Care Coordination in a New Health Care Model: Improving Outcomes for Patients with Diabetes

Sarah Kokosa, PharmD
Published Online: Friday, April 12, 2013
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Avoiding unnecessary utilization of hospitals, improving quality of care, and establishing continuous chronic disease management.
It has been widely accepted in that serious medical errors and miscommunications often occur as our patients shift from one health care setting to another. Resources, time, and money are spent caring for patients, and can increase exponentially when a breakdown in the flow of information takes place in an unorganized health care environment, especially when in the form of readmissions.

For example, imagine we have a patient with uncontrolled diabetes and low health literacy. We’ll call him AB. Over the years, AB has passed inconsistently through urgent care facilities, primary care offices, emergency departments (EDs), and pharmacies. He and his providers have dabbled with the gamut of therapies, yet his A1C remains above 10 and complications with his kidneys, eyes, and nerves have set in. He is often lost to follow-up, and reappears in the system, usually the ED, only when symptoms become unbearable. AB is typically noncompliant with medications and unable to provide an accurate home medication list. He is admitted, treated, released, and the cycle repeats.

Many have questioned how we, as a system, can intervene to promote better health outcomes for this patient. How can we avoid unnecessary utilization of hospitals, improve quality of care, and establish continuous chronic disease management?

One area of focus, as advocated by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), is coordination of care surrounding hospital admissions and discharges. Several models have been developed, which are currently undergoing research to assess impact, and they incorporate distinct elements. Simply stated, coordination and communication compose much of the foundation.

Now, imagine we have a new health care model where patients are encased within a team. This team may include a nurse care manager, primary care provider, specialists, pharmacist, social worker, hospital, and any other entities involved in the patient's care In this model, the team encircles the patient continuously as he makes his journey through the health system, and are in constant communication along the way. Let’s apply this to our patient, and map out his new course.

AB presents to the ED due to uncontrolled blood sugar. He is unable to provide the hospital with a complete list of his medications. He is subsequently admitted, and while beginning his treatment, is visited by his nurse care manager, who engages AB and initiates the care coordination process. She facilitates the gathering of his medication list from his various providers and pharmacy claims, while simultaneously assessing potential education and social needs and communicating with the hospital staff.

The medication lists are passed on to the team pharmacist, who reviews and reconciles them to ensure that a complete and accurate list is communicated back to the hospital. The pharmacist is also surveying for potential hurdles, such as high-risk medications, potential cost-saving opportunities, and evidence of noncompliance or educational needs. When discharge is planned, the hospital provides instructions to AB, both verbally and written, including an updated medication list.

Once he arrives home, AB is again visited by his nurse care manager. She has a lengthy discussion with him about his condition, and provides education on self-management. She then assists AB with scheduling a follow-up appointment with a primary care provider (PCP), who will become his “medical home.” Importantly, the nurse also evaluates his home medication use while reviewing the discharge instructions and discharge medication list with AB. These additional lists are compiled along with pharmacy claims and provider lists, and again sent to the team pharmacist, who troubleshoots discrepancies, performs a complete medication review, and ensures all relevant information and recommendations are communicated to the PCP.

AB’s nurse continues to follow up with him periodically via telephone, ensuring he made it to his PCP appointment, and providing additional education throughout the transition period.

During his PCP appointment, diabetes and pharmacist recommendations are addressed, labs are drawn, his chart is updated, and a follow-up appointment is made. The initial steps to reestablishing chronic care have begun. Prescriptions are e-prescribed to the pharmacy and a complete medication list is provided to AB at the conclusion of his visit.

AB's nurse care manager continues to follow up with him, ensuring he makes it to appointments, follows any new PCP instructions, and provides reinforcement, encouragement, and empowerment. She may even follow him long term if there is a perceived need. Then, if AB is not readmitted to the hospital within a set period of time, he has successfully traversed the transitional care process and is on his way to improved health outcomes.

Is this model of transitional care possible? Absolutely! In fact, a model quite similar to this--in which a clinical pharmacist plays a crucial role among the coordinated care team--is already established and under investigation in states such as North Carolina. Are we detecting many medication-related problems? Yes, many, and they are being resolved while focusing on additional methods of prevention.

We are headed down a path of change in several aspects of health care today. While it may seem a daunting new venture, at times, it's also exciting! We are infinitely optimistic and confident that we are uncovering the answers to improving quality of care and promoting better outcomes in a more efficient manner to create a brighter and healthier future for our patients.


Sarah Kokosa, PharmD, received her doctor of pharmacy degree in 2007 from Albany College of Pharmacy, in Albany, New York. Ms. Kokosa has been working with AccessCare since 2010, and currently serves as an ambulatory care clinical pharmacist for Sampson and Wayne Counties in North Carolina. In Sampson County, she is embedded within Clinton Medical Clinic, a 16-provider primary practice, where she has developed clinical pharmacy services with a focus on diabetes, hypertension, and lipid management, along with general medication therapy management (MTM) services. She has also worked with the AccessCare team in Sampson County to develop and implement a medication reconciliation and transitional care program with the local hospital, Sampson Regional Medical Center. In Wayne County, Sarah aids the nursing team with MTM for both transitional and chronic care patients, and is also involved with recent efforts to enhance the care team’s role within the local hospital.


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