Development of an Inventory to Assess Primary Care Practice Readiness for Diabetes Care Coordination

Diabetes care coordination ideally consists of a team of care providers implementing evidence-based protocols for managing high risk patients. Care coordinators provide specific services in order to assist patients in managing medications to achieve day-to-day blood glucose control, navigating transitions of care, scheduling preventive health services, providing appropriate self-management education, and contributing to care planning. Not all ambulatory clinics are prepared to implement care coordination services, and often clinics that nominally provide care coordination are lacking specialty services to optimize coordinated care. We have been unable to identify assessment tools that measure readiness and/or status of ambulatory clinics to engage in diabetes care coordination. Thus, it was the purpose of this project to develop and implement an inventory to assess ambulatory care clinic readiness for care coordination. As an initiative of the Beacon Community of the Inland Northwest (BCIN), we developed an inventory to assess care coordination readiness. The BCIN, funded through the Office of the National Coordinator for Health Information Technology, aims to support the information needs of diabetes care coordination by proliferating health information exchange among electronic medical records of ambulatory and inpatient facilities, laboratories, imaging facilities, and pharmacies. A primary objective of the project is to utilize information-enhanced care coordination to improve preventive health services receipt and patient outcomes of adult patients with Type 2 diabetes. The CCRA is also used to identify gaps in care services for clinics currently engaging in diabetes care coordination. Development of the CCRA took a content validity approach: Initially, medical literature was searched for existing tools that broadly assessed diabetes care coordination readiness; no tools were identified. Secondarily, clinical practice guidelines and peer-reviewed literature on successful care coordination programs were consulted to establish primary themes to address with the CCRA. A draft instrument was developed and refined in a consensus process. The final CCRA contained 5 domains: organizational capacity, care coordination best practices, case management capability, quality improvement capability, and technical infrastructure. Initial data indicate great variability in readiness for providing care coordination, and in the quality of care coordination already being provided. Subsequent use will reveal the impact of the BCIN on improving care coordination services. The CCRA is a brief readiness assessment aimed at enhancing delivery of diabetes care coordination by informing the clinic of its capacity for best-practice care. Provision of high quality care coordination holds promise to drive down inpatient and emergent care utilization and costs.