The IC4 coaching program accelerates the building of care coordination competencies within each group of new nurse care coordinators. It focuses on the development of real world, point-of care-skills to enable them to deliver comprehensive, family-centered, targeted supports for patients and families.
Care Coordination Quality Improvement Measurement
Quality improvement is a critical method used to propel each nurse care coordinator's acquisition of more effective processes. Data collection focuses on the key principles of the project, including frequent contact with enrolled families, regular updates of plans of care, effective sharing of plans of care, family satisfaction and primary care team satisfaction.
During the pilot, it was discovered that new nurse care coordinators were often familiar with types of quality measures used in primary care, without a functional background in the “why” of quality improvement principles. Therefore, an introduction of the basic methodology including the Plan, Do, Study, Act model for improvement was incorporated into the didactic series. Coaching support is essential to help translate quality improvement theory into real world applications to encourage action for individual improvements.
Care coordinators receive monthly reports on quality indicators and related care coordination activity to identify and monitor program improvements at the individual and practice level.
- Maintenance of a full registry of 100 patients.
- Regular family contact at least every 90 days for at least 80% of their panel of 100 patients.
- Shared Plan of Care updates at least every 6 months for at least 80% of their panel of 100 patients.
- Average score of at least 30 (out of maximum 40) or 75% on chart audits of a sampling of 8-10 charts using a 20-item audit tool as scored by their coach.
- Average distribution of at least 2 SPoCs to members of each patient's care neighborhood for at least 80% of their panel of 100 patients.
Family satisfaction surveys are collected semiannually from families who volunteer to participate. Each practice receives an individual report, as well as shared summary for the whole project. Composite scores for care coordination, shared plans of care and medical home principles have demonstrated progressive improvement over the course of the project.