampling.
  • Dissemination of SPoCs across each patient's care neighborhood semi-annually to at least 2 parties.
  • Semi-annual family satisfaction surveys evaluate persistent unmet needs, and family perceptions of their receipt of medical home and care coordination services and the efficacy of their shared plans of care.
  • Semi-annual primary care team surveys evaluate team member perceptions of their delivery of services to families as well as the time burden of care for complex patients and team member wellness.