NCM110

Care Delivery Across the

Care Continuum:
Hospital–Community–Home
NCM110

OBJECTIVES
1. Define the post-acute care delivery
continuum and their contribution to the Triple
Aims of increased quality at reduced costs,
improved patient experience, and improved
population health.
2. Identify the current state of standards
needed for care coordination across post-acute
care delivery.
NCM110

OBJECTIVES
3. Describe how healthcare policy and
regulations require participation of all care
delivery sites including post-acute care to
accomplish full care coordination.
4. Explain the current functionality and
adoption of electronic health record tools
available to and used by post-acute care
providers.
NCM110

• This chapter focuses on a little known,

often overlooked, and poorly understood
segment of our healthcare system—post-
acute care.
• Consequently, many health professionals
carry an insufficient understanding of the
post-acute care providers and how they
can augment their care plan for a given
patient.
NCM110

• A major challenge in achieving the Triple

Aims of increased quality at reduced costs,
improved patient experience, and improved
population health is our ability as a
healthcare system “to integrate its work
over time and across sites of care”
(Berwick, Nolan, & Whittington, 2008).
NCM110

• Informatics is front and center to health

reform because care delivery system
integration and care coordination require a
sophisticated information infrastructure
beyond where we are today (Rudin &
Bates, 2014).
NCM110

Development of the National

Strategy for Quality Improvement
• The current reform framework and changes in
reimbursement policies have been pushed forward by a
number researchers, private institutes, and government
agencies building upon each other’s work.
• Most notable are the contributions from Berwick and
colleagues from the Institute of Healthcare Improvement
(Berwick et al., 2008) and the work of the Commonwealth
Fund’s Commission on High Performance Healthcare
System (Shih et al., 2008).
NCM110

• Taken together, these two bodies of work

redefined what should be the focus of care
delivery—the Triple Aims (Berwick et al.,
2008), and detailed how a “high
performance healthcare system” needs to
operate and deliver care to achieve value
(Shih et al., 2008).
NCM110

• This reform framework is based on a translated

version of IHI’s triple aims of “better care, healthy
people/healthy community, and affordable care”
and six priorities that target making care safe,
coordinated, based on evidence of clinical
effectiveness, development of new care delivery
and reimbursement models, and community
level focus for healthier living (Agency for Health
& Research Quality, 2013a).
NCM110

• Significantly, for post-acute care providers,

one of the six national priorities targets care
coordination with expectations for managed
care transitions and communication across
care settings (Agency for Health &
Research Quality, 2013b).
NCM110

• The implications of these care delivery

mandates for the level of functionality,
standards and interoperability needed in
our EHR systems across all sectors
represent both opportunity and challenge
for all of us (Agency for Health & Research
Quality, 2012).
NCM110

INTRODUCING THE POST-ACUTE

PROVIDERS
• Table 25.1 (Centers for Medicare and Medicaid
Services, 2012; Centers for Medicare and Medicaid
Services, 2013a; Medicare Payment Advisory
Commission, 2012a, 2012b; Medicare Payment
Advisory Commission, 2013a, 2013b) lists each CMS
recognized entity, the type of patient services provided,
differences, patient eligibility requirement, payment
structure, and episode period.
NCM110

TABLE 25.1 Post-Acute Care Providers,

Defining Characteristics, Criteria for
Admission, and CMS Reimbursement
 Long-Term Acute Inpatient Acute
Skilled Nursing Home Health Nursing Home
Category Care Hospital Rehabilitation Palliative Hospice
Facility (SNF) (HHA) (NH)
(LTAC) (IRF
FOCUS Patients with Restoration of Step-down Health services are Patient living with
Disease directed Long-Term
multiple functional medical/rehab care provided in their serious and
therapies are no Supportive Care
comorbidities, independence (skilled care) places of residence complexlongerchronic working (Custodial)
exacerbation of for the purpose of illness(es) with
Projected terminal Considered
chronic illness, or promoting, significant burden
within six months patient’s home
catastrophically maintaining, or that may last for
Four Levels of
injured. High restoring health, or years Homebound
Care: *Routine
medical acuity maximizing the to qualify for Home
Care: in the home
level of Health Palliative
scheduled
independence, Services Can
intermittent visits—
while minimizing continue to seek
hospice staff
the effects of aggressive
available on-call
disability and treatment
*Continuous
illness, including Care: home setting
terminal illness — crisis
Home bound: intervention staff
Normally unable to may stay in home
leave home for many hours
unassisted To be *Respite Care:
homebound means allows break for
that leaving home caregiver. Transfer
takes considerable to a facility for up to
and taxing effort five days. *General
Inpatient Care:
more complex
needs—cannot be
managed in the
home.
Anticipated 25 days or greater 10 to 15 days 15–20 days or Per episode (Acute Not dependent on six months or less Indefinite—
Length of Stay greater or Chronic). And life expectancy   Patient’s Home
    had a skilled need    
 
 Category Long-Term Inpatient Skilled Home Health Palliative Hospice Nursing
Acute Care Acute Nursing (HHA) Home (NH)
Hospital Rehabilitation Facility
(LTAC) (IRF (SNF)

Program for
Medically
Complex YES NO SOME YES YES YES NO
Patients
 

Program for
Patients
High Flow
Requiring
YES NO NO SOME Oxygen NO NO
Ventilator
Needs
Weaning
 

24-Hour
Depending on
Respiratory
YES NO NO NO NO Level of Care NO
Therapy
Needs
 

YES NO NO Telehealth Telehealth SOME-Vital NO

Telemetry Monitoring of Monitoring of Signs
Monitoring Vital Signs Vital Signs
  and Weight and Weight
 Category Long-Term Inpatient Acute Skilled Nursing Home Health Palliative Hospice Nursing Home
Acute Care Rehabilitation Facility (SNF) (HHA) (NH)
Hospital (LTAC) (IRF

Three to five Based on Skilled Based on Skilled

Three to five Variable.
At least 6.5 hours hours per patient Nursing need Nursing need Based on Skilled
Nursing Activity hours per patient Custodial care
per patient day day Requires number of days number of days Nursing need
  day  
  daily skilled care per week per week  
   
     

NO Requires a NO Requires a
YES but Face-to-Face 90 Faceto-Face 90
YES May also minimally Three days prior to days prior to
NO As needed Depending on NO. As needed
Daily Physician have consultants times per week admission to admission to
and Minimally Level of Care and Minimally
visits Assessment or (Physiatrist) may home health or home health or
every 30 days Needs every 30 days
  Intervention Daily also have a within 30 days of within 30 days of
     
  consultant admission to admission to
  home health home health
   

YES Must be YES Based on YES Depending

Program for
able to tolerate YES as needed, Therapy on Functional
Rehabilitative YES as needed,
YES three hours per no minimum Assessment Level NO
Services no minimum
day   Functional Needs Assessment
 
     

Acute Hospital Acute Rehab Unit Skilled Nursing Home Health Level of Care Hospice Skilled Nursing
/Hospital Agency offered through  
  Home Health
License Agency
 
 Category Long-Term Acute Inpatient Acute Skilled Nursing Home Health Palliative Hospice Nursing Home
Care Hospital Rehabilitation Facility (SNF) (HHA) (NH)
(LTAC) (IRF
Three hours or Optional—usually
Depending on
more per day at one to two hours
Therapy Program Optional Core Functional Level
least five days per per day five days a NO Optional
      Assessment
week week
 
   
Patient has a
Acute Medical and Patient requires relief
terminal illness
Functionally Chronic Medical/ Chronic Medical/ from the symptoms, Chronic Medical/
and prognosis is
Patient Profile Medically Complex impaired/ Medically Functional Skilled Nursing and pain, and stresses of Functional
six months or less
    Stable Conditions Functional a serious illness— Conditions
that is certified by
    Conditions whatever the  
the physician
  diagnosis
 
 Medically stable
Intensive 24-hour rehab  Willing and able Medically stable
 Willing and able
medical/surgical nursing or caregiver Skilled 24-hour rehab
 Medically stable caregiver Skilled
treatment Medical restorative care, home care nursing or
24-hour rehab home care services  Patient has a
complexity therapy as needed services for restorative care,
nursing Must be for assessment, terminal illness
 General and 24-hour Three-day acute assessment, therapy as
able to tolerate treatment, and prognosis is
Admission intermediate critical care stay prior to treatment, needed Three-
three hours of monitoring, or six months or less
Criteria care/ acute admission is monitoring, or day acute care
therapy per day No education and/or Willing and able
medical surgical required Medically education and/ or stay prior to
acute hospital stay Skilled therapy need caregiver
No minimum short- complex with Skilled therapy admission is
require Medically stable
term acute stay comorbidities Can need Medically required from
Homebound
required  discharge to Home stable Homebound STACH 
Health or Hospice
 Category Long-Term Inpatient Acute Skilled Nursing Home Health Palliative Hospice Nursing Home

NCM110
Acute Care
Hospital
Rehabilitation
(IRF
Facility (SNF) (HHA) (NH)

(LTAC)
Patient
Uses either
Assessment CARES IRF-PAI MDS OASIS-C1 HIS MDS
Hospice or HHA
Data Set
RUG
CMG (Case Mix (Resource
Case Mix Uses either Uses either Uses either
Group) Level of Care Utilization
System Hospice or HHA Hospice or HHA Hospice or HHA
Groups)

Unit of Uses either

Discharge Discharge Day 60-Day Episode Day Day
Payment Hospice or HHA
86 days
Average LOS 26.6 days 13.1 days 27 days 2 episodes No data (Median = 18 ≥1 year
days)
Average
Payment per $38,582 $17,085 $10,808 $2,691 No data $11,321 Medicaid
Unit
Number of
Organizations
437 1,166 15,139 12,225 3,612 15,671
in 2012
NCM110

• Medicare and Medicaid pay the significant

portion of care expense for care delivered in
the post-acute sector.
• The Medicare benefit pays for skilled care,
therapy, and other services delivered by
inpatient rehabilitation facilities (IRF), skilled
nursing facilities (SNF), long-term care
providers (LTCH), home health agencies
(HHA), and hospice.
NCM110

• Patients accessing the post-acute providers

instead of ambulatory centers or clinics are
those who are home bound, or have need of
inpatient level of care, have restricted
mobility, or are at six months or less at end
of life.
NCM110

• As detailed in Table 25.1, every post-acute

care setting carries eligibility requirements
that must be met to be paid by CMS under
Medicare. Long-term care hospitals (LTCH)
and inpatient rehabilitation facilities (IRFs)
must meet the same conditions of
participation that acute care hospitals are
held to for admissions and facilities criteria
(Linehan, 2012).
NCM110

• Patients in need of skilled nursing facilities

services commonly are those recovering
from orthopedic surgeries, or other medical
conditions requiring short-term skilled
nursing care and rehabilitation services,
such as stroke, neurological conditions, or
acute pneumonia
NCM110

• Rehabilitative therapies include physical

therapy, occupational therapy, and
importantly for stroke and neurological
patients’ access to speech-language
services that address safe eating,
swallowing, and communication.
NCM110

• Home healthcare is the largest of all the

post-acute care providers and continues to
grow annually. Eligibility is tied to home-
bound status, defined as requiring
“considerable and taxing effort” to leave the
home, and to the need for skilled nursing
care or therapy to maintain or improve their
health status and/or functional capacities.
NCM110

• Over the past decade, home health

agencies are becoming less of a post-
hospital admission provider, and are taking
an increasing percentage of their referrals
from physician’s offices, clinics, and
community-based Assisted Living Facilities.
NCM110

• Hospice eligibility is linked to certification by

an attending physician and a hospice
medical director that the person is terminal
and at the end-stage of their disease
trajectory with six or less months to live.
• Hospice is also covered under the Medicare
benefit, but until recently, was seldom used
as a discharge destination from a hospital
stay.
NCM110

The Role for Post-Acute Care Providers

• Increasingly, as Care Transitions demonstration
projects mandated under the 2010 Affordable
Care Act (ACA) have generated lessons learned
in care coordination, other post-acute care
providers, such as Hospices and Kidney Dialysis
Centers, have started to be included in planning
(Linehan, 2012; Medicare Payment Advisory
Commission, 2012b).
NCM110

• For example, in Care Transition

partnerships between home health
agencies (HHA) and hospitals, these teams
quickly learned how imperative it was to
have a clinical profile tool with risk criteria
that could differentiate and identify
individuals at the “endof-life” stage of a
chronic disease from those with longer term
trajectories.
NCM110

• This advancement in care transitions

initiatives required care planning changes
that depended on informatics and data
analysis.
• In these early initiatives, the partners had to
have the ability to tract patients who had to
be readmitted within 30 days from hospital
discharge and report back to their partners.
NCM110

• This meant that the SNF’s or HHA’s clinical

information system had to have the ability to
capture patients’ clinical profiles, protocol
treatment outcomes, and clinical data with
the ability to share with the hospital partner.
• This level of functionality is largely missing in
today’s systems. (Agency for Health & Research
Quality, 2012; Bates & Bitton, 2010; Resnick & Alwan,
2010; Weaver & Moore, 2011).
NCM110

• The second major change that was

informed by the data was for hospitals to
actively include hospice as a post-hospital
destination and to take on the hard
conversations with physicians, patient, and
family to have that option available to the
patient.
NCM110

• Once organizations made the leap to start

looking for end-of-life criteria and defined
hospice as an appropriate discharge
placement (if patient and family agreed),
progress was made.
NCM110

• Doing appropriate discharge planning for

hospice eligible individuals rather than
referring to home health has helped mitigate
rehospitalizations in this vulnerable
population as well as improving the
individuals’ experience from their care.
NCM110

• It is in understanding the services that each post-

acute care provider offers, that will allow us to
align patients’ post-discharge care plan with their
needs and wishes.
• It is essential to know which setting offers what
services on the curative, rehabilitative to
preventative and palliative care continuum to
match patients wishes to correct setting and
achieve a healthcare system that embodies the
means to deliver on the Triple Aim goals.
NCM110

CLINICAL INFORMATION SYSTEMS IN

POST-ACUTE CARE
• Just as Meaningful Use (MU) incentives are
impacting acute and ambulatory care
providers, they are also affecting the post-
acute care providers even though they are
not included as eligible providers for
payment incentives. (Blumenthal & Tavenner, 2010;
Office of the National Coordinator for Health Information
Technology, 2014).
NCM110

• Under MU, hospital organizations and

physician offices are financially rewarded to
adopt and use EHR functionality.
• In just over a decade, EHR adoption has
profoundly impacted how clinicians work,
document, and use data in support of clinical
decisions and care planning in these
settings.
NCM110

• Accordingly, expectations for data exchange

and empowering data analytics are
expanding beyond the medical center and
are being placed upon the post-acute care
community (Centers for Medicare and
Medicaid Services, 2013d).
NCM110

Case Example: Evolution of Clinical

Information Systems in Home Health

• In 2000, CMS moved home health to

prospective payment reimbursement that
was linked to a new documentation tool—
the Outcome and Assessment Information
Set (OASIS) to be used at admission.
NCM110

• Few legacy systems offered a clinical

solution to capture even the routine visit
notes in the home at this time.
• Patient records and clinical documentation
were collected on paper and agencies’
medical records were paper-based.
NCM110

• In anticipation of the 2000 OASIS

introduction, vendors quickly responded by
developing documentation systems that
would allow for clinicians to capture the
OASIS data and pass it directly into the
backend billing system, eliminating the
need for office staff to reenter the OASIS
documentation.
NCM110

• Billing and ADT system vendors adopted a

“bolt-on” approach to capture OASIS
documentation.
• Consequently, the structure of the clinical
documentation was based on a task concept
that organized the patient record by visit
note type in chronologic order, with each
discipline having their separate
documentation tasks.
NCM110

• More than a decade later, current state still

has limited workflow support functionality,
integrated patient record views, multi-
discipline team workflow and patient care
data views, clinical decision support,
structured terminologies, and/or flexible
quality reporting capabilities.
NCM110

• There are a myriad of small vendors who

supply their local markets with systems
developed to cover the basic front office and
billing functions with added OASIS capture
functionality.
• These basic systems require minimal capital
outlay and are affordable for the thousands of
small sized agencies (over 10,000) that make
up the bulk of the home health industry
(Medicare Payment Advisory Commission, 2012a).
NCM110

• While the HIS vendors have matured their

products to deliver point of care, clinical
documentation, these systems still have a
strong focus on driving the reimbursement
process rather than supporting clinical
workflow and decision support.
NCM110

• Lack of structured clinical data still

characterizes the industry today and has
long challenged home health provider
organizations’ ability to provide quality and
clinical outcome measures.
• Most of the major vendor systems in the
market today remain on their original 1980s
technical platform architectures and
programming languages.
NCM110

• However, a very hopeful new development

is the entry of new start-up vendors who
have built their solutions as a Web-based
platform, using cloud technology and i-Pad
devices with the added advantage of
leveraging off of Apple built applications.
• These twenty-first century tools and
architectures allow for rapid development,
NCM110

• nimbleness, and options to plug into the side

application market for Apple devices, with a very
low cost of ownership (Weaver & Teenier, 2014).

• These new market developments offer a way

forward for home health and the other post-
acute providers and gives hope for significant
progress and catch up to MU functionality levels
over the next five years.
NCM110

EHR Adoption Levels in Home Health

• From 2000 to 2013, there have been three
national surveys conducted on the levels of EHR
adoption in the home health industry.
• These are the 2000 National Home and Hospice
Care Survey (NHHCS) (Pearson & Bercovitz, 2006);
the 2006-2007 American Association of Homes
and Services for the Aging (Resnick & Alwan, 2010);
and Fazzi Associates’ 2013 survey of over 1000
HHA agencies (Fazzi Associates, 2013).
NCM110

• Tracking across these surveys shows a shift from

only 32% of HHAs having clinical systems with
the basic EHR functions in 2000 to 58% as
reported in the 2013 survey.
• This means that a bit more than 40% of the
agencies sampled in 2013 are still in paper mode
for clinical documentation, and of those, only
42% reported that they would be looking to buy a
system in the next 12 months (Fazzi Associates,
2013).
NCM110

• Missing from these benchmarks, however, is the

degree to which the specific functionality that is
basic to EHR standards today is in the systems
being used.
• This functionality includes clinical decision support;
flexibility of views of patient care information; point-
of-care support for clinical documentation;
telemedicine and standardized, structured
terminologies; and ability to send and receive
patient information with other external providers.
NCM110

STANDARDS NEEDED FOR CARE

COORDINATION
• Standards for clinical information systems apply
to the ways data are named, stored, and shared
as well as to promote accuracy and to work
more efficiently.
• Ultimately, standardized systems can improve
patient safety and lower healthcare costs
(Thompson, Classen, & Haug, 2007).
NCM110

• The Continuity Assessment Record and

Evaluation (CARE) Tool was created by
CMS as part of the Post Acute Care
Payment Reform Demonstration (PAC-PRD)
authorized by the Deficit Reduction Act of
2005 (Centers for Medicare and Medicaid Services,
2013b; Office of the National Coordinator, 2014a).
NCM110

• The purpose of the CARE tool was to

standardize patient assessment
information from PAC settings to better
understand differences of care provided to
similar patients at different settings and
guide payment polices.
• It uses Web-based technology to develop
an interoperable data reporting systems for
the Medicare program.
NCM110

• It is also designed to minimize the provider

burden and only includes items related to
severity, payment, or monitoring the quality
of care.
• The tool was tested in a two-phased
demonstration project during 2008–2010
(Centers for Medicare and Medicaid Services, 2013d).
• Its initial use was required by CMS for Long-
Term Care Hospitals in the fall of 2012.
NCM110

• Another major focus of Standards

Development Organizations (SDO) has been
defining the shared care plan.
• The care plan has great potential for
facilitating coordination of care across
settings and between multiple disciplines.
• It is one centralized location where all care
team members can see a patient’s
individualized health goals.
NCM110

• Care Plan elements have been the topic of

standardization efforts for several years at
HL7. The HL7 Patient Care, Structured
Documents, and the Services Oriented
Architecture Working Groups have all
sponsored projects related to the care plan.
NCM110

• The Consolidated Clinical Document

Architecture (C-CDA) is the result of a
harmonization project addressing
overlapping efforts of HL7, IHE, Health
Information Technology Standards Panel
(HITSP), and the Health Story Project.
NCM110

• CMS adopted the C-CDA as a tool that

gave provider organizations a means to
accomplish patient information exchange,
and for EHR vendors to embed in their
products to meet ONC’s certification
requirements.
• It has also been reviewed and revised to
support its use for the exchange of care
plans. (Office of the National Coordinator for Health
Information Technology, 2014)
NCM110

• The 2014 Edition Certification Program for

Health Information Technology specifically calls
for the use of the HL7 C-CDA to be used for
capturing and exchanging patient summary
information.
• Implementation guides (IGs) are tools created
by the HL7 community to provide guidance on
how the standards developed by the
organization are to be implemented.
NCM110

• There are multiple domains, clinical and

other non-clinical healthcare domains,
represented in IHE.
• The Patient Care Coordination (PCC)
domain is specifically concerned with
identifying, clarifying, and testing
standards related to coordinating care
across settings and disciplines.
NCM110

• The framework maintained by IHE-PCC provides

technical specifications with clinical use cases and
examples specifically describing the implementation
of standards to facilitate care coordination.
• IHE tests each of the technical specifications
proposed for inclusion into the framework by inviting
vendors to participate in an annual “Connectathon”
event where vendors implement the proposed
specification as either a “creator” or a “receiver” of the
content included in the specification and demonstrate
a successful exchange of the content with other
participating vendors.
NCM110

• The ONC launched the S&I Framework in

January 2011 to engage community
involvement on interoperability challenges
critical to meeting Meaningful Use
objectives.
• The Transitions of Care (ToC) Initiative was
one of the first teams to be organized which
focused primarily on building consensus
toward the exchange of clinical summaries.
NCM110

• This care plan focus led to the formation of the

Longitudinal Care Coordination (LCC) Initiative
which has been dedicated to identifying and
validating a standards-based framework for care
management of chronic disease populations
across multiple settings and discipline.
• LCC also provides guidance to community
outreach pilot programs to implement evolving
care coordination tools in real-world situations to
identify policies required for operational systems.
NCM110

• For all this standards development work

and despite efforts on the parts of many
committed individuals and organizations to
collaborate and harmonize across the
different standards organizations, there is
not yet one data set or set of definitions
identified for the requirements of patient
information exchange for care coordination
or for the care plan.
NCM110

• Future work in the area is needed,

however, to harmonize data sets and
definitions identified for care coordination
to minimize confusion and maximize
information exchange for optimal care
coordination. The road to complete
interoperability is not yet complete.
NCM110

• Progress has been made through

standardized tools such as the CARE tool
and the C-CDA, but it is just a beginning.
• IHE has demonstrated interoperable
success through events such as the
Connectathon, but day-to-day use of
interoperable Care Plans between acute
and post-acute care areas is not yet
happening.
NCM110

• Complete implementation and use of

standardized interoperable care plans is
challenged by the long history of different
definitions and use of care plans over
many decades. There are as many
definitions and clinical processes for care
planning as there are unique sites of care
and individual care providers.
NCM110

• Care plans have served more as a tool for

the specific discipline to meet their
purposes or regulations than ever applied
as a patient-centered tool crossing care
setting or discipline boundaries.
NCM110

• The impact to vendors of the standards

development related to care coordination
varies based on their current tools in place.
Meeting requirements for CMS Certification
for use in meeting MU incentive payments
is the greatest focus for most.
NCM110

• Nursing has been represented in all

phases and environments of standards
development for care coordination. Each
of the SDOs reviewed here embraces
wide engagement from all disciplines.
NCM110

• The SDOs encourage clinicians and clinical

informaticists to contribute in leadership
roles, and also as contributors, reviewers,
testers, and/or implementers.
• Nurses engaged in these development
projects represent the full spectrum of
nursing including acute care, pediatric care,
chronic care, care management, and post-
acute care.
NCM110

DISCUSSION/SUMMARY
• System reform holds opportunity for post-
acute care to be tightly integrated partners
at community levels for the first time.
• Care coordination is multidimensional and
essential to preventing adverse events,
ensuring efficiency, and making care
patient-centered (Bodenheimer, 2008).
NCM110

• Effective care coordination requires well-defined

multi-disciplinary teamwork based on the
principle that all who interact with a patient must
work together to ensure the delivery of safe, high-
quality care.
• This integration calls for fairly sophisticated levels
of electronic health record system capabilities,
and this may present challenges for most
organization given the current state of information
systems in the postacute market.
NCM110

• Detailed information technology requirements

are needed for functionality that must be in
place in a cross-continuum to support care
coordination, communication and access data
collection, measurements, and reporting—all
infrastructure capabilities that are missing in
some degree in our electronic health records
(EHR) systems today across care settings
(Agency for Health & Research Quality, 2012;
Rudin & Bates, 2014).
NCM110

• Nursing and nursing informatics are

optimally positioned to be leaders in the
teams that design, build, and implement
these new health and IT systems that enable
care coordination.
NCM110

Thank you!