Patient-Centered, Community-Wide Care Coordination in Rural Areas

Purpose/Aims- To solicit feedback from a broad range of stakeholders on a novel care coordination (CC) approach that employs principles of person-centered care to enhance CC efforts in low-income, ethnically diverse populations in California’s rural communities. This nurse-led CC approach emphasizes patient engagement and addresses the triple aim: 1) enhanced patient experience; 2) improved population health; and 3) reduced healthcare costs, consistent with the Institute for Healthcare Improvement’s (IHI) framework for optimizing health system performance.

Rationale/Background- Individuals in rural and underserved areas face disparities in healthcare access, quality of care, and health outcomes. For the low-income, ethnically diverse population in California’s rural communities, these disparities include a high prevalence of cardio-metabolic conditions, such as heart failure, hypertension and diabetes, and worse outcomes related to these conditions. Traditional approaches that emphasize patient education and adherence often fail in this type of community setting. However, there is evidence that improved patient engagement and health information technology (HIT) could enhance traditional CC efforts.

Approach- Feedback was collected from an interdisciplinary group that included academic and clinical nurse leaders, public health and technology experts, and the leadership of sites serving this vulnerable population. We presented a CC model designed to engage patients, caregivers, and family members as equal partners with an interdisciplinary care team.  We discussed potential roles of Nurse Care Coordinators, Medical Assistants, Health Coaches, and Community Health Workers, who would be trained to support patients’ needs within the community context. We presented evidence-based protocols that could be used, technologies that could be integrated, and other interventions that might support the implementation of CC. This approach would permit the CC team to address not only clinical, but also behavioral and social determinants of health, using evidence-based techniques to  identify needs, goals, and challenges of importance to patients and their families.

Outcomes- Formative feedback has been uniformly enthusiastic, and also permitted us to identify areas of challenge.  These included 1) the competing needs for serial quality improvement versus a stable program that can be predictably disseminated; 2) issues of clinic-based Medical Assistants and LVNs versus Community Health Workers, and the sharp focus of community health centers on managing access; and 3) the need for technology not only to enhance communication among patients, family members, and care teams, but also to collect, analyze and display population-level improvements in health. There was agreement that the efficacy of this approach needs to be assessed rigorously, using triple aim criteria.

Conclusions- This innovative CC approach highlights the role of nurses in leading and transforming healthcare delivery in partnership with patients and communities. Careful attention to adapting the approach to the specific needs of the community is critical. Personalized interventions and innovative HIT support patients at the point of need and allow nurse-led CC teams to plan and deliver care more effectively. This empowering approach holds the potential to improve healthcare quality and patient experience while reducing costs for some of California’s most vulnerable rural communities.