Skip Navigation LinksHome > September 2012 - Volume 30 - Issue 9 > LONGITUDINAL CARE PLANNING AND COORDINATION IN LONG-TERM AND...
CIN: Computers, Informatics, Nursing:
doi: 10.1097/NXN.0b013e31826b8bc0


Alexander, Gregory L. PhD, RN, FAAN; Hull, Susan C. MSN, RN

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The authors have disclosed that they have no significant relationship with, or financial interest in, any commercial companies pertaining to this article.

Engaging patients and families over time and across multiple settings with longitudinal care planning, coordination, and measurement has long challenged the healthcare community. As nurses and informaticists, we are in key positions to contribute to further defining models, standards, and measures as well as innovations through mobile, telemedicine, consumer, and community-based solutions.

The Office of the National Coordinator (ONC) for Health Information Technology (HIT) efforts to achieve adoption and information exchange through meaningful use of HIT demonstrate a commitment to addressing these care coordination challenges. For example, stage 2, Meaningful Use regulations, are expected to include an expanded set of measures intended to ensure support for care coordination, including structural measures for care plan goals, patient instructions, and the ability to electronically identify and communicate with healthcare providers. Stage 3, focusing on Advance Care Processes, will likely trigger significant momentum for deeper EHR integration, information exchange, and incorporation of patient-generated data to promote care coordination.

Objectives have been outlined by several organizations depending on the clinical setting to meet these goals. For example, in long-term and post–acute care (LTPAC), one objective is to shape the issue of care coordination and define its relationship to clinical workflow. Another is to increase awareness and participation of experts in national efforts leading to standardization, interoperability, and certification of LTPAC technologies to enhance exchange systems and consistency of information provided between clinical settings. In this brief article, we outline important strategies to facilitate care coordination and workflow in LTPAC settings, which can also be used to influence greater IT adoption and understanding of impacts of information exchange systems.

Strategies to examine workflow issues as technology is incorporated into LTPAC settings include how staff communicates using IT to enhance patient outcomes, clarifying roles, and role shifts that occur as IT use influences networks. For instance, mobile documentation systems are thought to enable better patient care by allowing clinicians to spend more time at the bedside. These assumptions can be tested using clinical workflow analytics that measure time spent in clinical areas, location of where time is spent, work conducted during workflow, and interactions that provide knowledge about information exchanges occurring as clinical care is provided. These analytics illustrate connections between people, graphically demonstrating influences created by IT systems; additionally, these assessments can provide important feedback about other types of communication strategies used in patient care settings. Benchmarks using workflow analytics will become valuable tools as IT pervades patient care and as IT system administrators investigate its impact on outcomes.

Another important strategy for facilitating clinical coordination in LTPAC settings is to facilitate user participation in national efforts to standardize exchange systems and achieve consistency of information transfer. National efforts like the Standards and Interoperability Framework and workgroup community, sponsored by ONC’s HIT Standards Committee,1 are specifying structured data elements to be included in care transitions in diverse care settings. The Longitudinal Coordination of Care Initiative Workgroup, Elements of Transitions of Care, and Plan of Care Use Case for LTPAC are developing use cases to provide examples of how information exchange occurs between acute care settings and LTPAC settings. Expert opinions and participation by clinicians who are directly involved in transitions are needed to support development and enhance usability of these systems. As greater consistency of information transfer is achieved with these systems, patient care outcomes will likely improve, which has been a goal for IT developers in healthcare for a very long time now.

Future briefs will examine strategies and innovation in other settings throughout the care continuum demonstrating progress with longitudinal care planning and coordination. Of interest, the National Quality Forum’s steering committee for Coordination of Care across Episodes of Care and Care Transitions2 recently commissioned a paper titled “Health Information Technology to Support Care Coordination and Care Transitions: Data Needs, Capabilities, Technical and Organizational Barriers, and Approaches to Improvement.” The authors recognize that “an extended set of standardized key data elements, structure, and implementation guidelines to support the broader vision of care coordination and patient-centered care, including the co-management of longitudinal care plans, does not yet exist.”3,*

This article organizes findings according to a framework proposed by Singer et al.4 for “integrated care measurement” that considers both care coordination activities as well as the needs for patient centeredness that function as the basis for the need for IT improvements to serve as an underpinning for the National Quality Strategy.

By defining integrated care as a multidimensional construct rather than one-dimensional “organizational” activities, multiple constructs are considered (1) coordinated within care team, (2) coordinated across care teams, (3) coordinated among care teams and community resources, (4) continuous familiarity with patient over time, (5) continuous proactive and responsive action between visits, (6) patient centered, and (7) shared responsibility.

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1. R1. S&I Framework Initiatives. 2012. Accessed July 23, 2012.

2. National Quality Foundation. Endorsed Definition and Framework for Care Coordination. Accessed July 23, 2012.

3. Samal L, Hasan O, Venkatesh AK, Volk LA, Bates DW. National Quality Forum. Health Information Technology to Support Care Coordination and Care Transitions: Data Needs, Capabilities, Technical and Organizational Barriers, and Approaches to Improvement. Updated April 10, 2012. Accessed July 23, 2012.

4. Singer SJ, Burgers J, Friedberg M, Rosenthal MB, Leape L, Schneider E. Defining and measuring integrated patient care: promoting the next frontier in health care delivery [published online ahead of print June 16, 2010]. Med Care Res Rev. 2011; 68 (1): 112–27.

*Copyright 2012, National Quality Forum. Reproduced with permission. Cited Here...

© 2012 Lippincott Williams & Wilkins, Inc.



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