A Concise Tool for Measuring Care Coordination from the Provider’s Perspective in the Hospital Setting

RESULTS

Among the 1486 acute care professionals asked to participate in the survey, 841 completed the questionnaire (response rate 56.6%). Table 1 shows the characteristics of the participants from each hospital. Table 2 summarizes the item response rates, proportion scoring at the ceiling, and weighting from the factor analysis. All items had completion rates of 99.2% or higher, with N/A responses ranging from 0% (item 2) to 3.1% (item 7). The percent scoring at the ceiling was 1.7% for the global item and ranged from 18.3% up to 63.3% for other individual items.

Factor analysis yielded 3 factors comprising 6, 3, and 2 items, respectively. Item 7 did not load on any of the 3 factors, but was retained as a subscale because it represented a distinct domain related to care coordination. To describe these domains, factor 1 was named the “Teamwork” subscale; factor 2, “Patient Engagement”; factor 3, “Transitions”; and item 7, “Handoffs.” Subscale scores were calculated as the mean of item response scale scores. An overall scale score was also calculated as the mean of all 12 items. Average inter-item correlations ranged from 0.417 to 0.778, and Cronbach alpha was greater than 0.84 for the 3 multi-item subscales (Table 2). The pairwise correlation coefficients between the four subscales ranged from 0.368 (Teamwork and Handoffs) to 0.581 (Teamwork and Transitions). The correlation coefficient with the global item was 0.714 for Teamwork, 0.329 for Handoffs, 0.561 for Patient Engagement, 0.617 for Transitions, and 0.743 for overall scale. The percent scoring at the ceiling was 10.4% to 34.0% for subscales.

We used the new subscales to explore the perception of inpatient care coordination among healthcare professionals that were involved in the J-CHiP initiative (n = 646). Table 3 shows scores for respondents in different disciplines, comparing nurses, physicians and others. For all disciplines, participants reported lower levels of coordination on Patient Engagement compared to other subscales (P < 0.001 for nurses and others, P = 0.0011 for physicians). The mean global rating for care coordination was 6.79 on the 1 to 10 scale. There were no significant differences by profession on the subscales and global rating.

Comparison by hospital and primary department was carried out for nurses who comprised the largest proportion of respondents (Figure). The difference between hospitals on the transitions subscale was of borderline significance (4.24 vs 4.05; P = 0.051), and was significant in comparing departments to one another (4.10, 4.35, and 4.12, respectively for medicine, surgery, and others; P = 0.002).

We also examined differences in perceptions of care coordination among nursing units to illustrate the tool’s ability to detect variation in Patient Engagement subscale scores for JHH nurses (see Appendix).

DISCUSSION

This study resulted in one of the first measurement tools to succinctly measure multiple aspects of care coordination in the hospital from the perspective of healthcare professionals. Given the hectic work environment of healthcare professionals, and the increasing emphasis on collecting data for evaluation and improvement, it is important to minimize respondent burden. This effort was catalyzed by a multifaceted initiative to redesign acute care delivery and promote seamless transitions of care, supported by the Center for Medicare & Medicaid Innovation. In initial testing, this questionnaire has evidence for reliability and validity. It was encouraging to find that the preliminary psychometric performance of the measure was very similar in 2 different settings of a tertiary academic hospital and a community hospital.

Our analysis of the survey data explored potential differences between the 2 hospitals, among different types of healthcare professionals and across different departments. Although we expected differences, we had no specific hypotheses about what those differences might be, and, in fact, did not observe any substantial differences. This could be taken to indicate that the intervention was uniformly and successfully implemented in both hospitals, and engaged various professionals in different departments. The ability to detect differences in care coordination at the nursing unit level could also prove to be beneficial for more precisely targeting where process improvement is needed. Further data collection and analyses should be conducted to more systematically compare units and to help identify those where practice is most advanced and those where improvements may be needed. It would also be informative to link differences in care coordination scores with patient outcomes. In addition, differences identified on specific domains between professional groups could be helpful to identify where greater efforts are needed to improve interdisciplinary practice. Sampling strategies stratified by provider type would need to be targeted to make this kind of analysis informative.

The consistently lower scores observed for patient engagement, from the perspective of care professionals in all groups, suggest that this is an area where improvement is needed. These findings are consistent with published reports on the common failure by hospitals to include patients as a member of their own care team. In addition to measuring care processes from the perspective of frontline healthcare workers, future evaluations within the healthcare system would also benefit from including data collected from the perspective of the patient and family.

This study had some limitations. First, there may be more than 4 domains of care coordination that are important and can be measured in the acute care setting from provider perspective. However, the addition of more domains should be balanced against practicality and respondent burden. It may be possible to further clarify priority domains in hospital settings as opposed to the primary care setting. Future research should be directed to find these areas and to develop a more comprehensive, yet still concise measurement instrument. Second, the tool was developed to measure the impact of a large-scale intervention, and to fit into the specific context of 2 hospitals. Therefore, it should be tested in different settings of hospital care to see how it performs. However, virtually all hospitals in the United States today are adapting to changes in both financing and healthcare delivery. A tool such as the one described in this paper could be helpful to many organizations. Third, the scoring system for the overall scale score is not weighted and therefore reflects teamwork more than other components of care coordination, which are represented by fewer items. In general, we believe that use of the subscale scores may be more informative. Alternative scoring systems might also be proposed, including item weighting based on factor scores.

For the purposes of evaluation in this specific instance, we only collected data at a single point in time, after the intervention had been deployed. Thus, we were not able to evaluate the effectiveness of the J-CHiP intervention. We also did not intend to focus too much on the differences between units, given the limited number of respondents from individual units. It would be useful to collect more data at future time points, both to test the responsiveness of the scales and to evaluate the impact of future interventions at both the hospital and unit level.

The preliminary data from this study have generated insights about gaps in current practice, such as in engaging patients in the inpatient care process. It has also increased awareness by hospital leaders about the need to achieve high reliability in the adoption of new procedures and interdisciplinary practice. This tool might be used to find areas in need of improvement, to evaluate the effect of initiatives to improve care coordination, to monitor the change over time in the perception of care coordination among healthcare professionals, and to develop better intervention strategies for coordination activities in acute care settings. Additional research is needed to provide further evidence for the reliability and validity of this measure in diverse settings.