CONTEXT: Quality problems and spiraling costs have resulted in widespread interest in solutions that improve the effectiveness and efficiency of the health care system. Care coordination has been identified by the Institute of Medicine as one of the key strategies for potentially accomplishing these improvements.

OBJECTIVES: The objectives of this project were to develop a working definition of care coordination, apply it to a review of systematic reviews, and identify theoretical frameworks that might predict or explain how care coordination mechanisms are influenced by factors in the health care setting and how they relate to patient outcomes and health care costs.

DATA SOURCES AND REVIEW METHODS: We used literature databases, Internet searches, and personal contacts to assemble background information on ongoing care coordination programs; potential definitions; conceptual frameworks and related empirical evidence; and care coordination measures. We also conducted literature searches through September 30, 2006 of MEDLINE®, and November 15, 2006 for CINAHL®, Cochrane database of systematic reviews, American College of Physicians Journal Club, Database of Abstracts of Reviews of Effects, PsychInfo, Sociological Abstracts, and Social Services Abstracts to identify systematic reviews of care coordination interventions. We excluded systematic reviews with a narrow focus, namely those conducted solely in the inpatient setting, or where the only two participants involved in care were the patient and a health care provider.

RESULTS: We identified numerous ongoing programs in the private and public sector, most of which have not yet been evaluated. We identified over 40 definitions of care coordination and related terminology, and developed a working definition drawing together common elements: Care coordination is the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient's care to facilitate the appropriate delivery of health care services. Organizing care involves the marshalling of personnel and other resources needed to carry out all required patient care activities, and is often managed by the exchange of information among participants responsible for different aspects of care. We used this definition to develop our inclusion/exclusion criteria for selecting potentially relevant systematic reviews. Our literature search yielded 4,730 publications, of which 75 systematic reviews evaluating care coordination interventions, either fully or as a part of the review, met inclusion criteria. From these, we identified 20 different coordination interventions (e.g., multidisciplinary teams, case management, disease management) covering 12 clinical populations (e.g., mental health, heart disease, diabetes) and conducted in multiple settings (e.g., outpatient, community, home). Finally, we identified four conceptual frameworks (Andersen's behavioral framework, Donabedian's structure-process-outcome framework, Nadler/Tushman and others' Organizational design framework with Wagner's Chronic Care Model provided as an example of such design, and Gittell's Relational coordination framework) with potential applicability to studying care coordination by assessing baseline characteristics of the environment, specific coordination mechanism alternatives, and outcomes. The strongest evidence shows benefit of care coordination interventions for patients who have congestive heart failure, diabetes mellitus, severe mental illness, a recent stroke, or depression, though evidence about key intervention components is lacking.

CONCLUSIONS: Care coordination interventions represent a wide range of approaches at the service delivery and systems level. Their effectiveness is most likely dependent upon appropriate matching between intervention and care coordination problem, though more conceptual, empirical and experimental research is required to explore this hypothesis.

Context: Quality problems and spiraling costs have resulted in widespread interest in solutions that improve the effectiveness and efficiency of the health care system. Care coordination has been identified by the Institute of Medicine as one of the key strategies for potentially accomplishing these improvements.

Objectives: The objectives of this project were to develop a working definition of care coordination, apply it to a review of systematic reviews, and identify theoretical frameworks that might predict or explain how care coordination mechanisms are influenced by factors in the health care setting and how they relate to patient outcomes and health care costs.

Data Sources and Review Methods: We used literature databases, Internet searches, and personal contacts to assemble background information on ongoing care coordination programs; potential definitions; conceptual frameworks and related empirical evidence; and care coordination measures. We also conducted literature searches through September 30, 2006, of MEDLINE®, and November 15, 2006, for CINAHL®, Cochrane database of systematic reviews, American College of Physicians Journal Club, Database of Abstracts of Reviews of Effects, PsychInfo, Sociological Abstracts, and Social Services Abstracts to identify systematic reviews of care coordination interventions. We excluded systematic reviews with a narrow focus, namely those conducted solely in the inpatient setting, or where the only two participants involved in care were the patient and a health care provider.

Results: We identified numerous ongoing programs in the private and public sector, most of which have not yet been evaluated. We identified over 40 definitions of care coordination and related terminology, and developed a working definition drawing together common elements:

Care coordination is the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient's care to facilitate the appropriate delivery of health care services. Organizing care involves the marshalling of personnel and other resources needed to carry out all required patient care activities, and is often managed by the exchange of information among participants responsible for different aspects of care.

We used this definition to develop our inclusion/exclusion criteria for selecting potentially relevant systematic reviews. Our literature search yielded 4,730 publications, of which 75 systematic reviews evaluating care coordination interventions, either fully or as a part of the review, met inclusion criteria. From these, we identified 20 different coordination interventions (e.g., multidisciplinary teams, case management, disease management) covering 12 clinical populations (e.g., mental health, heart disease, diabetes) and conducted in multiple settings (e.g., outpatient, community, home). Finally, we identified four conceptual frameworks (Andersen's behavioral framework, Donabedian's structure-process-outcome framework, Nadler/Tushman and others' Organizational design framework with Wagner's Chronic Care Model provided as an example of such design, and Gittell's Relational coordination framework) with potential applicability to studying care coordination by assessing baseline characteristics of the environment, specific coordination mechanism alternatives, and outcomes.

The strongest evidence shows benefit of care coordination interventions for patients who have congestive heart failure, diabetes mellitus, severe mental illness, a recent stroke, or depression, though evidence about key intervention components is lacking.

Conclusions: Care coordination interventions represent a wide range of approaches at the service delivery and systems level. Their effectiveness is most likely dependent upon appropriate matching between intervention and care coordination problem, though more conceptual, empirical and experimental research is required to explore this hypothesis.

Objective: To describe the development of an instrument for assessing workforce perceptions of hospital safety culture and to assess its reliability and validity.

Data Sources/Study Setting: Primary data collected between March 2004 and May 2005. Personnel from 105 U.S. hospitals completed a 38-item paper and pencil survey. We received 21,496 completed questionnaires, representing a 51 percent response rate.

Study Design: Based on review of existing safety climate surveys, we developed a list of key topics pertinent to maintaining a culture of safety in high-reliability organizations. We developed a draft questionnaire to address these topics and pilot tested it in four preliminary studies of hospital personnel. We modified the questionnaire based on experience and respondent feedback, and distributed the revised version to 42,249 hospital workers.

Data Collection: We randomly divided respondents into derivation and validation samples. We applied exploratory factor analysis to responses in the derivation sample. We used those results to create scales in the validation sample, which we subjected to multitrait analysis (MTA).

Principal Findings: We identified nine constructs, three organizational factors, two unit factors, three individual factors, and one additional factor. Constructs demonstrated substantial convergent and discriminant validity in the MTA. Cronbach's  coefficients ranged from 0.50 to 0.89.

Conclusions: It is possible to measure key salient features of hospital safety climate using a valid and reliable 38-item survey and appropriate hospital sample sizes. This instrument may be used in further studies to better understand the impact of safety climate on patient safety outcomes.

Background: Accumulating evidence indicates that addiction and psychiatric treatment programs that actively promote self-help group involvement can reduce their patients' health care costs in the first year after treatment, but such initially impressive effects may wane over time. This paper examines whether the positive clinical outcomes and reduced health care costs evident 1 year after treatment among substance-dependent patients who were strongly encouraged to attend 12-step self-help groups were sustained at 2-year follow-up.

Methods: A 2-year quasi-experimental analysis of matched samples of male substance-dependent patients who were treated in either 12-step-based (n=887 patients) or cognitive-behavioral (CB, n=887 patients) treatment programs. The 12-step-based programs placed substantially more emphasis on 12-step concepts, had more staff members "in recovery," had a more spiritually oriented treatment environment, and promoted self-help group involvement much more extensively than did the CB programs. The 2-year follow-up assessed patients' substance use, psychiatric functioning, self-help group affiliation, and mental health care utilization and costs.

Results: As had been the case in the 1-year follow-up of this sample, the only difference in clinical outcomes was a substantially higher abstinence rate among patients treated in 12-step (49.5%) versus CB (37.0%) programs. Twelve-step treatment patients had 50 to 100% higher scores on indices of 12-step self-help group involvement than did patients from CB programs. In contrast, patients from CB programs relied significantly more on outpatient and inpatient mental health services, leading to 30% lower costs in the 12-step treatment programs. This was smaller than the difference in cost identified at 1 year, but still significant ($2,440 per patient, p=0.01).

Conclusions: Promoting self-help group involvement appears to improve posttreatment outcomes while reducing the costs of continuing care. Even cost offsets that somewhat diminish over the long term can yield substantial savings. Actively promoting self-help group involvement may therefore be a useful clinical practice for helping addicted patients recover in a time of constrained fiscal resources.

Socially housed rhesus monkeys rapidly acquired Helicobacter pylori infection, although the organism was rarely cultivated from saliva, feces, or the environment. Since the concentrations of H. pylori in vomit were compatible with what is known about the infectious dose, our results are most consistent with an oral-oral means of transmission.

The Patient Safety Consortium included a group of 26 diverse hospitals in or near California. In 2001 and 2002, many consortium hospitals were surveyed using the Patient Safety Climate in Healthcare Organizations (PSCHO) tool to present quantitative measures of hospital safety climate and qualitative reports on safety practices over 2 years. Investigators engaged in discussions with consortium hospitals to elicit reports about their patient safety activities. Overall quantitative measures of safety climate remained approximately the same over the 2 years, although in some specific survey areas climate appeared to improve. Hospitals reported a range and mix of patient safety activities. While considered an essential enabler of safety, cultural change takes time. Significant hospital efforts appear to be underway, and attention to a number of lessons from past patient safety efforts may benefit future undertakings.