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  1. Popejoy, Lori L. PhD, APRN, GCNS-BC
  2. Jaddoo, Julie BSc, CIS
  3. Sherman, Jan PhD, APRN, NNP-BC
  4. Howk, Christopher BA
  5. Nguyen, Raymond MS
  6. Parker, Jerry C. PhD


Purpose of the Study: This initial article describes the development of a health care coordination intervention and documentation system designed using the Agency for Healthcare Research and Quality (AHRQ) Care Coordination Atlas framework for Centers for Medicare & Medicaid-funded innovation project, Leveraging Information Technology to Guide High-Tech, High-Touch Care (LIGHT2).


Primary Practice Setting(s): The study occurred at an academic medical center that serves 114 counties. Twenty-five registered nurse care managers (NCMs) were hired to work with 137 providers in 10 family community and internal medicine clinics.


Methodology and Sample: Patients were allocated into one of the four tiers on the basis of their chronic medical conditions and health care utilization. Using a documentation system on the basis of the AHRQ domains developed for this study, time and touch data were calculated for 8,593 Medicare, Medicaid, or dual-eligible patients.


Results: We discovered through the touch and time analysis that the majority of health care coordination activity occurred in the AHRQ domains of communication, assess needs and goals, and facilitate transitions, accounting for 79% of the NCM time and 61% of the touches. As expected, increasing tier levels resulted in increased use of NCM resources. Tier 3 accounted for roughly 16% of the patients and received 159 minutes/member (33% of total minutes), and Tier 4 accounted for 4% of patients and received 316 minutes/member (17% of all minutes). In contrast Tier 2, which did not require routine touches per protocol, had 5,507 patients (64%), and those patients received 5,246 hours of health care coordination, or 57 minutes/member, and took 48% of NCM time.


Implications for Case Management:


1. The AHRQ Care Coordination Atlas offered a systematic way to build a documentation system that allowed for the extraction of data that was used to calculate the amount of time and the number of touches that NCMs delivered per member.


2. Using a framework to systematically guide the work of health care coordination helped NCMs to think strategically about the care being delivered, and has implications for improving coordination of care.


3. For the purpose of reimbursement and communication with payers about quality metrics, it is vital that the type of touches and amount of time spent in delivering care coordination be documented in a manner that can be easily retrieved to guide practice decisions.