721 - Process Measures in Complex Care Coordination Quality Improvement within the Primary Care Setting

Three pilot primary care practices were enrolled for 2 years in a Medicaid-funded nurse care coordination project to create shared plans of care for 100 CMC each.  Nurses were trained and coached by an interdisciplinary leadership team, through didactic sessions, quality activities and case-based coaching to guide management of their patients.  They utilized a web-based registry platform to log key processes: enrollment of patients, direct family contacts (figure 1), reassessments of shared plans (figure 2) and sharing of plans with other stakeholders.  Coaches performed a 20-item audit, with each item scored as 2= present, 1=partial, or 0=not present for a maximum score of 40, on a sampling of shared plans each month to evaluate quality of the plans and highlight areas for improvement (figure 3).  Care coordinators received monthly individual and group quality reports of these key measures to direct their own plans for improvement. Data was measured and reported for a 10-month period to date. 

Results: Turnover in one CC occurred during the measurement period, which impacted average scores attributed to the 2-month gap period.  The remaining two CC’s were able to rise to meet and maintain the family contact and shared plan reassessment goals steadily during the last quarter.  Shared plan of care audit scores jumped immediately upon initiation of audit process and remained high.

Conclusion(s): This measurement process and its indicators created positive and sustained improvements in care coordinator workflow and ability to reach quality metric goals.  Plan auditing methods were refined for the coming year to create stretch goals.