Background
Care coordination in Patient-Centered or Family-Centered Medical Home (PCMH/FCMH) models is one evidence-based strategy to better manage childhood chronic diseases. Although many Federally Qualified Health Centers (FQHCs) incorporate PCMH/FCMH care coordination models, few studies have investigated FQHC personnel understanding of care coordination, and the effect of FQHC location (rural versus urban) on care coordination for childhood diseases has not been well documented.
Objective
To investigate FQHC personnel understanding of care coordination for pediatric patients.
Subject
Thirty providers and staff from 1 urban and 1 rural FQHCs.
Measures
Interviews and reports were analyzed using content analysis to determine participants understanding of care coordination facilitators and barriers for pediatric patients.
Results
Seven categories of facilitators were identified: teamwork, integrated services, one-stop shop, dedicated referral coordinator, effective and open communication, technology, and culture. There were 3 levels of barriers to care coordination: individual, organizational, and systems. Many facilitators and barriers were universal to both urban and rural FQHCs, but some were distinct for only the urban or rural FQHC. For example, lack of pediatric specialty care happened more often in the rural FQHC.
Conclusion
FQHC personnel consider teamwork with all stakeholders and integration of services to be facilitators of care coordination. Urban and rural FQHCs had similar barriers to care coordination. To improve outcomes associated with care coordination, a solid working definition of care coordination is necessary, and reimbursing care coordination activities should be explored by FQHCs, other healthcare systems and healthcare policy.
In the past few decades, the number of children with chronic diseases has increased rapidly in the United States [1], and around 27% of children have at least one chronic health condition requiring continual medical attention and contributing to missing school and their parents missing work [2]. Many of these chronic diseases are costly but preventable or manageable. Multiple barriers, such as insufficient patient education, fragmented care, stress, health beliefs and cultural beliefs, environmental effects and financial burden, hinder quality of pediatric care [3-8], and children in low-income or minority families are especially vulnerable [9]. People, including children with complex chronic conditions can use more health and social services than the rest of the population [10]. Care coordination is an evidence-based strategy for addressing barriers and improving care [11,12].
Care coordination in Patient-Centered or Family-Centered Medical Homes (PCMH/FCMH) can be used to manage diseases. Patients receive multiple services in one location, and healthcare teams coordinate care throughout the healthcare system, social services, and the community [13,14]. However, providers have different definitions about care coordination, and more than 40 have been identified [15,16]. Thus, consensus on care coordination is lacking and necessary [17].
Federally Qualified Health Center (FQHCs) is local, nonprofit, community-based healthcare clinics serving low-income and medically underserved communities. They provide primary and preventive care across a range of health and social services [15,18]. Many FQHCs have established or are working to establish PCMH/FCMHs and implemented care coordination [19], but successful care coordination is affected by multiple factors. Further, rural FQHCs generally have fewer resources than urban FQHCs [20].
Few studies have investigated understanding of care coordination by FQHC personnel. One study [21] suggested care coordination should be investigated in urban and rural FQHCs, but little research exists for urban versus rural location on care coordination, especially for children. The purpose of this study was to investigate FQHC personnel understanding of care coordination for pediatric patients, particularly those with complex chronic diseases. Specifically, we evaluated care coordination facilitators and barriers in an urban and a rural FQHC.
Figure 1: Example of an ecological model for treating childhood asthma [22].
Urban FQHC |
Rural FQHC |
||||
Number |
|
Title |
Number |
|
Title |
4 |
|
Physician* |
2 |
|
Physician*** |
2 |
|
Nurse |
3 |
|
Nurse**** |
2 |
|
Behavioral Health Consultant |
2 |
|
Behavioral Health Consultant |
2 |
|
Registered Dietician |
|
|
Registered Dietician***** |
1 |
|
Care Coordinator |
2 |
|
Referral Coordinator/Care Coordinator****** |
2 |
|
Medical Assistant |
2 |
|
Medical Assistant |
2 |
|
Referral Coordinator |
|
|
|
2 |
|
Pharmacist** |
2 |
|
Pharmacist |
* This includes Chief Medical Officer (CMO), who is also a practicing physician, and Pediatric Head. ** We did not interview any pharmacist at one clinic site because we were told that they did not have a pharmacist in its pediatric department. At another clinic site, two pharmacists came to interview together and one of these was the Pharmacy Manager. |
*** The Chief Medical Officer (CMO) is an OB/GYN. Therefore, the Medical Director was selected for the interview concerning the overall effort of care coordination. He was counted under the category of physician. ***** The rural FQHC did not have a registered dietician on the care team during the interview time. |
Facilitator |
|
Urban |
Rural |
Teamwork |
|
√ |
√ |
Integrated services |
|
√ |
√ |
One-stop shop |
|
√ |
√ |
Dedicated referral coordinator |
|
|
√ |
Effective and open communication |
|
√ |
√ |
Technology (ECW, EHR) |
|
√ |
√ |
Culture |
|
√ |
|
Level |
|
Barriers |
|
Urban |
|
Rural |
Patient |
|
Hard to reach patients because of address and phone number changes |
|
√ |
|
√ |
|
Difficult to communicate with patients and families because of limited health literacy and English proficiency |
|
√ |
|
√ |
|
|
Lack of patient compliance because of financial difficulty or insurance issue |
|
√ |
|
√ |
|
|
Patient fear because of immigration status in the United States |
|
√ |
|
√ |
|
|
Lack of transportation for appointments |
|
√ |
|
√ |
|
|
Lack of time for appointments |
|
√ |
|
√ |
|
|
Parent(s) and the entire family lack education, awareness, and influence |
|
√ |
|
√ |
|
|
Patient’s belief system |
|
√ |
|
|
|
Provider |
|
Belief system about medication |
|
√ |
|
|
|
Lack of time to see patients because of high volume of patients and reimbursement model |
|
√ |
|
√ |
|
|
Lack of knowledge about where to refer the patient to community resources |
|
√ |
|
|
|
|
Lack of communication between primary care provider and specialist |
|
√ |
|
√ |
|
|
Barriers from specialists who ask parents to bring their own interpreters, take a long time to book an appointment, do not spend enough time with patients, and do not explain things enough to patients |
|
√ |
|
√ |
|
|
Not enough care coordinators who at the point of care involved with care |
|
√ |
|
|
|
Organizational |
|
Limited space for other providers to see patients after primary care provider visit |
|
√ |
|
|
|
Lack of communication between provider and patient |
|
√ |
|
√ |
|
|
A long time for the health plan to approve referrals |
|
√ |
|
√ |
|
Systems |
|
No behavioral health specialists accept private insurance for behavior health problems in a small town |
|
|
|
√ |
|
Lack of specialty care, particularly pediatric specialty care |
|
|
|
√ |
|
|
Health plans claim a data lag of 2-3 months |
|
√ |
|
|
|
|
Information does not flow freely between systems because of different electronic health records systems or Health Insurance Portability and Accountability Act issues |
|
√ |
|
|
|
|
Lack of resources in the community |
|
√ |
|
√ |
|
|
Care coordination activities are not reimbursed because it takes time to coordinate care |
|
√ |
|
|
|
|
Geographic barrier in the rural area |
|
|
|
√ |
Function |
Key Word |
|
Frequency |
Noun |
Patient(s) |
|
20 |
Family/families |
|
7 |
|
Team |
|
3 |
|
Need(s), needs met |
|
15 |
|
Resources |
|
3 |
|
Options |
|
1 |
|
Education |
|
2 |
|
Empowerment |
|
1 |
|
Communication |
|
2 |
|
Modified noun |
Multidisciplinary team/group |
|
3 |
Patient-centered medical home |
|
3 |
|
Best health outcome |
|
1 |
|
Best services |
|
1 |
|
Correct care |
|
1 |
|
Full cycle |
|
1 |
|
Good outcome |
|
1 |
|
Good understanding |
|
1 |
|
Holistic approach |
|
1 |
|
Quality care |
|
1 |
|
Whole health |
|
1 |
|
Verb |
Collaborate |
|
1 |
Connect |
|
2 |
|
Educate |
|
1 |
|
Empower |
|
1 |
|
Follow through |
|
3 |
|
Follow up |
|
3 |
|
Involve |
|
3 |
|
Interact |
|
1 |
|
Make sure |
|
11 |
|
Provide |
|
5 |
|
Take care |
|
6 |
|
Work together |
|
2 |
|
Adjective |
Cost-effective |
|
1 |
Internal/external |
|
1 |
|
Physical, mental, emotional and spiritual |
|
2 |
|
Quality-based |
|
1 |
|
Whole |
|
3 |
|
Adverb |
Holistically |
|
1 |
Internally/externally |
|
1 |
|
Timely |
|
1 |
|
Together |
|
1 |
|
Other phrase |
Best experience in medicine |
|
1 |
Beyond the walls of clinics |
|
1 |
|
Close any gaps |
|
1 |
|
Close the loop |
|
1 |
|
Everyone is talking to everyone |
|
1 |
|
From top to bottom |
|
1 |
|
Medical and nonmedical needs |
|
1 |
|
Optimal health and wellbeing |
|
2 |
|
Under one umbrella |
|
1 |
Table 4: Key words by function and frequency for definition of care coordination by urban and rural federally qualified health center personnel.
Participants from urban and rural FQHCs valued teamwork that included patients and families as a facilitator for care coordination. Involving patients and families in the care team is essential, particularly with pediatric patients [24,29,30]. Both FQHCs also integrated primary care and behavioral health and were working to integrate nutrition, dentistry, and pharmacy services. Previous research indicates coordinate care is easier when multiple services are together. Both FQHCs had similar barriers to care coordination. Lack of communication between the provider and patient or between the provider and specialist, emergency department, or hospital was common. To build good partnerships, specialty care should be part of the care team. Although technology may alleviate this problem, physicians believe EHRs negatively impact interactions [31] and only facilitate care coordination within a practice, not between practices and settings [28]. Our participants indicated the ECW helped with internal communication, but financial incentives for coordination were lacking.
To meet patient needs, partnerships must exist within and outside FQHCs. A constant relationship among patients, families, and healthcare providers enhances care coordination [32,33] and positively impacts patient health [34]. Using resources outside the clinic is key for helping patients. Thus, FQHCs and other providers should build long-term partnerships with community organizations. Conceptual frameworks are one way to create partnerships [22,35]. The Ecological Model, served as this study’s framework, illustrates layers of partnerships and a medical neighborhood to address childhood health conditions. To implement care coordination activities, as was recommended by this study, multiple layers of partnerships should be built, and all partners should work together and influence each other, which is aligned with the Ecological Model. The partners can be internal or external, including providers and their staff members, patients and their families and social and community services. The team approach and integration of services are two facilitators of care coordination services identified by the interviewees in this study, and both of these facilitators require partnership building. One of the most important tasks for the care coordinator is to build partnerships with patients and their families and the services that the care coordinator refers them to. Definitions of care coordination were diverse and based on practice and experience. Based on their definitions, some participants had a better understanding of care coordination than others; however, occupational background of the participants was not a contributory factor in their defining care coordination. Previous studies also found different people had different definitions [15,16]. Common keys words of patient(s) need(s), and make sure aligned with facilitators to care coordination. However, family or team was rarely used.
For one participant, care coordination was like case management because practice was driven by health plans. Thus, the term, care coordination, could be used differently by similar programs or agencies, causing confusion. Although defining case management is not in the scope of this research, it is worth discussing the similarities and differences between care coordination and case management to provide a better picture of care coordination in a primary care setting that cares for children with complex chronic diseases. It is also important to point out that different organizations/professions may look at case management and care coordination differently. Both care coordination and case management are intended to address fragmentation in healthcare delivery [16,36] and are strategies to manage chronic disease between primary care and other healthcare settings [16,37]. Care coordination is a process to deliberately organize patient care plans involving multidisciplinary teams and diverse services (including health and social services) to achieve appropriate healthcare delivery and optimal health outcomes, and communication is the key for teams and services to exchange information [16,38-40]. In a PCMH/FCMH setting, primary care providers play a vital role in the process of care coordination [38,40]. During the care coordination process, there are many interventions, and case management is one care coordination intervention that helps patients and their families determine their medical and social needs [16,38]. The Agency for Health and Research Quality adopted a definition for case management that “implicitly enhances care coordination through the designation of a case manager whose specific responsibility is to oversee and coordinate care delivery [targeted to] high-risk patients [with a] diverse combinations of health, functional, and social problems” [16]. Since care coordination is relatively new, FQHCs need to establish differences between care coordination and case management and adopt a working definition of care coordination. Training on care coordination may eliminate confusion and promote teamwork. One FQHC in our study had a chart where dental assistants discussed what care coordination meant to them. Other FQHCs could use similar activities.
Care coordinators in pediatric settings may reduce costs, so they are recommended for the care team [24,29,41,42]. Although both FQHCs had care coordinators, they were like case managers at the urban FQHC. At the rural FQHC, the referral coordinator and care coordinator were the same. Because health plans decide on reimbursement, care coordinator’s responsibilities will not change unless FQHCs find other payment methods or health plans change care coordination. Most health plans practice a fee-for-service model, but it creates barriers between primary care and other providers. A value-based payment model may be better for FQHCs [43]. More research is needed on this payment model for FQHCs.
The current study had several limitations. The two FQHCs may not be representative of other FQHCs. We focused only on FQHC personnel; patients and families may have different views about care coordination. Further, we did not collect clinic data or consider outcomes of care coordination. The rural FQHC in this study was in a county, which used to be a rural county. However, due to economic development and expansion, the county is centrally located between two metro areas. Debate has occurred on whether the county should be considered a rural county or rural-urban county. Although it is still known as a center of American agriculture, the County lacks a truly rural feature, and this possibly impacts findings. Future research should include studies with more FQHCs, and the effect of FQHC location on the family’s level of engagement should be investigated by the following study.
Our findings suggested neither the personnel’s occupational title nor urban or rural FQHC location was a contributory factor to affect understanding of care coordination. In addition to behavioral health, both FQHCs were working to integrate nutrition, dentistry, and pharmacy services. To improve outcomes of care coordination, FQHCs should have a working definition of care coordination, build partnerships, and explore the feasibility to reimburse care coordination activities. To effectively treat pediatric patients from low-income or minority families, FQHCs need to also address nonmedical needs like lifestyle changes and social and cultural needs. Such endeavors go beyond clinic walls. Teamwork between FQHC personnel and patients and families is necessary to improve pediatric health outcomes.
Citation: Chartrand HZ, Rosales CB, MacKinnon NJ (2019) Understanding of Care Coordination by Healthcare Providers and Staff at Federally Qualified Health Centers: A Qualitative Analysis. J Community Med Public Health Care 6: 041.
Copyright: © 2019 Hong Z Chartrand, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.