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Designing a care coordination model for older adults

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Content Running head: A CARE COORDINATION MODEL 1

DESIGNING A CARE COORDINATION MODEL FOR OLDER ADULTS

by
Corsha S. Caughman

A Dissertation Presented to the
Faculty of the USC Rossier School of Education
University of the Southern California
In Partial Fulfillment of the
Requirements for the Degree of
Doctor of Education

May 2019

Copyright 2019 Corsha S. Caughman

A CARE COORDINATION MODEL 2
Dedication
This study is dedicated to my husband, Allan, and my children, Corlan and Waverly. You
have been with me through my doctoral journey and I am proud to serve as an example of hard
work and dedication towards pursuing your ultimate goals and purpose in life. To my extended
family, my mother Lucille Samuel, my sister Royal Martin and her family, and my host of aunts
and cousins, thank you for always encouraging me to press on and being proud of me as the first
doctoral graduate in the family. To my mentors, Aniedi Abasiekong and Guerdon Stuckey,
thank you for providing me with your academic, professional and personal experiences that have
provided insight and advice that guided and encouraged me along this journey. Also, to my
tightknit circle of friends (you know who you are!) who have always encouraged and supported
me in everything that I have decided to accomplish. You ALL are my ROCKS!
This study is also dedicated to the tireless efforts of healthcare providers, nurses,
therapists (physical, occupational speech and others), behavioral healthcare specialists, social
worker, pharmacists and others within the healthcare field, who aim to improve the healthcare
outcomes of the growing demographics of older adults through care coordination efforts. An
example of this is displayed at PACE of the Southern Piedmont, my current employer. Thank
you for all you do!
Finally, this study is dedicated to God, the Father Almighty. Without You, none of this
would have been possible. I will always strive to continue to fulfill my purpose as an inspiration
and a role model for others, just as your Son, Jesus Christ is for us.

A CARE COORDINATION MODEL 3
Acknowledgements
Thank you to my committee members, Dr. Kimberly Hirabayashi, Dr. Kendra Jason,
Dr. Karen Lincoln and most of all my Chair, Dr. Helena Seli, for the hours that were dedicated to
aligning my dissertation and ensuring that it represented rigorous academic work. I aspire to
have the knowledge, wisdom and passion that you all possess and I am honored that you agreed
to serve on my committee.
Thank you to my classmates, Tammy Allen, Nadia Assaf, Estella Chavarin, Sindy
Fleming, Stephanie Hardaway, Karen Juday, Jerrilyn Miles and Reginald Ryder (Student
Success Advisor) for your unwavering support and encouragement along the way. You are my
lifelong friends.
Finally, thank you to Renee Rizzuti, CEO of PACE of the Southern Piedmont, my current
Leadership Team and Marketing Team; as well as Tomico Evans, Senior Vice President of
Client Services at the Housing Authority of the City of Charlotte (CHA) and my former Elderly
Services team (La Tonya McFadden, Michelle Sims, Diane Smith, April Witherspoon and
Perdensal Springs); and, my lifelong friend and resident of CHA, Mr. Henry Gantt. I will always
be indebted to you for your unwavering support and encouragement. Thank you for your
commitment and all the work you do towards the goal of ensuring that older adults remain in the
community safely and with dignity and respect.
You are all my Heroes!

A CARE COORDINATION MODEL 4
Abstract
Care coordination, or coordination of healthcare services, has emerged as a promising
solution to an increasing older adult population who are living longer with higher incidences of
chronic illness (Institute of Medicine, 2001; National Coalition on Care Coordination, 2010).
The purpose of this study is to conduct a gap analysis to understand the knowledge, motivation
and organizational influences that contributed to or inhibited the design of a care coordination
model for older adult patients. Clark and Estes’ (2008) gap analysis is a systematic, analytical
method that helps to clarify organizational goals and identify the gaps between the actual
performance level and the preferred performance level within an organization.
A qualitative study was conducted of seven healthcare providers employing qualitative
interviews and document analysis. The emergent themes revealed that there were gaps in
knowledge around the definition of care coordination and how it should be delivered for older
adult patients. Another potential barrier was healthcare providers’ motivation to design a care
coordination model because perceptions were split about the organization’s commitment towards
this goal. Finally, organizational barriers emerged around of lack of time, infrastructure and
resources, along minimal communication between healthcare providers and the leadership team.
Based on the results and findings, Kirkpatrick and Kirkpatrick (2016) New World Model was
used as a framework for implementing and evaluating a training program for addressing
identified gaps in designing a care coordination models for older adults.

A CARE COORDINATION MODEL 5
Table of Contents
Dedication ........................................................................................................................................2

Acknowledgements ..........................................................................................................................3

Abstract ............................................................................................................................................4

List of Tables ...................................................................................................................................7
List of Figures ..................................................................................................................................8
Introduction to the Problem of Practice ...........................................................................................9
Organizational Context and Mission .............................................................................................11
Importance of Addressing the Problem .........................................................................................13
Organizational Performance Goal ..................................................................................................15
Purpose of the Project and Questions ............................................................................................18
Methodological Approach .............................................................................................................19
Review of the Literature ................................................................................................................20
History of Care Coordination.............................................................................................21
Healthcare Providers and Care Coordination Models .......................................................24
Older Adult Patient Perspectives on Care Coordination Models .......................................26
Provider Knowledge, Motivation and Organizational Influences .................................................29
Knowledge Influences .......................................................................................................30
Motivation Influences ........................................................................................................32
Organizational Influences ..................................................................................................34
Participating Stakeholders: Sampling and Recruitment ................................................................42
Interview Sampling Criteria and Rationale........................................................................42
Interviewing Sampling (Recruitment Strategy) and Rationale ..........................................43
Data Collection and Instrumentation .............................................................................................44
Interviews ...........................................................................................................................44
Document and Artifacts Review ........................................................................................46
Data Analysis .................................................................................................................................47
Findings..........................................................................................................................................49
Findings for Research Question 1: Knowledge and Motivation Findings .........................50
Findings for Research Question 2: Organizational Findings .............................................58
Document Analysis Findings .............................................................................................66
Summary of Findings .........................................................................................................69
Recommendations for Practice to Address KMO Influences ........................................................71
Knowledge Recommendations ..........................................................................................72
Motivation Recommendations ...........................................................................................73
Organizational Recommendations .....................................................................................74
Recommendations Specific for Providers and RCHC’s Minority Older Adult
Population ..........................................................................................................................80
Future Research .............................................................................................................................81
References ......................................................................................................................................83
Appendix A: Definitions ..............................................................................................................101
Appendix B: Protocols .................................................................................................................103
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Appendix C: Additional Resources Needed ................................................................................107
Appendix D: Credibility and Trustworthiness .............................................................................110
Appendix E: Ethics ......................................................................................................................111
Appendix F: Limitations and Delimitations ................................................................................113
Appendix G: Implementation and Evaluation Plan .....................................................................115
Appendix H: Immediate Evaluation Instrument ..........................................................................130
Appendix I: Delayed Evaluation Instrument ...............................................................................132

A CARE COORDINATION MODEL 7
List of Tables
Table 1: Organization Performance Mission, Performance Goal and Stakeholder Goal ..............18
Table 2: Knowledge, Motivation and Organizational Influences and Types ................................38
Table 3: Summary, Knowledge Recommendations.......................................................................72
Table 4: Summary, Organizational Recommendations .................................................................75
Table 5: Interview Participant Comments Regarding Additional Resources Needed for Care
coordination models for Older Adults .........................................................................................107
Table 6: Outcomes, Metrics, and Methods for External and Internal Outcomes ........................117
Table 7: Critical Behaviors, Metrics, Methods, and Timing for Evaluation ...............................119
Table 8: Required Drivers to Support Critical Behaviors ............................................................120
Table 9: Evaluation of the Components of Learning for the Program ........................................125
Table 10: Components to Measure Reactions to the Program .....................................................126

A CARE COORDINATION MODEL 8
List of Figures
Figure Y. Conceptual framework of provider’s knowledge and motivation influences and
interaction with organizational influences (KMO) to design a care coordination model for older
adult patients. .................................................................................................................................40

A CARE COORDINATION MODEL 9
Introduction to the Problem of Practice
The U. S. healthcare system is in crisis. Providing and financing healthcare between
distinct and separate entities with competing interests has led to a system that provides
fragmented care for patients who have complex medical needs, complicated by disparate social
needs (Cebul, Rebitzer, Taylor, & Votruba, 2008). Fragmentation in the healthcare system has
resulted in communication failures among all participants, contributing to increased healthcare
costs, decreased patient outcomes and lower quality of care (AHRQ, 2010). According to the
Institute of Medicine (2010), designing care coordination models has emerged as a key strategy
to improving the effectiveness, safety and efficiency of a disjointed U. S. healthcare system that
is not meeting the needs of its consumers.
Care coordination is defined as 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 healthcare services (AHRQ, 2010). The benefits of care coordination
are widely accepted across multiple disciplines. For example, research has found that care
coordination activities can improve the quality of care and lower health care costs for high risk
children with chronic illnesses (Klitzner, Rabbitt, & Chang, 2010; Lindeke, 2015). Cancer
patients have realized decreased length of hospital stays, lower readmission rates and a higher
quality of life as a result of care coordination activities (Bourque, Chan, Wilson, Lau, Yuh, B,
Yamzon… Crocitto, 2015; Daly, Douglas, Gunzler, & Lipson, 2013). Cancer patients also
report the value of having assistance in navigating through an uncoordinated, confusing and
inefficient care system, which also helps to improve cancer care outcomes (Carroll, Humiston,
Meldrum, Salamone, Jean-Pierre, Epstein, Fiscella, 2010). Other benefits to care coordination
activities include higher interprofessional collaboration (DelBoccio, Smith, Hicks, Lowe, Voight,
A CARE COORDINATION MODEL 10
Graves-Rust, Volland, & Fryda, 2015), increased synergy among interdisciplinary teams
(Zimmerman, & Dabelko, 2007) and improved healthcare system performance (Hofmarcher,
Oxley, & Rusticelli, 2007).
Care coordination has been particularly beneficial for older adults in addressing chronic
disease. As adults age, they are likely to suffer from at least one type of chronic disease and as
they grow older they are likely to suffer from multiple chronic conditions (Agency for
Healthcare Research and Quality, 2016; Journal of the American Geriatrics, 2012; Qiu et al.,
2010). Additionally, the growth in the number of older adults is unprecedented. According to
the Pew Research Center (2010), 10,000 individuals from the Baby Boomer generation turn 65
everyday. By the year 2050 one out of every 65-year old will live to the age of 90 years old
(American Psychological Association, 2017; U. S. Census Bureau, 2014).
A growing number of older adults with multiple chronic conditions are resulting in
healthcare costs that are exponentially higher, especially among minority and low-income
populations. Healthcare disparities persist within and across racial, ethnic and socioeconomic
groups as it relates to accessing healthcare and the quality of healthcare received (AHRQ, 2010).
Healthcare inequities are common among African American, Hispanics and Asian populations
and more research is needed to understand how environmental, sociocultural, behavioral and
biological factors contribute to dismal health outcomes in minority older adults who may also be
experiencing the additional challenges of decreased physical and cognitive abilities (AHRQ,
2017; NIA, 2019).
Care coordination, or coordination of healthcare services, has emerged as a promising
solution to an increasing older adult population who are living longer with higher incidences of
chronic illness (Institute of Medicine, 2001; National Coalition on Care Coordination, 2010).
A CARE COORDINATION MODEL 11
Addressing the healthcare outcomes of older adults through care coordination activities have the
possibility of decreasing medication errors, unnecessary emergency room visits and diagnostic
tests and reducing hospital admissions and readmissions, all of which leads to decreased health
care costs and improved health outcomes (AHQR, 2019). Practitioners, policy makers and
researchers are calling for the design of care coordination models for older adults as an
innovative approach to improving patient experiences and increasing and the quality of
healthcare (Browdie, 2010; Lee, 2013; Naylor, Hirschman, O’Conner, Garg, Pauly, 2013;
Scholtz, 2015).
According to Robinson (2010) there are three models of care coordination: social,
medical and integrated. Social models were developed by state Medicaid programs to manage
the long term needs of older adults. Medical models were developed to manage chronic disease
and integrated models manage both social and medical needs. What follows is an exploratory
study that will analyze the organizational capacity of the Royal Community Health Center
(RCHC), (a pseudonym), via its stakeholders to design a care coordination model for its older
adult patients. Because this is a new initiative for RCHC, results from the study will culminate
into recommendations for implementation of this model for RCHC’s older adult patients by the
Fall of 2019.
Organizational Context and Mission
The Royal Community Health Center (pseudonym) emerged as a typical healthcare
organization at this point in time that was available to be studied. Its leaders expressed interest
in measuring the organization’s capacity to design care coordination models for its older adult
patients. Located in the Southeastern region of the United States, Royal Community Health
Center (RCHC) is a 501(c)(3) community-based organization whose mission is to provide the
A CARE COORDINATION MODEL 12
highest quality, medical, dental and mental health services for low-income and underserved
individuals who lack access to healthcare. Established in the early 2000’s, RCHC initially began
as a free health clinic for low income uninsured adults ages 55 and over and care was provided
quarterly through a network of volunteers supported by a small foundation grant. Within a
couple of years, services expanded to two nights a week and included adults ages 19 and over.
Healthcare provided was episodic and addressed acute medical issues. In the mid-2000’s, RCHC
began to provide chronic disease management services and through a Health Resources and
Services Administration collaborative, RCHC introduced both the Chronic Care Model and the
Patient Electronic Medical Record System to support improved outcomes for individuals with
chronic disease. Funding of RCHC’s services from 2000 through mid-2015 was dependent on
grants and donations and a small revenue stream from nominal patient fees of $10 for a primary
care visit. This system of funding allowed the provision of much needed services but was
woefully inadequate to meet the needs of the community. Faced with the widening gap between
needs and services, the RCHC Board of Directors voted in 2013 to transition from a free clinic
model of services to a Federal Qualified Health Center (FQHC) and accept patients covered by
Medicaid and other forms of health insurance. RCHC implemented a comprehensive electronic
practice management and medical record system to support care coordination, clinic operations
and third-party billing in 2015. Additionally, receipt of New Access Point funding in 2015
allowed the expansion of services and supported the addition of a second service delivery
location within the geographic area. Subsequently, RCHC received supplemental oral health
funding and began provision of dental services using a temporary dental operatory. Federal
funding has been leveraged with local and county funding to support the development of three
operatory dental clinics, scheduled to open within the next year.
A CARE COORDINATION MODEL 13
Services at RCHC include acute and chronic disease treatment and management,
preventive health services, behavioral health, women’s health, pediatrics, diagnostics, health
education and dental. Clinical services include outpatient diagnostic x-ray and lab, health
screenings and immunizations, OB/GYN services, including prenatal (up to 12 weeks), postnatal
and well child care, and pharmacy. RCHC also provides counseling, follow-up and discharge
planning, support for Medicare/Medicaid enrollment, health education, assistance transportation,
translation and outreach. Of the patients served at RCHC in 2016, 100% of them qualify as low
income, with over 90% being uninsured. The demographic makeup of patients is as follows:
50% Latino, 47% as non-Hispanic, and 3% as Vietnamese, Asian and West African. Of its 2738
patients, 389 or almost 14% of patients are ages 65 and older.
Importance of Addressing the Problem
Designing care coordination models for older adult patients is important for four main
reasons. First, there has been considerable growth in the older adult population. According to
the Pew Research Center (2010), 10,000 individuals from the Baby Boomer generation turn 65
everyday. By the year 2050, those ages 65 and older will make up 21% of the population.
Meanwhile this population will live longer, with one out of every 65-year-old adult living to the
age of 90 years old. This dramatic increase in population is causing a strain on our U.S.
healthcare system due to rising healthcare costs.
Second, rising healthcare costs has driven the need for innovative solutions for older
adult healthcare. Medicare beneficiaries 65 and older often have multiple healthcare needs
which require additional time and resources in diagnoses and treatment, thus requiring more
resources (Gorichky & Hershey, 2015). And the longer individuals age, the more likely they are
to suffer from multiple chronic conditions. Older adults with multiple chronic conditions have
A CARE COORDINATION MODEL 14
healthcare costs that are seven times costlier that those with one chronic condition (Stanton,
2006). Furthermore, those with chronic conditions account for 78% of all healthcare spending,
98% of all Medicare spending and 77% of all Medicaid spending (Partnership for Solutions,
2003).
Third, providing care for older adults with multiple chronic conditions has been delivered
in an uncoordinated, fragmented way that fails to meet the individual healthcare needs of older
adult patients. For example, in addition to seeing their primary doctor, older adult patients will
see multiple specialists within their healthcare plan. Often their primary care doctor will not be
informed of these visits. Furthermore, doctors may not know if their patient was hospitalized
unless informed by the patient. Delivering healthcare in this way not only contributes to high
costs in the form of duplicate doctor office visits and medical tests, hospital stays and
polypharmacy, it also decreases the quality of healthcare for older adults. The Agency for
Healthcare Research and Quality (2017) assert that innovative care coordination models are
critical to ensuring that health systems are connected, patients have established clear
communication channels with their specialists and referral coordinators can efficiently connect
patients to services.
Fourth, although this perspective was not thoroughly explored in this study, health
disparities among vulnerable racial and ethnic groups may benefit from the design of care
coordination models. Racial and ethnic disparities have been well documented with respect to
access to and quality of healthcare services for older adults (CDC, 2010; IOM, 2013). According
to Smith and Brawley (2003), socioeconomic factors such as poverty, inadequate income and
lack of health insurance are the main culprits that create disparities around minority older adult
health. Lack of access to social services and support, combined with complex medical issues,
A CARE COORDINATION MODEL 15
present challenges for healthcare professionals in increasing the health and wellness of this
patient population. Coordinating medical and social support services needed, such as
transportation, food inefficiency and housing, could be promising in helping vulnerable older
adults maintain stable health outcomes (Lee, 2018; Robert Wood Johnson Foundation, 2009).
Considering the consequences of a rising aging population along with increasing chronic
illnesses leaves serious implications for a healthcare system that is critically unprepared for its
new client base (Mitchell, 2014). An analysis of nine million Medicaid and dual
Medicare/Medicaid claims revealed that healthcare costs for patients with uncoordinated care
was 75% higher than those with uncoordinated care (Berry, Rock, Housekamp, Brueggeman &
Tucker, 2013). Care coordination has promise to improve the efficiency of collaborating
medical and social needs of older adults, while incorporating community supports, so that a
holistic view of care is realized (John Hartford Foundation, 2014). Policy makers and
practitioners seek out care coordination models as a promising solution to addressing the needs
of older adults who require high cost treatments for multiple chronic conditions.
Organizational Performance Goal
A Patient Satisfaction Survey was conducted by an independent evaluator who surveyed
100 patients from RCHC from 2016-2017. Although the results were not separated by the age of
the patients, the status of organizational performance goals as they relate to medical costs per
patient and satisfaction with overall quality of care was enlightening. During this timeframe,
total medical costs for patients were up by 35%. Additionally, lower levels of satisfaction were
reported when patients were asked about the quality of time spent with medical providers.
Furthermore, patients reported that healthcare providers did not always take adequate time with
them and they felt as though providers did not always treat them with respect.
A CARE COORDINATION MODEL 16
In summary, the patient satisfaction survey reflected patient perceptions that their
medical providers provided a lower quality of care. Additionally, financial data obtained by
RCHC indicated that healthcare costs had risen for their patients. In my initial discussions with
organizational leaders, I utilized Clark and Estes (2008) framework to assist them in creating an
aspirational goal that would reflect improvement in older adult patient care. Although the
organization had not adopted a specific strategic direction in designing a care coordination model
for its older adult patients, RCHC leaders wanted to understand the organization’s capacity to
design this model and believed that they were in a position to implement it. This led to the
wording of the organizational goal that by October 2019, RCHC would implement a care
coordination model for its older adult patients. The Chief Executive Office, Chief Operating
Officer and Medical Director aspired to create and meet this goal as a result of feedback from the
independent evaluation which highlighted performance gaps in patient satisfaction of healthcare
services received. Measures to track achievement of this goal would be developed and
monitored by RCHC’s Quality Improvement Team. The goal of the study, therefore, was to
explore RCHC’s capacity to reach the aspirational goal and make recommendations to support
the organizational capacity to implement a care coordination model for its older adult patients.
Stakeholder Group of Focus and Stakeholder Goals
Healthcare providers were the stakeholder group of focus. Fragmentation of care occurs
when communication between different providers does not occur; causing serious defects in
patient quality of care (Marabelli, Newell, Krantz, & Swan, 2014). There are several stakeholder
groups who contribute to care coordination activities for older adult patients. They include
primary and specialty care doctors who are the first point of contact in care coordination when
information is shared with respect to preventive treatments and after treatments of comorbid
A CARE COORDINATION MODEL 17
conditions (Synder et al., 2015). Also included are nurses who play a major role in connecting
patients with their providers and forming strong collaborative partnerships in promoting
continuum of care and optimal health outcomes on their patients’ behalf (Cropley & Sanders,
2013). Care coordinators monitor and evaluate patient care by supervising the activities of
multiple specialists and social supports the patients may need. Referral coordinators make
appointments and ensure that information is relayed to medical providers for the stakeholder
group at the center of care coordination activities. Behavioral health specialists provide care
management that specializes in the education, prevention and treatment of mental health illness.
Also included are clinicians, front desk and appointment staff who are engaged with the patients
to provide multiple services and deliver care coordination activities according to FQHC rules and
the Centers for Medicare and Medicaid Services (CMS). For purposes of this study, the
stakeholder group of focus was RCHC’s primary and specialty care doctors, care coordinators,
nurses and behavioral health specialists because they were the individuals who initiated the
design of care coordination models for older adults.
The stakeholder goal was that by August 2019, a care coordination model would be
designed for RCHC’s older adult patients. Meeting this goal would contribute towards RCHC’s
mission of providing higher quality care and reduced health care costs for its older adult
population. Additionally, the RCHC desired to be on track to meeting its organizational of goal
of implementing this innovative care coordination model by October 2019.
The following table list RCHC’s organizational mission, organizational performance goal
and the stakeholder performance goal.

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Table 1
Organization Performance Mission, Performance Goal and Stakeholder Goal
Organizational Mission

The mission of the Royal Community Health Center (RCHC) is to provide the highest quality,
patient-centered healthcare services for low-income and underserved individuals.
Organizational Performance Goal

By October 2019, Royal Community Health Center (RCHC) will implement a care
coordination model for 50% of its older adult population (ages 65+) for the purposes of
reducing costs and increasing overall quality of care.

Stakeholder Performance Goal

By August 2019, RCHC providers will design a care coordination model for its older adult
population.

Purpose of the Project and Questions
I designed this study to conduct a gap analysis to understand the knowledge, motivation
and organizational influences that contributed to or inhibited the design of a care coordination
model for older adult patients. A secondary focus was the exploration of understanding the
organization’s capacity to serve the clinic’s population, (who were older adults from vulnerable
minority populations), and the specific characteristics and needs of this group as it related to the
design of a care coordination model that would address their complex medical and social needs.
Because this was a new initiative for RCHC, this was an exploratory study that examined
organizational capacity through the lens of its healthcare providers. Recommendations follow on
how RCHC should proceed in designing a care coordination model for its older adult patients.
RCHC will execute the recommendations from this study for purposes of implementation by
October 2019.
A CARE COORDINATION MODEL 19
The analysis began by exploring a list of probable or assumed influences and then
examining these methodically to determine actual or validated causes. Semi-structed open-ended
interviews commenced with providers, followed by document analysis to identify patterns of
knowledge, motivation and organizational culture that promoted or inhibited the design of care
coordination models for older adult patients. While a complete analysis would have focused on
all stakeholders who participated in patient care coordination, for practical purposes the
stakeholders of focus were the healthcare providers who initiate the design of care coordination
models for older adults. The research questions that guided this study are as follows:
1. What are the RCHC healthcare providers’ knowledge and motivation influences related
to designing a care coordination model for its older adult patients?
2. How do the RCHC healthcare providers’ knowledge and motivation influences interact
with RCHC to shape the providers’ ability to design a care coordination model for its
older adult patients?
3. What are the recommended knowledge and skills, motivation, and organizational
solutions?
Methodological Approach
Clark and Estes’ (2008) gap analysis is a systematic, analytical method that helps to
clarify organizational goals and identify the gaps between the actual performance level and the
preferred performance level within an organization. This framework was utilized to
conceptualize and frame the study. To address RCHC’s performance gap, I employed the
method of qualitative research through a social constructivist lens. Qualitative research is of the
assumption that individuals’ meanings and experiences are historically and socially constructed
(Creswell, 2014). Locke, Silverman and Spirduso (2010) states that an individuals’ perception is
A CARE COORDINATION MODEL 20
their reality. These events may be different or shared among individuals based on their age,
gender, ethnicity, and culture, as well as other social, political, technological or environmental
factors that are occurring at that time. Perceptions of events by individuals of diverse
backgrounds at any given time are based on their individual experiences.
Although I had a priori assumptions, qualitative research was the best fit for my study
because I also wanted interpretations to occur inductively, as themes and patterns developed
naturalistically as the result of data collection methods. Researchers state that gathering data
from semi-structured interviews and other data analysis techniques can capture the multiple
experiences and meanings of research participants (Creswell, 2014; McEwen & McEwen, 2003).
Another reason why qualitative research was appropriate was because of the intellectual goals
that can be achieved in interpreting the experiences of others (Maxwell, 2005). Intellectually, I
sought to understand participants’ meaning of experiences, situations and events and how they
influence behaviors in relationship to knowledge and motivation influences and how they
interact with the organizational culture to design care coordination models that include the
perspectives of older adults. Definitions of terminology utilized throughout this study may be
found in Appendix A.
Review of the Literature
This section includes a review of the literature relevant to the history of care coordination
efforts in the United States. First is a discussion about the history of care coordination and
healthcare providers’ role in care coordination. Next, research about older adult patient
characteristics will be revealed specifically as it relates to older adults of color. Finally, literature
on cognition, social environments and caregiver support will be presented, as each may influence
the design of care coordination models for older adults.
A CARE COORDINATION MODEL 21
History of Care Coordination
American Association of Pediatrics (AAP) introduced the concept of care coordination
with the idea of a single medical home for children with chronic conditions (Jackson et al.,
2013). The definition expanded to include a partnership approach that provided accessible
healthcare that was patient-centered and delivered in a seamlessly coordinated, compassionate
and culturally responsive manner (The Robert Graham Center, 2001). Care coordination further
evolved to include healthcare for adults ages 65 and over after the passage of Medicare and
Medicaid funding in 1965. The dramatic increase in the demand of healthcare services for adults
who have never had access to care spurred discourse around primary care, care coordination and
the lack of healthcare providers (Brandt, 2015). Also foreseen was the increasing population of
older adults and high healthcare costs for a those who were living longer with multiple chronic
conditions (Scholtz, 2015). Imbalances between a growing aging population, high healthcare
costs, lack of access to healthcare and low patient satisfaction prompted innovations such as care
coordination to address chronic illnesses in older adults.
The response from federal government was to introduce innovations that creatively
addressed chronic illnesses of older adults through care coordination models. For example, in
1982, the Department of Health and Human Services funded the National Long-Term
Demonstration project which encouraged coordination of services for older adults who needed
long term care and caregiver support (Coughlin, 1989). The overall goal was to enable older
adults to remain in their homes, thereby reducing healthcare costs and increasing quality of care.
An evaluation of the project revealed that channeling patients through a community-based care
model provided minimal financial incentives but increased the quality of life for its patients and
their caregivers (NCBI, 2017). Continuing the quest to reduce rising healthcare costs for long
A CARE COORDINATION MODEL 22
term supports, the Healthcare Financing Administration (HCFA) financed the Social Health
Maintenance Demonstration project (SHMD) (Harrington & Newcomer, 1991). The SHMD
combined Medicare Health and Maintenance Organization (HMO) coverage with expanded
healthcare benefits. Earlier efforts did not show cost reductions in medical care; however, it was
noted that healthcare, facilitated by care coordination efforts, would make a difference
(Newcomer, Harrington & Friedlob, 1990). The HCFA also funded the On Lok program which
provided for health, nutrition, and recreational services to frail adults and as a result of its
success, the Program of All-Inclusive Care for the Elderly (PACE) program was borne (NPA,
2017). Evaluations of PACE have been mixed, mostly finding that medical costs are not reduced
as a result of participation in the program; however, certain aspects of quality of care were
increased (ASPE, 2014).
A 2001 report from the Institute of Medicine Crossing the Quality Chasm called for an
overhaul of the U. S. healthcare system, adopting care coordination as the key to improving to
quality of healthcare delivery and reducing healthcare costs. Behavioral healthcare providers,
informed by the earlier care coordination practices of AAP, began to develop person-centered
homes as a means to coordinate the multiple healthcare needs of those who suffered from mental
health and substance abuse disorders (Galbreath, 2012). Interventions also included aspects of
the Chronic Care Model (Bodeinhemer, Wagner, & Grumbach, 2002) while federal legislation
simultaneously allowed the Centers for Medicare and Medicaid Services (CMS) to solicit
proposals for Medicare Demonstration Projects that would include elements found to previously
increase the quality of care, while reducing Medicaid expenditures (Robinson, 2010). Several of
these reforms were included in the most comprehensive healthcare legislation through the Patient
Protection Affordable Care Act (ACA) of 2010. The ACA extended healthcare coverage to
A CARE COORDINATION MODEL 23
millions of individuals and formalized the concept of care coordination by offering incentives for
healthcare organizations to deliver care through greater teamwork, integration of care, and
increasing communication among providers and patients in efforts to improve quality of care and
reduce costs (Burwell, 2015). Incentives included alternative payment models such as Patient
Centered Medical Homes (PCMH), Accountable Care Organizations (ACO) and other bundled
options which tie Medicare payments to value and quality of healthcare. Burwell noted that this
was the first time that Medicare payments have been linked to value-based systems.
Additionally, CMS continued to implement pilot programs to encourage care coordination
among providers and educate their patients in treating chronic health conditions sooner than later
to improve the overall quality of healthcare and reduce healthcare costs (Nester, 2016). Despite
this movement, a five-year evaluation of the ACO reports that it is still too early to understand
whether it is effective in reducing health costs or increasing quality of care; however, the ACOs
have expanded insurance coverage to those who were previously uninsured (Reisman, 2015).
As ACO’s continue to expand healthcare coverage, the need to include older patient
feedback in the design of their care coordination models is promoted (Bravo et. al, 2016; Stuart
& MacPherson, 2014). Research notes that individuals desire to know their healthcare options
and want to be actively engaged in the coordination of care (IOM. 2001). Healthcare treatment
should be aligned with patient preferences in order to eliminate duplication of services and
unwanted medical or social service needs (Reinhart, 2013). A quantitative study conducted by
Naylor et al. (2004) found that when heart failure patients provided feedback in their care
coordination plans, they experienced reduced hospitalization costs and lower deaths than those
who did not provide feedback about their care preferences. Bodenheimer (2008) posits that older
adult patients must be decision-makers in coordinating care along with their primary physicians,
A CARE COORDINATION MODEL 24
specialists and other providers for cost efficiency. Older adult patients who are active
participants in their care coordination models can help manage the costs of medical care.
Additionally, shared decision making will increase older adult patients’ quality of care.
Healthcare Providers and Care Coordination Models
Although healthcare providers serve a pivotal role in the design of care coordination
models, the literature is deficient in providing guidance on how providers can do so. Scarce
literature exists because providers have historically minimized the role and voice of older
patients in the design of care coordination models (Rugianno, Shtompel, & Edvardsson, 2013).
Notwithstanding, researchers have provided hints about how this loss in communication between
providers and older adult patients can be mitigated.
Healthcare providers are more likely to design care coordination models when they
understand the definition of care coordination and the role they play in designing care
coordination activities. The Agency for Healthcare and Research Quality (AHRQ) provides a
consensus definition of care coordination and provides specific steps for designing models that
include the perspectives of older adults:
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 healthcare services. Organizing care involves the marshaling of
personnel and other resources need to carry out all required patient activities and is often
managed by the exchange of information among participants responsible for different
aspects of care. (2017)
Because care coordination requires that providers must work in team-based model,
doctors must have clarity around their roles and clearly understand their responsibilities in
A CARE COORDINATION MODEL 25
coordinating care for their patients (True, Stewart, Lampman, Pelak, & Solimeo, 2014). Also
developed was the Care Coordination Quality Measure for Primary Care, which informs
providers about their role in care coordination models that include feedback from older adult
patients (AHRQ, 2017). When healthcare providers have clarity around the expectations of care
coordination models from their patients, they will begin to understand the value that such models
can have.
Providers who value the importance of designing care coordination models will be
motivated to do so. Physicians should avoid being paternalistic and not use professional
language that older adult patients do not understand, as patients may ultimately feel
disempowered because they are not comfortable engaging in their care coordination decisions
(Dyrstad, Testad, Aase & Storm, 2015). Providers should also be motivated to embrace the
PCHM model, which heavily relies on care coordination activities, and they should be confident
that these strategies can improve patient experiences (Alexander, Cohen, Wise & Green, 2013).
Healthcare providers who value the importance of care coordination will align with
organizational support in designing care coordination models for older adults that meet their
complex medical and social needs.
An organizational culture which promotes shared values of designing care coordination
models will encourage providers to do the same. Critical is that organizations make available to
its providers the resources they need to design care coordination activities (AHRQ, 2010; True,
Stewart, Lampman, Pelak, & Solimeo, 2014). Leadership should also promote the frequency of
interprofessional meetings in order to support collaborative practice in the design of such models
(Mavronicolas, Laraque, Shankar, & Campbell, 2017). When providers can work in a highly
collaborative environment, greater individual and team satisfaction occurs and shared values are
A CARE COORDINATION MODEL 26
formed (Nester, 2016). Doing so will also reduce the stress that providers experience in
managing patients with chronic conditions, which negatively affects the coordination of care for
older adult patients (Davis, Abrams, & Stremikis, 2011). An organization that fosters a culture
which supports care coordination models will help support the design of such models.
Older Adult Patient Perspectives on Care Coordination Models
At the center of care coordination activities are older adult patients who suffer from
chronic illnesses. Research notes that older adult patient perspectives must be considered in the
treatment and management of their complex conditions (Wagner et al., 2001) Older adults value
healthcare providers who have the expertise to perform care coordination activities because their
doctors can serve as expert liaisons in connecting them to a range of holistic interventions that
can meet their complex healthcare needs (King, Boyd, Dagley & Raphael, 2017). Additionally,
older adult patients value simple, clear instructions in addressing their healthcare needs, in
addition to high quality interpersonal skills which demonstrate active listening, concern and
empathy for their healthcare outcomes (Hazzard, Barone, Mason, Lambert, & McMahon, 2017).
Finally, older adult patients express a need for a care coordination model that provides
convenient access to their healthcare providers in person, on the telephone or over the internet
and they desire a single point of contact within the healthcare facility that can help them address
the multiple, competing interests of their complex healthcare conditions (Bayliss, Edwards &
Steiner, 2008). Designing care coordination models that align with older adult perspectives
about the type of interventions needed to address their chronic conditions may be influential in
improving their healthcare outcomes, while decreasing healthcare costs to treat their chronic
conditions.
A CARE COORDINATION MODEL 27
Older adult patients of color. Although scant research exists, there are a few studies
that hint at the implications of care coordination models for older adult patients of varying racial
and ethnic backgrounds who are at the poverty level. Research has found that chronically ill
patients of color face more barriers in obtaining specialty care because of less financial resources
to treat them based on lower paid Medicaid reimbursements to providers (Reschovsky &
O’Malley, 2008). Challenges also exist for ethnic minority patients because of their lack of
familiarity with the U.S. healthcare system, cultural barriers related to illnesses and treatments
and language barriers that lead to inadequate communication inhibiting coordination of care
(Zangi, 2015). Data from the 2015 Medicare’s Consumer Assessment of Healthcare Providers
and Systems (CAHPS) reveal that minority groups tend to have worse patient outcomes across a
broad range of metrics than their White counterparts (AHRQ, 2018). On the other hand, a study
on older adult patient perspectives report that minority older adult patients, regardless of their
income, are just as likely as their White counterparts to report care coordination problems
(Maeng, Martsolf, Scanlon, & Christianson, 2012; Martsolf et al., 2012). These findings suggest
that care coordination models that primarily focus on racial/ethnic older adult patient
characteristics may not be productive in increasing patient healthcare outcomes and reducing
healthcare costs. In designing care coordination models, providers must also take into account
other factors such as older adult patient cognition, their social environments and family and
caregiver support.
Older adult patient cognition, social environments and caregiver support. Although
not the main focus of this study, it is necessary to include information on patient cognition, social
environments and caregiver support. As adults age, it is important to understand cognitive
changes that accompany aging. According to Harada, Love and Triebel (2013), cognitive ability
A CARE COORDINATION MODEL 28
can be described in six different domains: processing speed, or the rate at which cognitive
activities are performed with motor responses; attention, which is the ability to concentrate;
memory, or the ability to recall information; language that remains the same or even improve
with aging; visuospatial abilities/construction, or understanding space in two and three
dimensions; and, executive function, which is the ability independent, appropriate behaviors.
Mild cognitive decline is normal for individuals as they age but can also be the precursor to more
serious neurological conditions such as dementia or Alzheimer’s. Studies have found that racial
and ethnic minorities have higher rates of dementia than their White counterparts (Anderson,
Bulatao, & Cohen, 2004; Nielsen, Vogel, Phung, Gade, Waldemar, & Nielsen, 2011).
Additionally, African Americans and Latino populations have higher rates of Alzheimer’s
disease (Mindt, Arentoft, Coulehan & Byrd, 2013). Cognitive changes are also impacted by
social environments.
Studies have found that social environments and access to social supports can positively
impact cognition in older adults (Shaoqing, Donald, XinQi Dong 2017; Sims, Hosey, Levy,
Whitfield, Katzel, & Waldstein, 2014). An individual’s sense of safety and security within the
community, exercise and physical activity, access to healthy foods, green space, transportation
and potential for social interactions improves cognition in older adults, improving psychosocial
behaviors and overall well-being (Besser, McDonald, Song, Kukull & Rodriguez, 2017).
Cognition is also preserved when social supports are available immediately following a traumatic
event (Greene & Graham, 2007). Living in a neighborhood that is comprised mostly of older
adults is associated with lower rates of depression, increased health and lower rates of mortality
(Friedman, Shih, Slaughter, Weden & Cagney, 2017). Providers must understand that having
access to social supports and social engagement increases the health outcomes of vulnerable
A CARE COORDINATION MODEL 29
older adults (Jacobs, 2018) and thus, positively impacts cognitive abilities. Evidence of social
supports includes interactions with family members and caregivers who are willing to be present
in providing support that adults may need as they age.
Caregiver support has always been critical in providing support to older adults with
cognition disorders. Historically, caregivers have been family members; however, caregiver
support has become more complicated, as 60% of caregivers are now employed as a result of
work and family life (Bookman & Kimbrel, 2011). Caregivers are now a part of the social
support network that older adults have hopefully established at some point in their lifetime.
Contributing to the challenges of caregiver support is the fact that caregivers are vulnerable to
systems of care that are not designed to recognize or treat individuals with cognitive impairments
(Naylor et al., 2007). There are many studies that focus on caregiver stressors related to the
demands of caregiving, but very few focus on the difficulties that caregivers face in dealing with
multiple healthcare providers, social service professionals or the bureaucracies in which they
work (Levin & O’Shaughnessy, 2014). Interventions such as the Caring for Older Adults and
Caregivers at Home (COACH) (D’Souza, et al., 2015) are critical to providing caregivers the
support they need to provide care for older adults with cognitive disorders such as dementia or
those related to physical impairments and behavioral disorders.
Provider Knowledge, Motivation and Organizational Influences
This section will focus on RCHC’s provider capacity to design care coordination models
for its older adult patients. Clark and Estes (2008) posit that goal achievement is dependent upon
employees’ knowledge and skills, their motivation to achieve a goal and organizational barriers
that contribute to inadequate work processes. Analyzing knowledge, motivation and
organizational influences is a research-based method for determining the gaps between goals and
A CARE COORDINATION MODEL 30
current performance. What follows is a discussion of RCHC’s assumed knowledge, motivation
and organizational influences.
Knowledge Influences
Although the goal of care coordination is to strengthen communication between providers
and their older adult patients, it cannot be realized unless providers possess the necessary
knowledge and skills around the concepts of care coordination and its potential influence on
overall health outcomes. Rueda (2011) posits that addressing knowledge gaps ensures that
interventions match solutions around knowledge influences that may arise. Krathwohl (2010)
describes different types of knowledge into four categories: declarative or factual, conceptual,
procedural and metacognition. An example of declarative or factual knowledge is the
understanding of specific facts, terminology and details as it relates to the field of care
coordination. Conceptual knowledge is the ability to classify, organize and differentiate between
more complex forms of care coordination activities and the relationships among them.
Procedural knowledge is the understanding of how to implement care coordination activities
step-by-step to address health outcomes. Finally, Krathwohl describes metacognition as the
awareness of one’s own thought processes with respect to strengths, weaknesses, and self-
regulation to address health conditions through care coordination models. In a review of the
literature on care coordination models, research reveals that healthcare providers possess
minimal knowledge in designing care coordination models for their older adult patients as they
strive to address their multiple healthcare conditions (Bodenheimer, 2008; Sholtz, 2015).
Providers need to know the definition of care coordination. There is a lack of
consensus around the definition of care coordination. According to the AHRQ (2017) care
coordination has more than 40 definitions depending on the complexities within the healthcare
A CARE COORDINATION MODEL 31
system. Additionally, there is limited guidance on who should provide care coordination
activities within a healthcare organization (Browdie, 2013; Monterio, Arnold, Locke, Steinhorn,
& Shanske, 2015). This has been problematic as researchers and clinicians have tried to
determine what should be included in care coordination interventions (McDonald, 2004). In
order for providers to design care coordination models for their older adult patients, they must
first have a clear understanding of what constitutes care coordination.
Providers need to understand the specifics of older adult cognitive capacity as they
affect the design of care coordination models. As a secondary focus, providers need to know
how cognitive capacity may have an impact on the design of care coordination models for their
older adult patients. According to Browdie (2013), one of the challenges of designing care
coordination models is the fact that most providers do not understand how to coordinate
activities with patients who have diminished cognitive capacity. Despite this lack of knowledge,
researchers note that older adult patients affected by cognitive disorders must have increased
outpatient medical visits, must be connected to interventions provided by non-clinical
community-based care coordinators and they should have access to a variety of home and
community services, which is often an overlooked component of those suffering cognitive
disorders (Amjad et al., 2017). Providers need to know the specifics of care coordination models
and how their designs may be impacted by older adult cognitive capacity (Harada, Love, Triebel,
2013). Knowing how the design of care coordination models are influenced by older adult
cognition may prove valuable in helping to manage debilitating psychosocial behaviors.
Providers need to know how social environments inform the design of care
coordination models for their older adult patients. In addition to the primary of focus of
designing a care coordination model for older adult patients, of interest was providers’
A CARE COORDINATION MODEL 32
understanding of how social environments may influence the design of care coordination models.
According to Dressler (2016), social supports are the emotional and practical assistance that an
individual believes is available to him or her during their time of need. Examples of social
supports are transportation, homemaker services, legal services and emotional support for older
adult patients and their caregivers (Shier, Ginsburg, Howell, Volland, & Golden, 2013).
Engaging social supports that are not a part of the established healthcare environment can unlock
multiple resources and provide a wider network of care to support complex healthcare needs
(Abendstern et al., 2016). Social environments of older adult patients must be considered in the
design of care coordination models to ensure that there is a comprehensive perspective with
regards to treating multimorbidity.
Motivation Influences
As providers gain knowledge about how to design care coordination models for their
older adult patients, they must have adequate motivation to achieve this goal. Motivation
increases in individuals when he or she has expectations for success and when there is value for
the task at hand (Wingfield & Eccles, 2000). Equally important is an individual’s understanding
and perception of why certain events occur (Anderman, 2006). Provider motivation to design
care coordination models depends on whether they believe that they can positively influence
health outcomes of their older adult patients within the context of their organization.
Providers need to value the role of care coordination models in the care of their
older adult patients. The Affordable Care Act encourages high-quality care and reduction of
healthcare costs by providers who are motivated to provide care in more collaborative settings
and across provider networks. Despite the benefits touted by researchers and practitioners of
care coordination for older adults, it is still a formidable task to get healthcare professionals
A CARE COORDINATION MODEL 33
interested in designing care coordination models for their older adult patients (Vedel et al.,
2009). One reason this may be the case is because providers report that they do not have the
proper clinical training to manage multiple complex conditions and they lacked confidence
regarding polypharmacy and the different pharmacology options (McGilton, et al., 2018).
Additionally, they are not in a position to design care coordination models because of the
majority of their time is utilized to address chronic illnesses of their patients (Elliott, Stolee,
Boscart, Giangregorio, & Heckman, 2018). Also, Burwell (2015) notes that providers are not
currently motivated under the grossly underpaid fee-for-payment system that exists today and
proposes that financial incentives be revised to include improved information networks focused
more critically on patient needs. Landman, Aannestad, Smoldt and Cortese (2014) also offer the
suggestion to provide payment for services when patient healthcare quality increase and
healthcare costs decrease over time.
Financial incentives alone do not improve healthcare quality and should not be used to
increase provider interest in care coordination models. Solely utilizing financial incentives may
undermine provider motivation if the incentives are not aligned with the goals of care delivery or
appropriately targeted to have the desired effect on provider motivation (Banfield et al., 2003;
Berkowitz & Miller, 2011). Nonfinancial incentives have proven to be just as effective when
they were tied to public recognition and respect (Lee, 2015). Additionally, feedback about
providers’ clinical performance or patient experiences increases provider value in care
coordination (Schoen et al., 2006). Both financial and nonfinancial incentives should be utilized
as tools in increasing provider motivation and thus, increasing value in care coordination models
for older adult patients.
A CARE COORDINATION MODEL 34
Providers should feel as though they can influence the health outcomes of their older
adult patients through the use of care coordination models within the context in which they
work. There should be provider confidence in knowing that interventions proposed through
informed care coordination models will facilitate positive healthcare outcomes for their older
adult patients within their organizational context. One way to increase this confidence has been
through the use of electronic health records which include information about patient registries,
care reminders for doctors and support tools that enable providers to make decisions regarding
healthcare interventions (Reid et. al, 2010). Another has been to ensure that providers
understand treatment modalities of complex chronic illnesses and how they can influence patient
healthcare outcomes that are outside their role as a healthcare provider (Claborn, 2017).
Providers often feel frustration because the focus is instead on increasing the number of patients
they can see for larger financial reimbursements for services (Porter, Pabo & Lee, 2015). When
providers have assurance that their treatment plans for chronic conditions can have an actual
impact on patient healthcare outcomes within the organizational environment in which they
operate, they will more likely value the design of care coordination models for their older adult
patients.
Organizational Influences
Organizational goals cannot be realized until organizational influences are realized that
inhibit implementation of such goals. Examples of organizational influences include policies
and procedures, lack of equipment and materials or other resources which may hinder an
organization from achieving its performance goals (Clark & Estes, 2008). Solutions that are
intended to address organizational barriers must align with the goals, policies and procedures that
support organizational goals and values. Additionally, shared meanings and beliefs that manifest
A CARE COORDINATION MODEL 35
themselves unconsciously within the organization must support organizational performance
goals; otherwise, employee resistance to change may jeopardize the survival of an organization
(Schein, 2004). These shared values and beliefs manifest themselves as components of
organizational culture.
Organizational culture. Understanding organizational culture helps to explain the
unforeseen results of resistance to change among employees. Schein (2004) states that culture
can be explained as what personality is to an individual. Just as our personality can guide and
constrain our actions, so can the culture of an organization in guiding the behavior of a group of
employees in promoting or resisting organizational change. Leaders must be able to decipher
group norms, espoused values, shared meanings and patterns of basic assumptions in order to
influence employee group behaviors. As important is examining behaviors that can be caused by
forces other than culture (Schein, 2004). As such, communication within the organization must
be regular, cyclical and positive in providing feedback to employees as well as constituents who
are beneficiaries of organizational performance outcomes. Schein summarizes that if leaders do
not learn to manage the culture of an organization and the environment in which it is embedded,
the organizational culture will manage them.
The dynamics of culture can be further described by the interaction between cultural
models and cultural settings and how they influence RCHC’s providers in designing care
coordination models for older adult patients. Cultural models are shared meanings and
interpretations of what is valued and ideal and how the world should work and cultural settings
occur when individuals work together over time to accomplish a goal; (Gallimore & Goldenberg,
2001). How providers work together daily to accomplish mutually valued goals will provide
RCHC’s leaders a much more comprehensive understanding of shared patterns of beliefs
A CARE COORDINATION MODEL 36
between providers and their older adult patients. Specifically, organizational barriers to meeting
performance goals can be addressed by strategically aligning cultural models to cultural settings,
creating positive shared values and beliefs about implementing care coordination activities for
older adult patients. Within the RCHC, the cultural model influence is related to organizational
commitment to the design of a care coordination model and the cultural setting influence is
related to the acquiring of resources providers need to successfully accomplish this goal.
Organizations should demonstrate a commitment to designing care coordination
models for older adult patients. Organizations must be committed to all levels of change as
they strive to design care coordination models for older adult patients. Edwards and Saltman
(2017) state that hospitals, especially those that are public operated and owned, are extremely
resistant to change. For this reason, healthcare organizations must be deliberate in implementing
care coordination activities by partnering with other hospitals, individual practices and
physicians to develop a system of care which is responsive to patient needs initiated by care
coordinators and assist in finding patients who may be eligible for care coordination services
(Coburn, Marcantonio, Lazansky, Keller, & Davis, 2012). This strategy is an example of the
coalition building process that Rosenthal et al. (2006) discuss emphasizing increased networking
and collaboration among healthcare providers who have traditionally worked in silo, producing
higher quality of care and patient outcomes for older adults.
Another way that organizations can demonstrate commitment is by providing continual
training that will inform providers about the design of care coordination models for older adults.
Carayon et al. (2012) state that organizational barriers exist when healthcare training is not
present around the multiple uses of technology that are necessary for communication among
several providers. In fact, there should be a team-based approach or collaborative learning which
A CARE COORDINATION MODEL 37
occurs across all healthcare disciplines, given the changing environment of healthcare (Landman,
Aannestad, Smoldt, & Cortese, 2014). Furthermore, the researchers declare that there needs to
be a value-based training for all healthcare professionals, which includes both quality and cost
implications for older adult patients (Bharija, & Block, 2017; Putera, & Putera, 2017).
Providing ongoing training, which would also include additional incentives for designing and
implementing such interventions (Wang et al., 2016), would ensure that healthcare providers stay
abreast of design strategies related to care coordination models for older adult patients.
Healthcare organizations should acquire the resources providers need to design care
coordination models for older adult patients. Organizational leaders must strive to overcome
the challenge of scarce resources as a means to demonstrate the organization’s commitment to
designing care coordination models for older adults. Lack of resources include staff who are
needed to design care coordination activities in a healthcare compensation system that is
fragmented, with services and payments negotiated in a disjointed manner that does not value
integration and coordination of care activities (Landman, Aannestad, Smoldt, & Cortese, 2014).
Also included is the lack of capacity in dedicating the time and additional capital needed to
design care coordination activities that require communication with multiple providers and
stakeholders, along with care planning for tracking patient outcomes and healthcare costs
(Claiborne, 2006). Last, healthcare organizations do not always have the technology in place to
design care coordination activities among varied healthcare providers (Carayon et al., 2012). If
providers do not have access to the resources they need to implement care coordination activities
older adults, they will not be motivated to do so. This study explores the extent to which
knowledge, motivation and organizational influences contribute to or inhibit the design of a care
coordination model for older adult patients.
A CARE COORDINATION MODEL 38
Table 2 lists the knowledge, motivation and organizational influences that were addressed
in this literature review and will be examined in this study.
Table 2
Knowledge, Motivation and Organizational Influences and Types
Assumed Knowledge Influences
Providers need to know the
definition of care
coordination.
Declarative

Providers need to understand
the specifics of older adult
cognition, as they affect the
design of care coordination
models.
Declarative
Providers need to know how
social environments influence
the design of care
coordination models.
Declarative
Assumed Motivation Influences
Provider need to value the
role of care coordination
models in the care of their
older adult patients.
Utility Value

Providers should feel as
though they can influence the
health outcomes of their older
adult patients within the
environment in which they
work.
Expectancy Value
Assumed Organizational Influences
Organizations should
demonstrate a commitment to
designing care coordination
models that include older
adult perspectives.
Cultural Model Influence
Organizations should acquire
the resources providers need
to design care coordination
models that include older
adult patient feedback.
Cultural Setting Influence

A CARE COORDINATION MODEL 39
Conceptual Framework: The Interaction of Providers’ Knowledge, Motivation and
Organizational Influences
The conceptual framework is a visual representation of the key concepts and assumptions
that inform the research topic of study. It displays the main ideas of study, along with the
relationships between them and why (Maxwell, 2013). Additionally, the conceptual framework
provides a context of the variables and constructs identified within the research and encourages
the development of theory, as the diagram is constructed from themes that emerge from the
literature (Merriam & Tisdell, 2016). While the knowledge, motivation and organizational
influencers presented are independent, they interact with each other to inhibit performance
outcomes. Clark and Estes (2008) posit that if a stakeholder does not have the knowledge to
perform their duties, their motivation to perform will be adversely affected, which will prevent
organizations from meeting their performance goals.
As RCHC’s demonstrates its commitment to designing care coordination models that
include older adult perspectives, providers’ knowledge, skills and motivations will interact with
the organization to have a direct impact on stakeholder performance outcomes. Figure Y is a
representation of this interaction.
A CARE COORDINATION MODEL 40

Figure Y. Conceptual framework of provider’s knowledge and motivation influences and
interaction with organizational influences (KMO) to design a care coordination model for older
adult patients.

Referring to Figure Y, the blue circle lists the organizational influences (O) on the design
care coordination models for older adults. Perceived organizational value of care coordination
activities serves as the foundation of providers’ value towards care coordination activities. The
organization must demonstrate this commitment by interacting with providers to develop cultural
settings and cultural models that will encourage the interest of providers toward the practice of
care coordination. Interactions may include a coalition building process that Rosenthal et al.,
(2006) discuss that increases networking and collaboration among community healthcare
A CARE COORDINATION MODEL 41
providers who have traditionally worked in silo. Another example would be receiving feedback
from providers about what they need in the form of resources to design care coordination
models. Interactions from organizational leaders to their providers must embody commitment to
care coordination activities for older adults in order for the stakeholder goal to be realized.
The green circle lists providers’ knowledge (K) and motivational influences (M) around
care coordination activities for older adults. As providers begin to trust that the organization’s
interactions demonstrate commitment to and value towards interactive care coordination
activities, they begin to have interest in the design of such models. They desire to obtain
knowledge around concepts of care coordination and increase motivation to design this
intervention for their older adult patients. Schraw and Lehman (2006) state that increased
personal interest occurs through increased engagement and acquisition of new knowledge. The
development of sustained personal interest develops over time as the organization continues to
interact and maintain the culture around value in the design of care coordination activities for
older adults. Providers become motivated to participate because they become optimistic about
the value and potential benefits that care coordination can have as it relates to patient health
outcomes.
There is a two-way arrow that connects the Organizational circle to the Knowledge and
Motivation circle. This two-way arrow demonstrates interactive communication and activities
around the commitment of the organization towards interactive care activities for older adults
and whether providers will want to embark on care coordination activities. As the organization
continues to communicate its values toward care coordination, providers begin to value the same.
As providers become motivated about care coordination activities, they strengthen the culture of
the organization towards care coordination models for older adults. The interactions between the
A CARE COORDINATION MODEL 42
organizational influences and the providers directly impact the success of the stakeholder goal,
which is represented by the one-way arrow that connects the provider’s circle to the purple box
which displays the stakeholder’s goal.
There is a one-way arrow from the Knowledge and Motivation circle to the purple box,
which represents the Stakeholder Goal. The one-way arrow demonstrates that realization of the
stakeholder goal is directed impacted by providers having the knowledge and motivation to
design a care coordination model. In summary, if organizational influences are addressed in a
way the demonstrates the RCHC’s commitment to care coordination activities, providers will
develop personal and sustained interest in the design of a care coordination model by August
2019.
Participating Stakeholders: Sampling and Recruitment
The healthcare providers of RCHC were the stakeholders of focus. There were 10 providers
identified as those who had a direct impact on the design of care coordination models for their
older adult patients. Each provider had older adult patients who were treated with a range of
diagnostic and medical services provided by RCHC.
Interview Sampling Criteria and Rationale
The criteria associated with this stakeholder group for the purposes of sampling and the
rationale for sampling are presented below.
Criterion 1. Primary and specialty care providers of RCHC. They are the initial point of
contact as it related to addressing chronic health conditions of older adult patients through care
coordination activities (Schultz, 2015). These providers had older adult patients who were
diagnosed with more than three chronic health conditions.
A CARE COORDINATION MODEL 43
Criterion 2. Individuals who supported primary care providers. Supervisors and co-
workers who supported the stakeholder group could provide information about organizational
influences. Support activities include communicating and sharing knowledge with patients,
linking patients to community resources, helping with transitions of care and assessing patient
goals and needs (Agency for Healthcare Research and Quality, 2017). Primary care providers
would specifically state those positions which critically supported them in providing care
coordination activities for older adults.
Ultimately, the framework would display how organizational influences interacts with
providers’ knowledge and motivation to design care coordination models for RCHC’s older adult
patients.
Interviewing Sampling (Recruitment Strategy) and Rationale
Purposeful sampling strategies employed to select the providers at RCHC. because
according to Johnson and Christensen (2015), it is used when the researcher seeks out a
population who all possess the same characteristics. It was also utilized because it is the best
technique to use to obtain a detailed, useful understanding of a research topic (Creswell, 2014;
Maxwell, 2013). This strategy was appropriate because I wanted to understand the specific in-
depth experiences of RCHC providers as it related to designing care coordination models for
older adults (Creswell, 2014; Johnson & Christenson, 2015; Merriam & Tisdell, 2016). The
providers selected were the first point of contact in initiating care coordination activities for older
adults and they provided information around their knowledge and motivation influences as it
related to designing care coordination models. Additionally, obtaining information from
providers revealed perspectives about how organizational influences interacted with provider
influences to meet the goal of designing care coordination models.
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To obtain access to these providers, I employed Walker and Read’s (2011) process of
engagement that encourages gatekeepers who serve vulnerable populations to participate in
research that contributes to organizational goals. Following this process, I called RCHC’s Chief
Executive Officer (CEO) and introduced my professional experiences and the research interests.
Consequently, a meeting was convened with the Medical Director, Chief Operating Officer and
the Office Manager, where the research topic was discussed in detail and how it would support
RCHC’s organizational goals. I described the Institutional Review Board process and provided
assurance of high ethical standards and confidentiality of participants throughout the research
process. Subsequently, I was forwarded provider contact information so that one-on-one
interviews would be scheduled to understand knowledge, motivation and organizational
influences towards designing a care coordination model. Based on suggestions by Johnson and
Christensen (2015), the goal was to elicit participants who could provide rich, detailed
descriptions about designing a care coordination models. As such, the CEO granted full
disclosure of clinic operations for the purposes of this research.
Data Collection and Instrumentation
Interviews
Data were collected through individual semi-structured interviews. According to
Creswell (2014) semi-structured, open-ended interviews are advantageous because they can
provide valuable information when participants cannot be observed directly. Qualitative
interviewing consists of open-ended questions guided by probes and prompts that can provide
explicitness around the research topic (Johnson & Christensen, 2015; Merriam & Tisdell, 2015;
Weiss, 1994). Data were collected data through one-time, audio-recorded interviews that ranged
from 35-50 minutes long. These confidential interviews were conducted wherever the
A CARE COORDINATION MODEL 45
respondent was comfortable and in environments where there were no interruptions. The
interview protocol was useful because as Merriam and Tisdell (2015) suggest, it was easier for
me as a novice researcher to have questions written out ahead of time (see Appendix B). The
questions on the protocol were open-ended, enabling me to veer away from the interview
protocol slightly to ask follow-up or probing questions as needed. Open-ended questions were
utilized because they allowed respondents to provide rich, detailed descriptions of their
experiences not affected by my researcher perspective or past research findings (Creswell, 2014).
Asking for clarification of responses, or probing, allowed respondents to talk more freely about
their experiences (Bogdan & Biklen, 2007; Merriam & Tisdell, 2015; Patton, 2002;). Having
this type of interview protocol was preferable because it was simple to locate patterns and form
themes for data analysis (Patton, 2002; Weiss, 1994).
Guided by the conceptual framework, each interview item was carefully designed to
match the knowledge, motivation and organizational influences that were based on literature to
ensure that adequate data was yielded about each influence and how they either promoted or
inhibited the design of a care coordination model for RCHC’s older adult patients. I also made
sure that the questions were not leading and that I only addressed one influence at a time.
Additionally, I asked questions that would provide rich descriptions of the research topic. I
utilized Patton’s (2002) six categories of questions to stimulate feedback from respondents.
Experience and behavior questions were asked to learn about providers’ behaviors and actions as
they relate to designing care coordination models that are driven from the perspectives of older
adult patients. Opinion and value-related questions were asked to learn what providers thought
about the research topic. Feeling questions were posed to understand the emotional responses of
providers, expressed in the forms of happiness, frustration, anxiousness and other like adjectives.
A CARE COORDINATION MODEL 46
Knowledge questions were included to learn the facts about what providers know about
designing care coordination models. Sensory questions were also included to describe specific
evidence about what providers see or hear within RCHC regarding the design of care
coordination models. Patton’s last category, background and demographic questions, were not
included in the interview protocol because identifying specific characteristics of the providers
such as age, gender or ethnicity did not contribute to the research questions. Considering
Patton’s categories of questions helped me in planning interviews and helped to focus the
priorities of my study on the conceptual framework related to the design of a care coordination
model for older adults. Nonverbal communication was also observed and recorded after each
interview. For example, interviewees would make facial expressions, move around in their chair
or changed their voice pitch and tone to communicate their feelings and attitudes about certain
questions. This information would allow me to react appropriately by asking probing questions
if there was hesitation in answering questions or reassuring interviewees that they could express
their feelings openly and that they would remain confidential. Nonverbal communication is an
underutilized method of collecting data that often yields thicker descriptions and interpretations
compared to the sole use of verbal data (Onwuegbuzie & Frels, 2013).
Document and Artifacts Review
Data were collected from documents and artifacts to provide insight on deliberate actions,
language, words and behaviors at they related to the concept of care coordination. As Merriam
and Tisdell (2015) suggest, I was deliberate about being open and creative to locating relevant
materials that provided rich, descriptive data as it related to the research topic. Although I
requested various documents related to care coordination activities within the organization such
as an Operations Manual or information related to Standard Operational Procedures, I was only
A CARE COORDINATION MODEL 47
provided three types of documents. First, I received the Patient Satisfaction Survey conducted by
an outside consultant. Second, I received two policies and procedures documents that outlined
care coordination activities for emergency room visits and for hospital stays. Finally, I was
forwarded a Care Coordination Manual, created by a private insurance company, that guided
care coordination activities within the organization. Documents were obtained from the Chief
Operating Officer, which validated the authenticity and accuracy of documentation. Documents
also included a researcher log and researcher reflective journal to help me evaluate the quality of
the interviews and to record impressions about the respondents’ verbal and nonverbal
communication. They also helped raise my consciousness about my role of the researcher and to
keep my bias in check. As an artifact the organization’s website provided insight into RCHC’s
perspective towards care coordination activities. In summary, the triangulation of data from
interviews, documents and artifacts provided rich data about how providers would design a care
coordination model for RCHC’s older adult patients.
Data Analysis
All interviews were taped and transcribed verbatim by a professional transcriptionist.
Data was then analyzed using ATLAS ti.8 qualitative analysis and research software. Data
analysis occurred iteratively, using Lincoln and Guba’s (1985) constant comparative analysis to
break data down data into “units of information” (p. 344) that served as a basis for confirming a
priori categories. During the first phase, I read all of the interviews multiple times to gain a
sense of the data. I then began to organize the data according to general concepts and beliefs that
I understood in relation to the research questions. In the second phase, I engaged in open coding
where I analyzed the raw data of each interview line-by-line to identify repeated words, phrases,
ideas, concepts and sentences. This allowed me to identify common patterns that emerged both
A CARE COORDINATION MODEL 48
deductively through a priori codes from the conceptual framework and inductively as a result of
emerging themes.
In understanding the data, I focused strictly on the research questions and utilized Corbin
and Strauss’ (2008) analytic tools to facilitate the coding process. For example, in addition to
making comparisons within the data, I asked questions of the data and explored the multiple
possibilities so that I could better understand respondents’ perspectives. I recognized the “red
flags” when interviewees made comments about the organization “never” being able to
accomplish a specific task or referring to the organizational culture and leadership actions as
“that is the way it is.” I listened to the stories and recognized nonverbal communication and
expressions when certain questions were asked. I also asked the question “so what does this
really mean?” in order to understand the data.
This strategy led me to the third phase in the grouping of my open codes, or analytic
coding. According to Merriam and Tisdell (2016), analytic coding allows the researcher to
reflect on meaning with the analysis. As a result, I assigned codes to pieces of data that allowed
me to efficiently organize data and retrieve it easier. During this process, I developed a codebook
which helped me to categorize the codes and frequencies throughout the coding of the data and
measure typicality, serving as evidence of the importance of data. The fourth phase consisted of
identifying patterns and themes, relationships between them and understanding explanations of
the research questions. Document analysis was performed in the same way, confirming
typicality of the data presented. In the final stage, this analysis was related back to the
conceptual framework and the a priori codes with respect to organizational and stakeholder
capacity to design a care coordination model for RCHC’s older adult patients. All data presented
A CARE COORDINATION MODEL 49
was responsive and informative as it related specifically to the research questions and the
conceptual framework.
Findings
The purpose of this study was to conduct a gap analysis to understand the knowledge,
motivation and organizational influences that contributed to or inhibited the design of a care
coordination model for older adult patients. While a complete analysis would have involved all
the stakeholders who are instrumental in the design of this model, the stakeholders of focus
included primary and specialty care providers of RCHC. These providers were the first point of
contact in care coordination when information was shared from older adult patients about their
complex medical conditions. The research questions that guided this study are:
1. What are the RCHC healthcare providers’ knowledge and motivation influences related
to designing a care coordination models for older adult patients?
2. How do the RCHC healthcare providers’ knowledge and motivation influences interact
with RCHC to shape the providers’ ability to design care coordination models for older
adult patients?
3. What are the recommended knowledge and skills, motivation and organizational
solutions?
Twelve RCHC providers were asked to participate in the qualitative interviews to
answer the research questions. The providers were primary care and specialty care doctors,
physician assistants, care coordinators and behavioral healthcare specialists who split their time
between two of RCHS’s clinics to provide care for their older adult patients. There was an even
distribution of Caucasian and African American providers and most have been in their respective
fields for more than 10 years. Providers revealed that although adults ages 60 and over
A CARE COORDINATION MODEL 50
consisted of 15% – 25% of their patients, they understandably demanded the most time and
resources for their patient care because of chronic illnesses. The interviews were completed over
a two-month period in the Summer of 2018. When the interviews commenced, it was announced
that the Medical Director was going to retire. Also, providers were not available because of pre-
approved vacation time. These two factors may explain why of the 12 providers who were asked
to participate in the study, only eight were available to be interviewed face-to-face. This sample
size was appropriate because information resulted in no themes emerging after approximately
five interviews had been analyzed. In other words, data saturation had occurred. In addition to
participant interviews, documents were provided by RCHC to demonstrate core values of care
coordination along with the policies and procedures that guide care coordination initiatives at the
clinic. The following sections address each research question and the knowledge, motivation
and organizational influences that interacted to shape providers’ abilities to design care
coordination models that include older adult patient feedback.
Findings for Research Question 1: Knowledge and Motivation Findings
In order to explore organizational capacity to design a care coordination model, data was
gathered about three knowledge influences and two motivation influences in this study. As it
related to knowledge influences, providers need to know the definition of care coordination.
Findings also emerged regarding older adult cognition and how it influenced the design of care
coordination models. Furthermore, data revealed that older adult patients’ and their social
environments influenced the design of such models. As it related to motivation influences,
providers must value the role of care coordination in addressing multimorbidity of older adult
patients and providers must feel as though they can influence the health outcomes of their
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patients within the context in which they work. What follows were the findings for the
knowledge and motivation influences as they emerged from the data collected.
Providers do not provide a consensus definition around the concept of care
coordination. Providers interviewed described the concept of care coordination in different
ways. Four providers described care coordination as a means to address more than just the
medical needs of patients. One individual explained, “I see it in more like a system where we
integrate holistically all avenues.” Another provider described that care coordination is “the
components that need to exist with not just their medical care, but also their social care.” One
provider noted “Care coordination is the overall importance of a patient’s care, home care,
medical care, socioeconomic status, psychosocial status, just coordinating all that.” Another
provider commented “Doing what it takes to keep someone out of the hospital, so it takes a
multidisciplinary approach, a lot of phone calls and follow up.”
The remaining four providers did not offer a definition of care coordination. Instead,
they spoke on the importance of communication and the delivery of care in their care
coordination efforts. For example, one provider noted, “We as medical professionals must have
open communication with our patients”, while another added, “We must listen more than we
talk.” Another commented that the relationship between the provider and patient must be such
that “We must have a partnership with the patient.” When the interviewees were probed to
provide a specific definition of care coordination and its components, their responses indicated
lack of clarity. For example, one provider said, “To me care coordination, it can be a lot of
things. In this setting it definitely means a lot of things here.” Another commented, “We all have
to know the rules and the laws that we have here in North Carolina well to be able to assist
people…like, this is how you can get a power of attorney and this is how you get the family to
A CARE COORDINATION MODEL 52
help with this.” Another provider stated that she was not sure what components existed in care
coordination, but she understood that it was about “making sure that people did not fall through
the cracks.” Finally, one provider professed “I'm gonna have to research it more.” Echoing this
sentiment were two providers who yearned for additional training. One commented, “I think it
would be nice if everyone had the understanding or just maybe possible training on the older
adult population” while another added, “Training and evaluation is integral to a care coordination
model that will provide good care coordination and make sure of good patient outcomes.” While
describing their thoughts around the concept of care coordination, RCHC providers also revealed
different perspectives on how care coordination should be delivered.
Providers perspectives were split on how they thought care coordination was delivered
to older adult patients. Half of the providers thought that care coordination was an individual
task, whereas the other half thought of care coordination as a team-based function. Explaining
that care coordination was an individual task, one provided reflected “It’s more to me…of a
social work or nursing type role in terms of coordinating access to care, access to medications,
access to follow up appointments, transportation, et cetera.” Another provider indicated that care
coordination was “driven by an assistant to help the pieces of your healthcare work together
towards the end of improving your health.” Explaining that care coordination was a team-based
function, one provider explained, “With care coordination there is a team approach, you sit at a
table, everybody's there, and everybody's just giving their individual aspects to come up with the
plan for the patient.” Another provider noted the same, but offered a suggestion that instead of
providers getting together, RCHC should assemble a team of older adult patients and ask them
how they would like care coordination to be delivered to them, stating “I bet you would get a ton
A CARE COORDINATION MODEL 53
of ideas just with that.” RCHC providers had differing perspectives on how care coordination
should be delivered among its older adult patients.
In summary, the interview data revealed that providers did not possess a consensus
definition around the concept of care coordination. Additionally, they were unsure about how
care coordination should be delivered and as such, they yearned for additional training on the
subject. Lack of a consensus definition around the concept of care coordination is a major
barrier to designing care coordination models (Goodwin, 2016). Because RCHC providers
revealed a lack of conformity around the definition of care coordination and its components, this
finding emerged as a gap in designing care coordination models for RCHC’s older adult patients.
Providers are knowledgeable about how older adult cognition influences the design
of care coordination models. All providers interviewed revealed that cognition played a major
role in the provision of healthcare for their older adult patients. They commented on the
challenges presented with declining cognition. One provider stated:
It's definitely a huge challenge, because it's a whole lot easier getting in touch with
someone who can answer their phone, who can respond to email, who can physically get
here, than someone who has dementia and other medical issues.
Another provider described how comorbidity intensifies cognitive decline stating that older
adults “have very many physical disabilities or illnesses and so that's impacting a lot of their
mental health.” Other providers additionally noted challenges related to cultural preferences,
lack of health literacy and lack of financial and family supports which negatively impact
cognitive decline.
All eight providers explained the importance of investigation or that “extra prodding” of
older adults’ regarding their health because cognition naturally declines with aging. One
A CARE COORDINATION MODEL 54
provider noted “I think assessing and meeting the patient where they're at is really important.”
Another interviewee stated, “It is important to make sure that you're explaining everything on
their level, while giving them still respect that they understand their care and what they need to
do.” One provider added, “You're just going to have to be aware of what that patient can process
and what they can't, and just kind of keep notes about it.” Two providers noted that because of
cognitive decline, they must go beyond their usual tasks as strictly a medical provider. One
commented, “So, finding out about transportation and finances, so that you can get them their
medications. Do they need food? Getting those resources.” Another provider indicated that “It's
very important to have clear written instructions. So that cognition. Is the patient able to
understand what you're saying over the phone or is that confusing to them?” Providers continued
to acknowledge going the “extra mile” to overcome declining cognition in their older adult
patients in providing care. Data also revealed that providers welcomed caregiver support in
helping them to address these challenges.
All providers interviewed expressed the importance of friends, family members and
caregivers in the design of care coordination models when cognitive decline is present in their
older adult patients. One provider stated that as cognition declines “You're not really dealing so
much with the patient as you are so much the caregiver and getting the caregiver on board.”
Another explained that when there is no caregiver support “We actually could see that their
progress is very slow and limited and they actually turn out to be in the nursing home after their
required 120 days in rehab.” Another individual reported that when there is family member
involvement, older adults with cognitive decline are often able to return to independent living or
sometimes move in with their family members. Interviewees cautioned that caregiver burnout is
possible because “That person is working already at least two jobs, has small children at home,
A CARE COORDINATION MODEL 55
and they're trying to take care of mom.” All providers indicated the importance of involvement
from family members and friends in caring for those who have cognitive decline.
In summary, data emerged about providers’ knowledge around older adult cognition in
caring for older adult patients. As such, this knowledge influence emerged and contributes as an
asset towards the design of care coordination models for RCHC’s older adult patients. Care
coordination models that focus on cognition in older adults will yield positive health outcomes
and increased quality of care for older adults who suffer from cognitive decline (Amjad et al.,
2017).
Providers are knowledgeable about the influence of social environments in the
design of care coordination models. All providers expressed the importance of social
environments of older adult patients and the influence on the design of care coordination models.
Providers described the importance of ensuring that the social environments of older adults are
supportive in their care. For example, there was a consensus among providers that social
environments must include regular involvement, particularly exercise, because depression is
common among older adults with chronic illness. One interviewee noted that mental health
resources are also necessary for depression because “One of the biggest struggles is just the
relationships that people that are elderly struggle with, maintaining relationships, creating new
relationships, that's huge.” Another provider described the presence of a senior center as a part of
social environments to help older adults maintain interaction because “As they're getting older
their supports are dying or they're passing away.” All the providers interviewed echoed the
theme of older adult involvement with friends, family and community supports and why these
aspects of patients’ social environment are important in the design of their care coordination
models.
A CARE COORDINATION MODEL 56
In summary, data indicated that providers possessed knowledge about social
environments and their influence on the design of care coordination models older adult patients.
As such, this knowledge influence emerged as an asset. Data from one provider revealed the
consensus of her peers when she stated, “Care coordination models are imperative to our ability
to ensure that we are providing not only good care, but we're providing care that is appropriate
for the patient culturally, appropriate for the patient in the environment that they're in.” Research
confirms that social supports and social engagement is critical to older adults who suffer from
multiple chronic conditions (Warner et al., 2013).
Providers value the role of care coordination models in the care of older adult
patients. All eight providers interviewed described the value of care coordination models. Five
providers indicated their level of value towards care coordination models with terminology such
as “extremely valuable,” “huge,” “very important,” “vital,” with one provider emphasizing that
“they are very, very, very, needed.” Furthermore, providers revealed that the main reason they
all valued care coordination models is because older adult patients have historically not been
encouraged to participate in their health outcomes. For example, one individual interviewed
stated that older adults are so used to the “paternalistic environment” in which healthcare was
dictated to the patient. She went on to say that in order for patients to receive better care “we
must put the choice back on the patient” and “have the patient trust themselves more to ask
questions about their care.” Another provider added “The reason why I say that it is valuable is
because older adults sort of lose their voice as far as their own care.” Three interviewees noted
the value of care coordination to navigate a complex, fragmented healthcare system and to
connect older adults to their necessary resources. Lastly, one individual noted that in order to
A CARE COORDINATION MODEL 57
treat chronic illnesses of older adult patients, “We have to come up with a better way to treat
them”, acknowledging that care coordination models are a way to do so.
In summary, because providers value the role of care coordination with older adult
patients, this motivation influence emerged as an asset towards the design of care coordination
models. Research notes that when individuals value a task at hand they are more motivated to
complete the task (Clark and Estes, (2008)
Providers do not feel as though they could influence the health outcomes of their
older adult patients within the context of their work environment. Although seven out of
eight providers expressed high self-efficacy in designing care coordination models, they
expressed uncertainty in being able to influence the health outcomes of their patients within the
organizational context of RCHC for two reasons. The two themes that emerged from the data
were time constraints and the perceived lack of communication between leadership and staff.
Since both influences were revealed as unanticipated organizational influences, they will be
discussed in the next section.
Notwithstanding, these themes also negatively influence motivation because if providers
do not feel as though their work will be effective, they will not be inclined to designed care
coordination models. Expectancy value theory (Eccles, 2006) asks the questions “Can I do the
task?” and “Do I want to do the task?” Additionally, Clark and Estes (2008) posit that the
motivation to complete a task is dependent upon “our beliefs about ourselves, our coworkers and
our prospects for being effective” (p. 82). These theories suggest that if providers feel as though
they cannot influence the health outcomes of their older adult patients, a barrier is presented
towards their motivation to design care coordination models.

A CARE COORDINATION MODEL 58
Findings for Research Question 2: Organizational Findings
In designing care coordination models that include older adult feedback, two
organizational influences were explored. First, providers should have the confidence in an
organization’s commitment to designing care coordination models that include older adult
patient feedback. Second, organizations should acquire the resources providers need to design
such models. What follows are the findings for organizational influences and how they interact
with providers’ knowledge and motivation to shape their ability to design care coordination
models for RCHC’s older adult patients.
Providers have mixed perceptions on the organization’s commitment to designing
care coordination models. Providers’ confidence in the organization’s commitment towards
designing care coordination models for its older adult patients revealed mixed feelings. As four
of the eight providers stated the organization’s commitment to care coordination models for
older adults, they expressed motivation to help RCHC further its goals. One provider said “I'm
confident in them because then they recognize where and who they can have to carry it out and
be a partner in that. I feel confident in them and I want to help.” Three of the providers
demonstrated motivation by identifying membership with RCHC. For example, when they were
asked about the extent of RCHC’s commitment, one provider replied, “Very much, because it's
always on the topic. What can we do, where are we at.” Another commented, “We’re definitely
committed. We brought on a care coordinator and that definitely helps.” The third provider
explained why the organization was committed, noting “Because truly everyone wants our
patients to be healthier…That's what works. And so then that's what we would want to do.”
While four of the eight providers interviewed indicated complete confidence in RCHC’s
commitment, the remaining four providers were not so sure.
A CARE COORDINATION MODEL 59
Four of the eight providers interviewed commented that they believed RCHC was
committed to the design of care coordination models; however, they remained skeptical and in
fact, one provided stated, “On a scale of one to ten, I would say it’s more like a seven.” Providers
explained that the reason for the skepticism was because RCHC is involved in so many
healthcare initiatives. One provider commented “There's so many things that are open and that
they are working on. If you choose two or three of them, then the other three may not get done,
or the other three may fall to the wayside.” The same provider went on to add:
I’m uncertain because there's a little bit of fear that the more projects we take on in the
community we don't have as much staff to do things that we need and I worry about that
sometimes, but you can't fail if you don't try I guess.
Wondering about the organization’s commitment, one provider commented, “It's hard to say if
they’re committed to this one thing because are involved in so many things, which can be a good
or bad thing.” Another provider mentioned, “We’re doing it in a piecemeal way” adding “We're
just sort of in that build the airplane in the air type of situation”. One of the providers
summarized the general sentiments about RCHC’s uncertain commitment:
What's the best way to say it? We're very good with big picture, we're very good with
wanting to do all these ambitious things and helping communities and helping people
out but when it actually comes down to the nuts and bolts of making an action plan and
carrying out that operation, I've noticed from my time here that that's when we get a
little bit stuck sometimes. We have to actually be able to follow through on them and
create plans and structure. It's not enough to just have big ideas.
In terms of provider knowledge influences interacting with organizational culture, data
revealed that all eight providers possessed some knowledge of care coordination, but none have
A CARE COORDINATION MODEL 60
experience in the design of care coordination models. Three providers thought it was best to hire
independent professionals to start the design process. One provider stated, “Whoever they feel is
an expert in this field is going to actually take to designing this model based on the research that
they get.” Another said, “When we look to do something they're always reaching outside for the
different resources that we identify that we need, and then making it happen.” Lastly, another
provider stated “Man, if we had a consultant that could come in and say, 'this is what you need
and this is how we can get there', that would probably be the best mechanism to do that.” The
provider added “Especially with current leadership, they would probably be more receptive to an
outsider, with Consultant as a title”.
In summary, there is no consensus among the providers as to whether RCHC is
committed to the design of a care coordination model for its older adult patients. The motivation
influences emerged as a potential barrier to completing this goal. This influence is noted as a
potential barrier because data revealed that half of the providers who were skeptical about the
organization’s commitment believed the clinic was fairly committed to providing the best care
for vulnerable populations but lacked focus on how to do it. This barrier could be overcome with
the recommendations that will be suggested as a part of this study.
Providers do not have time to engage in care coordination for their older adult
patients. Seven out of eight providers interviewed indicated high self-efficacy in designing a
care coordination model for their older adult patients; however, they noted that one major barrier
to doing so was lack of time. When providers were asked if they could design care coordination
models that included older adult perspectives, 88% of them stated that they could if they have
enough time. Three providers reflected on their days, noting that they arrive at the office most
A CARE COORDINATION MODEL 61
times before 7:30am, log in the system, and start greeting patients continuously, breaking for a
30-minute lunch at their desk. One provider described in detail:
Patients may or may not come with their medical records in hand and to navigate that
visit with that patient can often be very time consuming and the appointment slots that we
have in primary care often do not allow for, let's say, an hour and a half visit to go
through a whole comprehensive medical history and what medications are you taking,
why are you here, et cetera. So we take that time if it's needed, of course, but then that
does affect your work flow for the rest of the day.
The same providers described the end of their day with charting labs, reviewing radiology
reports or completing a variety of tasks associated with their patients. One provider commented
“our day-to-day is patient, patient, patient…just limitations in time of the day, and we don't have
the opportunity, we're not presented with the choice to design care coordination models.”
Another provider reiterated:
Time is the biggest limiting factor for virtually everything. We're all stressed and
pressured to do more with less, especially with decreased reimbursement and the change
in the healthcare landscape. We're already being pressured to see more patients chart and
document more, have improved outcomes, which is all a good thing, we need to be held
to that, but finding the extra time to research those barriers, develop a model that will
address the risks and implement it is just the biggest barrier. So time.
Lack of time to address care coordination is especially challenging for four of the providers who
practice in both clinics. They lament that this is stressful for them because “our list is always,
every day, growing, because we will identify a new patient, and then they're added to us with
their “mixed bag” of illnesses.
A CARE COORDINATION MODEL 62
In summary, lack of time was revealed as an unanticipated organizational influence and
emerged as a barrier to the design of a care coordination model for RCHC’s older adult patients.
Having the time to speak to patients about their chronic illness and plan care coordination
activities is a main factor in the design of their care (Kelley, Meier & Aldridge, 2014).
Providers state that there is no infrastructure to support the design of care
coordination models. All eight providers interviewed indicated that there was a lack of
infrastructure within RCHC to support a care coordination model for its older adult patients.
They commented on what needed to be present within the RCHC to support this goal. One
provider said, “I think moving forward, there should be an awareness that they need certain key
people in place in order to make this happen and to observe and to capture the day-to-day
activities to make sure data is collected.” Three providers noted that there was no policy or
guidelines in place on how to design care coordination models. One provider said, “I feel
confident with all my experience, it just would be nice if there were a model already there.”
Another’s comment supported this stating, “I'm sure there's information out there, I'm sure you
know, but it's not something I've seen here at the clinic.” One provider offered the model of
PACE and how they take an interdisciplinary approach to provide care coordination to its older
adult population. The individual added “they're very efficient with their resources, but they
exist. So I think first of all having the infrastructure in place is key.” There were two providers
interviewed who lamented “I think we would need some restructuring,” while the other added “I
guess I'm trying to think of the structure of how, I think we would need to adjust the structure
actually, definitely”.
In summary, lack of infrastructure was revealed as an unanticipated organizational
influence and emerged as a barrier to the design of a care coordination model for RCHC’s older
A CARE COORDINATION MODEL 63
adult patients. Not having adequate infrastructure as it relates to policies and procedures,
fragmented internal and external communication with constituents or inadequate electronic data
and health information systems will negatively affect care coordination and the quality of health
outcomes for patients (Anon, 2010).
Providers feel as though there is a lack of communication between providers and
leadership. Of the eight providers interviewed, six of them noted that there was a lack of
communication between them and RCHC’s leadership. Providers described their perceptions of
communication with leadership. One provider reluctantly shared, “It's not because they're not
supportive, they are, but it's just, there's a little bit of a disconnect between administration and the
providers”. Four providers indicated that leadership did not return phone calls and did not
address questions that providers may have. One provider summarized the sentiments of the
group:
Leadership does not do well with follow up in this organization, they do not take
suggestions well. Anytime I've noticed that a suggestion has been given, even one that
would increase revenue or productivity, the suggestion has either been ignored or said
'that's a great idea, let's do that', and the person will remind them 3-6 months later, 'that's
a great idea, let's do that', and there's never follow through.
When one provider was asked to describe the communication between themselves and
leadership, the individual reflected, “In some other ways it's, like people aren't married to
workflow here the way they are sometimes in a big organization, and sometimes that's a bad
thing, but I don’t know.” Finally, one provider offered a reason why leadership was not as
responsive contemplating “I think our leadership, they are pulled in a lot of directions that don’t
always give them that time to make phone calls. They should do better.”
A CARE COORDINATION MODEL 64
In summary, lack of communication between the providers and administration emerged
as an unanticipated organizational barrier toward the design of a care coordination models for
RCHC’s older adult patients. Ensuring that communication breakdown does not occur within an
organization increases the chances of successful care coordination for its patients (Roberts et al.,
2014).
Providers do not have the resources they need to design a care coordination
models for its older adult patients. All eight providers interviewed stated that lack of
additional resources would inhibit the organization’s efforts to design a care coordination model
for older adults. When asked about what resources they would need to design care coordination
models, providers indicated that they would need additional staff. One provider explained, “We
have a care coordination nurse that we just hired but that nurse who's assigned to care
coordination is also assigned to probably nine or ten other tasks that occupy her time.” All
providers described the additional staff that would need to be hired to design a care coordination
model which included, physicians, the adequate staff in the areas of social work, mental health
and physical, recreational and occupational therapy; a team of care coordinators formed possibly
through a partnership with other clinics; senior adults that form a Care Coordination Panel that
would contribute to the design; and administrative and data management staff to track and
analyze data. Two providers summarized the theme expressed by all eight providers of not
having enough staff. One stated “When an organization wants to start a new venture, human
capital is what makes or breaks it” while another interviewee commented “Everyone is a little bit
overworked. I don’t think we have the manpower at this point, but we would have to get others
in. We could do it”.
A CARE COORDINATION MODEL 65
Another major resource all eight providers noted was having funding available for the
design of care coordination models. All providers concluded that in order for this care
coordination model to be developed, there must be additional funding available in an already
“cash strapped” community clinic. Providers noted that funding will be critical to hiring
additional staff, acquiring more capital and obtaining the myriad of aforementioned resources
that it will take to design such model. When asked about the level of funding needed to design a
care coordination model for RCHC’s older adults, one provider amusingly said, “$10 million
dollars!” After chuckling, the provider proceeded, saying “So I think that's something that we
have to kind of look into a little bit more is to see if there's any type of grant funding that we can
achieve for what we need.” Two more providers indicated the need for grant funding, but stated
the need to generate revenue from RCHC’s insurance patients. One of them commented, “There
are a lot of moving parts all the time.” Three providers acknowledged the need for diverse
funding strategies stating “There needs to be funding for incentives for providers. The question
is who’s incentivized to design this model?” The other provider commented, “We need money
to certify staff in care management” while the other stated:
We need funding for mammograms, like we already reached a certain amount of what
was allotted to us for the month and we’re reaching more of what was left for us for the
year already. We need funding for imaging and referrals as well.
There were two providers who summarized the sentiments of all providers when one said,
“Money is always going to be a huge barrier and finding some way to get a grant to support for
this would be huge”, while the other mentioned “Financially we are pulled in a lot of directions.
Staff. Adequate staff. And time. Money and time, isn't that everything?”
A CARE COORDINATION MODEL 66
Data from provider interviews detailed an array of resources that RCHC needed to acquire
such as transportation, education materials with larger font, medical office supplies that would
accompany older adults with special needs and an updated technology system for both providers
and patients. (Please see Appendix C). In summary, the organizational influence of lack of
resources emerged as a barrier to the design of care coordination models of older adults.
Organizations will need to garner the necessary resources to redesign their health systems and
restructure payment systems to incentivize care coordination efforts in successfully meeting the
healthcare needs of their older adults with chronic illnesses (Osborn, Moulds, Squires, Doty &
Anderson, 2014).
Document Analysis Findings
The nature of RCHC’s documents. I asked for a review of documents for the purposes
of triangulating data from the qualitative interviews. A document protocol was sent to RCHC
leaders to inform them of the type of information that would be needed. Forwarded was the Care
Coordination Handbook (CCH), published by a national healthcare insurance plan. The purpose
of the handbook was to provide user-friendly lessons, self-guided activities and education around
the role of care coordination, along with resources that are available in a Provider Toolkit. Also
forwarded was a policy related to care coordination and patient tracking for preventable
hospitalizations, readmissions and Emergency Room (ER) visits. Lastly, a policy was
forwarded that guides tracking and coordination of all RCHC patients presented to the hospital
for admission or treatment in the ER to ensure continuity of care is maintained. What follows is
an analysis of the documents as they relate to knowledge, motivation and organizational
influences.
A CARE COORDINATION MODEL 67
Definition of care coordination. Findings from RCHC’s documents revealed important
aspects as it related to care coordination. The CCH included a definition for care coordination in
the CCH. Care coordination was defined as: the deliberate organization of patient care activities
between two or more participants involved in a patient’s care to facilitate the appropriate
delivery of health care services. The CCH included information about Patient Centered Medical
Homes (PCMH), which are guided by the practices of care coordination to improve relationships
between patients and their clinical providers. Detailed is the practice of care coordination and
how it should be administered to reduce fragmentation in a patient’s healthcare. The CCH lists
additional tools and resources in administering care coordination models and case studies
provided information about the knowledge influences of cognition and social environments of
older adults and care coordination activities.
RCHC’s policies present valuable information as it relates to how care coordination
activities are to be tracked and monitored; however, there is no information around the definition
of care coordination or its impact on older adult cognition or their social environments on care
coordination models. Both the CCH and RCHC’s policies have the potential of emerging as an
asset to the organization; however, data collected from provider interviews reveal that they do
not have a consensus definition around the concept of care coordination. Furthermore, all
providers lamented that having enough time in a day was challenging for them. Based on these
indicators, it can be assumed that providers have either not had a chance to read the CCH or that
it has been a long time since they have. If providers receive training or are allow the time to read
both the CCH and RCHC’s policies to increase their knowledge around care coordination, both
documents will have the potential of becoming assets to designing care coordination models.
A CARE COORDINATION MODEL 68
Value of care coordination for older adults. Information located in the CCH promoted
the value of care coordination models to patients who are chronically ill. It provided a graphic of
the Care Coordination model and illustrated the value of it in terms of increasing provider
accountability, patient support, relationships and agreements among providers and patients and
connectivity between all systems involved in the care of an individual. To motivate providers
toward the design care coordination models, the CCH provided a step-by-step guide to how care
coordination models may be administered to decrease fragmentation in the delivery of
healthcare. It also provided case studies of care coordination being delivered in different
contexts, including private and research hospitals and community healthcare organizations.
Although the CCH does not speak specifically to the design of care coordination models, it does
repeat the concept of the patient being at the center of care and designing care plans that are
specific to their medical needs.
The RCHC policies statements indicated the value of care coordination and tracking
activities to ensure that older adult patients receive continuity of care. They also list detailed
steps that providers should take in order to ensure that the organization can influence the health
outcomes of its older adult patients; however, it did not alert providers to any contextual or
organizational influences that may occur. Because the CCH provides information about
contextual influences, RCHC’s policies can be an asset if both documents are presented together.
Unfortunately, data from providers indicate that they have little motivation that they can
influence health outcomes within their current context due to lack of time, minimal resources and
lack of communication between provider and leadership. If providers receive training or are
allow the time to read both the CCH and RCHC’s policies to increase their motivation around
A CARE COORDINATION MODEL 69
care coordination, they will have the potential of becoming assets to designing care coordination
models.
Organizational influences on the design of care coordination models. The Reducing
Care Fragmentation booklet located in CCH’s toolkit provided detailed information on how
organizations can change its internal systems to demonstrate commitment to care coordination
models. There are five key changes that can be made:
1. Decide as a primary care clinic to improve care coordination.
2. Develop a referral and transition tracking system.
3. Organize a practice team to support families during referrals and transitions.
4. Identify, develop and maintain relationships with key specialist groups, hospitals and
community agencies.
5. Develop formal agreements with these key groups; and develop and implement an
information transfer system.
All of these key changes emerged from provider data when they were asked about resources
needed to design care coordination models. RCHC’s policies reveal commitment to care
coordination and tracking of data; however, data also reveal that not all providers are convinced
of commitment towards these model designs. Communication must occur between leadership
and providers before the CCH and RCHC polices can be characterized as positive organizational
influences on the design of care coordination models for its older adult patients.
Summary of Findings
Themes emerged from knowledge, motivation and organizational influences identified
RCHC’s assets and barriers in regard to designing care coordination models that include older
adult patient feedback.
A CARE COORDINATION MODEL 70
Knowledge findings. Although RCHC’s medical providers possessed general
knowledge about the concept of care coordination, there was a lack of consensus of what care
coordination meant or its specific components. Additionally, providers did not agree on whether
care coordination should be delivered on an individual provider basis, or as a team-based
approach. The knowledge finding around the definition of care coordination emerged as a barrier
to designing care coordination models for older adults.
All providers revealed that older adult cognition affects the design of care coordination
models that include patient feedback. All providers noted that it is important to have family or
caregiver support whenever there is evidence of cognitive decline in older adult patients.
Providers also believed that social environments are equally important in the design of such
models. They all agree that older adults need to continually be connected to social supports and
referral resources in the community in order to ensure that care coordination models are
appropriately designed within the social environments in which they live. Provider knowledge
influences around cognition and social environment emerged as assets to the organization.
Motivation findings. RCHC’s medical providers all agreed about the value of care
coordination models and how they can positively influence the health of their older adult
patients. This motivation influence emerged as an asset to RCHC. On the other hand, providers
were not confident that they are able to influence the health of their older adult patients because
of organizational influences. These influences are summarized in the next section.
Organizational findings. When providers were asked about the RCHC’s commitment to
designing care coordination models for its older adult patients, there were mixed responses. Half
of the providers adamantly agreed that the organization was committed to patient feedback to
inform their care and expressed motivation to help them achieve this goal, which emerged as an
A CARE COORDINATION MODEL 71
asset to the organization. Conversely, half of the providers were not sure if RCHC was
completely committed because they saw evidence of the organization initiating many different
projects in the community, which emerged as a barrier. Providers also mentioned that the
organization is effective at starting projects, but RCHC leaders do not always complete them.
RCHC leaders need to be proactive in demonstrating which projects they are committed to by
directing resources mainly towards those efforts. RCHC’s commitment to designing care
coordination models was revealed as a barrier because providers indicated mixed responses
around the organization’s commitment.
There were three unanticipated organizational influences that emerged when data was
analyzed for motivational influences. First, providers demonstrated frustration in not having
enough time in their day to speak to older adult patients who may have multiple medical and
social needs. Second, providers revealed that they felt there was a lack of infrastructure within
RCHC to meet their stakeholder goal. Third, providers commented on the lack of
communication between providers and leadership. All three organizational influences emerged
as barriers to meeting the goal of designing care coordination models for its older adult patients.
Providers indicated that the organization did not have the necessary resources need to
meet their goals. They commented on not having capital in the form of human, social and
relationship capital to design care coordination models, emerging as a barrier to the
organizational goal.
Recommendations for Practice to Address KMO Influences
This section details the proposed recommendations for addressing the knowledge,
motivational and organizational gaps that emerged as it relates to designing care coordination
models that include the perspectives of older adults. A comprehensive implementation and
A CARE COORDINATION MODEL 72
evaluation plan based on the New World Kirkpatrick Model (Kirkpatrick & Kirkpatrick, 2016) is
presented in Appendix G.
Knowledge Recommendations
The knowledge influences of social cognition and social environments of older adults and
their role in designing care coordination models emerged as assets for RCHC. A knowledge gap
revealed that providers did not have a consensus definition around the concept of care
coordination. The frameworks utilized to guide the discussion for knowledge influences is Clark
and Estes (2008) and Krathwohl (2002). The recommendations in Table 4 lists the knowledge
gap that needs to be resolved and the recommended solutions based on theoretical principles to
achieve the organizational goal.
Table 3
Summary, Knowledge Recommendations
Knowledge Influences Principle and Citation Context-Specific
Recommendations
Providers need to know
the definition of care
coordination.

The basic elements of a term or
concept must be understood in
order to solve problems within a
specific discipline. (AHRQ, 2017;
Scholtz, 2015; Krathwohl, 2002).
Provide information on the
definitions of care
coordination and the definition
that best suits the
provider/patient relationship at
RCHC.

Develop a job aid or utilize
the CCH in obtain information
about the design of care
coordination models.

Focus on modeling, role-
playing and practice to gain
feedback from their peers on
whether they are designing
care coordination models that
include older adult feedback.

A CARE COORDINATION MODEL 73
Developing a consensus definition for care coordination. Declarative knowledge is
the understanding of specific facts, terminology and details around a phenomenon (Krathwohl,
2002). The data revealed that providers had varying answers when asked to define the term care
coordination. The basic elements of a term or concept must be understood in order to solve
problems within a specific discipline (AHRQ, 2017; Krathwohl, 2002; Scholtz, 2015). One of
the knowledge recommendations would be to provide information on the various definitions of
care coordination through a series of monthly brainstorming sessions or mini-retreats so that
knowledge can be obtained and materials shared and thoroughly all care coordination definitions,
models and how they aligned with RCHC’s mission. Providers will then come to a consensus on
which definition will guide them in designing care coordination models for its older adult
patients. Next, a job aid should be developed or a current one referenced, such as the CCH, to
provide the framework for the discussion and increasing knowledge about designing care
coordination models. Job aids can be useful tools to remind employees what they have learned
when acquiring new skills (Clark & Estes, 2008). The third recommendation is that providers
should practice role-playing to gain feedback from their peers on whether they are including the
components necessary in the care coordination model. The goal would be to develop a
consensus definition around the term of care coordination that guides the design of a care
coordination model that best suites the provider/patient relationship at RCHC.
Motivation Recommendations
The motivation influences of provider value of care coordination models informed by
their older adult patients emerged as an asset for RCHC. The motivation influence related to
whether healthcare providers felt as though they could influence the health outcomes of the older
adult patients with the context in which they worked emerged as a barrier; however, the barriers
A CARE COORDINATION MODEL 74
were identified as organizational barriers. They will be discussed more in the Organizational
Recommendations section.
Organizational Recommendations
The organizational influence that providers should have confidence in the organization’s
commitment to designing care coordination models for their older adult patients emerged both as
an asset and a barrier for RCHC. Providers had mixed responses, indicating that providers’
perception of organizational commitment must be addressed.
The remaining organizational influences emerged as barriers towards the design of care
coordination model for RCHC’s older adult patients. Providers revealed frustrations about not
having enough time in their day to coordinate care for their older adult patients. Providers also
felt as though the organization did not have the infrastructure to design care coordination models.
Another gap revealed the lack of communication between providers and leadership. Finally, a
gap emerged with respect to lack of organizational resources to complete the design a care
coordination models. The framework used to guide recommendations is Clark and Estes (2008)
and their discussion about organizational culture aligning with organizational behavior, policies
and procedures. Table 5 lists the organizational gaps that needed to be resolved and the
recommended solutions based on theoretical principles to achieve the organizational goal.

A CARE COORDINATION MODEL 75
Table 4
Summary, Organizational Recommendations
Organizational Influences Principle and Citation Context-Specific
Recommendations
RCHC must demonstrate
commitment towards the
design of care coordination
models for their older adult
patients.

RCHC must promote a
culture that encourages
time to design care
coordination models for
older adult patients.

RCHC must develop the
infrastructure needed to
design care coordination
models for their older adult
patients.

RCHC must develop a
culture of open
communication between
providers and leadership
to encourage innovative
ideas towards the design
of care coordination
models.

RCHC must provide the
necessary resources to
design care coordination
models for their older
adults patients.
Design an incentive structure and
use of incentives are more
important than the type of
incentives used (Elmore, 2002).

Promote an enabling learning
environment which focuses on the
practices that facilitate or hinder
learning (Ellstrom, Ekholm &
Ellstrom, 2007).

Align the structures and the
processes of the organization with
goals (Clark & Estes, 2008).

Communicate constantly and
candidly to those involved about
plans and progress (Clark & Estes,
2008).

Healthcare organizations must
strive to obtain resources that will
implement, design and monitor
care coordination activities among
varied healthcare providers
(Carayon et al., 2012).
Provide incentives that align
organizational goals with care
coordination activities for
older adults.

Provide opportunities for
training planning and
information exchange through
formal and informal learning
settings.

Strategic meetings should be
held with staff to align the
structure of the organization
with key business processes.

Increase the opportunities for
communication between
leadership and providers.

Advocate for resources on
behalf of the organization
locally and regionally for
additional funding and form
mutually beneficial
partnerships to design care
coordination models older
adult patients.

A CARE COORDINATION MODEL 76
Demonstrate commitment to the design of a care coordination models for older
adult patients. Of the eight providers interviewed, half of them did not have confidence that the
organization was committed to designing care coordination models its older adult patients.
Elmore (2002) states that an incentive structure must be created, along with the appropriate uses
of those incentives, as a way to demonstrate organizational commitment to new innovations. As
such, the recommendation suggestion is to provide incentives that align organizational goals with
designing a care coordination model that includes the perspectives of older adult patients.
Healthcare providers lament that organizations are not committed to care coordination activities
because they offer no incentives for designing such interventions (Wang et al., 2016). When a
healthcare organization and its staff are integrated around a common goal with appropriate
incentives for a specific population, they will work together for the betterment of the patients
(Lynn & Kamp, 2014). Incentives must also be created for the development of information
systems and the infrastructure necessary for better management of chronic conditions (Kocher &
Sahni, 2010). When healthcare organizations create incentives as a way to demonstrate their
commitment to designing care coordination models for older adult patients, providers may be
more motivated to the design of such models.
Promote a culture that encourages the time needed to design care coordination
models. All providers interviewed noted that there was not enough time in the day to coordinate
care for their patients. As such, RCHC should examine how work conditions inhibit providers
from being productive in their daily work environment. Specifically, RCHC leaders must allow
their providers time to meet individually or as teams for the purposes of creating knowledge that
can align with patient needs. Establishing learning environments within healthcare organizations
allows employees time to innovate and design strategies, while they orient their tasks towards the
A CARE COORDINATION MODEL 77
needs of their patients (Ellstrom, Ekholm and Ellstrom, 2007; Ratnapalan & Uleryk, 2014). As
such, the recommendation is for RCHC to allow providers time for training and planning in
formal and informal settings so that providers can have the freedom to design care coordination
activities for their older adult patients.
When RCHC is purposeful in allowing providers the time to plan care coordination
activities, innovations can be created that align with patient healthcare needs. Time should be set
aside at the beginning or the end of the day within the formal context of the clinic. Providers can
also be encouraged to meet at local coffee shops or other informal settings to discuss care
strategies outside of the clinic. Providers should be allowed time to attend professional
development trainings, visit Best Practices models and engage in diverse learning activities in
order to obtain the information they need to design care coordination models. Leadership must
also be accessible, making a commitment to developing a learning environment which will foster
active learning among its care team (Ellstrom, Ekholm & Ellstrom, 2007). A culture which
fosters a learning environment or one which allows time for continuous training and planning in
formal and informal settings, will result in employees who are continuously engaging in active
learning to support their patient needs.
Develop an infrastructure needed to design a care coordination model for RCHC’s
older adult patients. Providers revealed concern for RCHC’s lack of infrastructure to design a
care coordination model for RCHC’s older adult patients. Developing organizational capacity to
deliver a care coordination model is essential in increasing the health outcomes of older adult
patients. Clark and Estes (2008) note that an organization’s structures and processes must align
to meet organizational goals. The recommendation is that RCHC hold a series of strategic
A CARE COORDINATION MODEL 78
planning meetings with staff to create a collaborative strategic plan that aligns the organization’s
structure with its goals.
Wilson (2006) argues that having a communicative planning approach towards strategic
planning builds collaborative organization cultures that fosters human commitment,
organizational cohesion and high morale. Meetings should be held every other month between
leadership and providers to determine key business processes and how they align with the goal of
designing care coordination models for older adults. The strategic planning process should also
include key stakeholders such as older adult patients. Failure to include key stakeholders in the
strategic planning process and listen to their values and beliefs may hinder an organization in
meeting its goals (Wheeler & Sillanpa’a, 1998). During these planning meetings, strategies
would be developed to enhance the infrastructure of the RCHC and improve its capacity to meet
its goals of designing care coordination models for older adult patients.
RCHC leaders must increase the opportunities for communication with its
providers. All providers acknowledged the lack of communication between themselves and
leadership. Leadership must communicate constantly and with candor with employees when
new projects are introduced (Clark and Estes, 2008). Communication should include feedback
loops that include information and corrective feedback which helps employees to adjust their
performance in order to meet stakeholder and organizational goals. The recommendation is that
organizational leaders should increase communication by increasing opportunities for group and
one-on-communication with its providers and staff.
RCHC leaders should demonstrate commitment to two-way feedback in several ways.
First, leaders need to return all phone calls from employees within 72 hours. Second, leadership
should allow a set amount of time bi-weekly to meet with providers and staff who need answers
A CARE COORDINATION MODEL 79
or clarification to any processes occurring within the organization. The time should exceed no
more than 4 hours per month. Third, there should be a quarterly meeting with all providers to
have open communication related to information related to the mission of the organization and
how it relates to organizational goals. Last, leaders must hold themselves accountable to
providers and staff by creating an internal, ad-hoc Communication Committee who will present
any lingering concerns or questions that providers may have at an All Staff yearly meeting.
Having clear communication engenders trust and commitment to change for employees on all
levels (Clark and Estes, 2008). Additionally, increased communication between leadership and
staff can promote higher levels of success and confidence and positively influence learning and
behavior (Eccles, 2006). Increasing communication among leadership and providers will
positively influence the design of care coordination models for RCHC’s older adults.
Advocate for resources on behalf of the organization. RCHC providers do not
currently have the resources needed to design care coordination models that are informed by
older adult patients. It is essential that healthcare providers have access to resources they need in
order to design care coordination models for their patients. This includes additional time for
coordination and adequate provider training. Additionally, Carayon et al., (2002) state that
healthcare organizations must strive to obtain technologies that will design, implement and
monitor care coordination activities among varied healthcare providers.
Lack of resources will inhibit employee performance, even in those who possess the
knowledge, skills and motivation to complete meet performance outcomes (Clark & Estes,
2008). As such, the recommendation is to advocate for resources on behalf of the organization
within the healthcare community locally and regionally for additional funding needed to design
such models. Additionally, innovative community health partnerships must be formed to
A CARE COORDINATION MODEL 80
leverage scarce resources in the form of financial, human, social and intellectual capital for the
purposes of meeting mutually beneficial interests designed to increase the healthcare outcomes
of older adult patients.
Recommendations Specific for Providers and RCHC’s Minority Older Adult Population
I designed this study to conduct a gap analysis around the knowledge, motivation and
organizational influences that promoted or inhibited the design of care coordination models for
an organization that was accessible and available at the time of my doctoral studies. RCHC’s
older adult population was mostly vulnerable, ethnic and racial older adults. Although the
study’s main focus did not focus on designing care coordination for this specific population, it is
appropriate to include recommendations and provide insight to a similar organization with a
similar patient population.
Provide cultural competency training. First, the organization should provide
professional development training for its providers with regards to cultural competency. Cultural
competence in healthcare means depends on a team of healthcare services, from primary care
and specialty providers to social workers, being able to provide services that meet the social,
cultural and linguistic needs of patients (Campinha-Bacote, 2002; Galambos, 2003; Streltzer &
Tseng, 2008). It also can serve as a framework for addressing healthcare disparities that may
exist with this population (Betancourt, Emilio & Ananeh-Firempong, 2003).
Learn more about the resources in the community. Providers need to learn more
about the resources that are available in the community in order to address their patients’ needs
from a medical, as well as a social and economic perspective. RCHC providers appear to
understand the social determinants of health and how they can negatively influence healthcare
outcomes; however, they do not necessarily know how to address them and do not always initiate
A CARE COORDINATION MODEL 81
conversations because they do not have solutions. Encouraging open conversations about what
their patients need in terms of housing, transportation or food is one of the foundational elements
of care coordination (Smith, 2013) and often feels uncomfortable to providers who are used to
the traditional model of care (Berwick, 2009). Feedback from providers noted that there is a
staff member who provides care coordination activities; however, that individual also serves in
multiple roles. Since the providers are the first point of contact in initiating the design of care
coordination models, a list of referral resources should be handed to their older adult patients
during the doctor visit to address barriers to transportation, food inefficiency, frauds and scams,
elder abuse, violence and legal services. Understanding the social contexts of their vulnerable
older adult patients will enable providers to align medical needs with social needs, increasing the
probability of increased patient experiences, with decreased health care costs.
Future Research
Opportunities for future research emerged from the study. The focus of the study was to
explore RCHC’s capacity, via its providers, to design a care coordination model for its older
adult patients. Further research around the diverse needs of vulnerable racial and ethnic older
adult populations and how care coordination models can impact health disparities among this
specific population are recommended. Additionally, empirical evidence is needed around the
characteristics of this population and how they impact providers understanding of designing care
coordination modes.
The lack of infrastructure emerged as a limitation in the design of care coordination
models for RCHC’s older adult patients. Further research is needed with regards to how
providers define the specific components of infrastructure and how the lack of it impacts the
design of care coordination models. Finally, research is necessary that focus on vulnerable older
A CARE COORDINATION MODEL 82
adult patient perspectives and how their preferences are included within their care coordination
models.

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Appendix A: Definitions
Accountable Care Organization. A group of doctors, hospitals and other medical providers who
come together voluntarily to coordinate high quality care for its Medicare patients.
Care Coordination. 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 healthcare services.
Centers for Medicare & Medicaid Services. A federal agency that administers the Medicare
program and works in partnership with state governments to administer Medicaid programs.
Community Health Clinics. Nonprofit clinics located in medically under-served communities
that have a mission of providing comprehensive primary care regardless of insurance status.
Federally Qualified Health Centers. Community-based healthcare centers that provide primary
care services in underserved communities. They operate under a strict set of requirements,
including providing healthcare on a sliding fee scale basis based on individuals’ ability to pay
and they operate under a governing board that includes patients.
Medicare. A federal health insurance program for those ages 65 and older, specific younger
persons with disabilities, and those with permanent kidney failure.
Medicaid. A federal and state-funded health insurance program for low income adults, children,
pregnant women, elderly adults and people with disabilities.
Multimorbidity. Any older adult who has three or more chronic health conditions.
Older Adult Patients. Any individual over 65 who is under the care of primary and specialty
doctors.
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Patient Protection Affordable Care Act. Often referred to as the Affordable Care Act or
Obamacare, is a U.S. federal statue whose goals are to expand access to healthcare, provide
patient protection from insurance companies and reduce healthcare costs.
Polypharmacy. More commonly in elderly patients, the use of multiple medications, usually
considered to be five or more, to treat chronic conditions.
Primary Care Medical Homes. Often referred to as Patient Centered Medical Homes (PCMH),
whose purpose is to provide comprehensive, patient-centered, coordinated care that provide
access to safe and high-quality health services.
Healthcare Providers. Clinical staff who have a lead role in designing care coordination models
that include the perspectives of older adult patients.

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Appendix B: Protocols
Interview Protocol Introduction
I would first like to thank you for agreeing to participate in this study. Thank you for
taking time out of your very busy schedule to meet with me to answer some questions. This
interview will take about 45 minutes to an hour, although I have allocated 90 minutes if we need
it.
I am currently enrolled in a doctoral program at the University of Southern California and
am conducting a study on the design of care coordination models that include the perspectives of
older adults. Today I am not here as an employee of RCHC, but as a researcher collecting
information for my study that will hopefully be beneficial for you, your older adult patients and
RCHC. The information you share with me will be included in my study as part of my data
collection and will be strictly confidential. Your name and responses will not be disclosed to
anyone or anywhere outside the scope of this study and will be known only to me for purposes of
my data collection. While I may choose to directly quote you in this study, I will not use your
name and I will make the best effort possible to remove any potential identifying information. I
will gladly provide you a final copy of this study upon request.

During the interview I will use a recording device to ensure that I capture all of your
response accurately. The information recorded will not be shared with anyone besides me, or
anyone else outside of the scope of this study. The information will be transferred to password-
protected files on a cloud file storage account. Once the information is transferred to the cloud
account, it will be immediately deleted from the recording device. The information will then be
destroyed after two years from the date my dissertation defense is approved.

Participation in this study is completely voluntary. There will be no repercussions to you
on behalf of RCHC whether you decide to participate in this study or not. Do you have any
questions about the study before we get started? If not, I would like your permission to get
started with the interview. May I also have your permission to record this conversation?

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Interview Questions
1. Can describe your typical day at Royal Community Health Center (RCHC)?
2. How important do you believe it is to design care coordination models for that include
the perspectives of older adults?
3. What does the concept of care coordination mean to you?
4. Tell me a little bit about your experiences, if any, in designing care coordination models.
What has this been like for you?
5. How would you describe the process of developing care coordination models that include
the perspectives of older adults? Specifically, which critical components do you think
need to exist?
6. In your opinion, what are some of the challenges providers face in developing care
coordination models?
7. What do you think you do well as a medical provider in contributing to care coordination
models that include the perspectives of older adults?
8. How confident do you feel about your abilities to design a care coordination model that
includes the perspectives of older adults? How confident do you feel about the
organization’s ability to do the same?
9. Are there any other factors to consider when designing care coordination models for
older adults? What are they in your opinion?
10. Which aspects of RCHC’s culture support the goal of designing a care coordination
model that includes feedback from older adult patients? Which aspects of culture hinder
this goal? Please explain.
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11. To what degree do you feel that RCHC is committed to designing a care coordination
model that include the perspectives of older adults?
12. If you were to design a care coordination model that includes the perspectives of older
adults, what materials, resources and equipment would you need?
13. How does the cognitive capacity of older adult patients influence the design of care
coordination models, if at all?
14. How do the social environments influence the design of care coordination models, if at
all?
15. In thinking about RCHC’s organizational structure, is there a mechanism that you see that
can facilitate the design of care coordination models that include feedback from older
adults?

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Document Analysis Questions
1. Is there a policy and procedures manual or similar document?
2. When was the policy and procedures manual developed or created?
3. What is the purpose of the policy and procedures manual?
4. Is the term care coordination defined in the policy and procedures manual?
5. Does the definition of care coordination in the policy and procedure manual align with
the U. S. Department of Health and Human Services definition of care coordination?
6. What specific guidance does the policy and procedure manual give to providers with
respect to the design of care coordination?
7. What specific guidance does the policy and procedure manual give to organizations with
respect to designing care coordination models?
8. Are there other documents that exist? For example, marketing materials, PowerPoint
presentations, etc.?
9. What is the tone of all documents? Does the organization seem to support the design of
care coordination for older adults?

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Appendix C: Additional Resources Needed
Table 5

Interview Participant Comments Regarding Additional Resources Needed for Care coordination
models for Older Adults

Q.10 If you were to design a care coordination “More visual aids”
model that includes the perspectives of older adults,
what materials, resources and equipment would
you need? “Definitely a big van. Transportation.
Assistive devices. It's really just
anything to get them to be able to do
the same things that they did before.
Reading, walking, eating, bathing
easier, so you would need all of that,
everything to be able to adapt their
living or their surroundings.”

“One thing that I can think about is
accessibility to technology. Because
especially in the medical field
nowadays, a lot is moving towards
electronic medical records of course,
and then as part of that, these online
patient portals, accessing your labs on
line…”

“Of course we would need an upgrade
with our current EMR to have better

data tracking to that we could support.
We just don't have the data reporting
that we need.

“So, equipment, mobility equipment.
So you know, having things like
wheelchairs easily accessible, beds
that can go up and down for our
patients to be able to get on to an
exam bed, because right now they're

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pretty high, and the step they need to
get onto the bed is pretty narrow, so
for some of our older adults it's
actually very difficult for them to get
up for an exam. So mobility
equipment”.

“Materials, definitely probably larger
font patient education materials,
because a lot of this Times Roman 12
font isn't going to work”.

“Little things like pillboxes and stuff
would be nice to have, but patients
can go buy those”.

“We would also something for the
hearing impaired, where they may
have some hearing, but they're not
hearing everything. So, devices that
could help them, not just when they're
at the clinic and getting the
information, but actually having it in
the home, like the attachments that
can go on the TV, but it can go on the
phone, so they're actually hearing
everything that's going on”.

“Just having the resources and the
education tools for the staff to use”.
“I guess resourcing with other
agencies in the community that are
working with care coordination,
because we do have, I don't know if
you'd call them committees or not,
but there's different groups.

“Some type of tracking or survey or
something that patients and their
family members would be able to
express themselves and just kind of
let us know how that model is, how
it's working or is not working”.
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“Some computer stations where
people could come in and get some
education done, or a room where
people could have some group
meetings about common topics for
senior adults, or that type of thing”.
“I think the biggest thing is looking
at the research and the literature
that's already been done, seeing
where the holes are, looking where
the organization is, and then
developing a plan based on that”.
“Technology, we would need a new
phone system”.

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Appendix D: Credibility and Trustworthiness
Trustworthiness of the study refers to validating the findings or interpretations of a study
to determine the accuracy or credibility of my finding through different strategies (Creswell,
2015). It is a way of finding out how my interpretations may be wrong and ensuring that
alternative explanations cannot be posited (Maxwell, 2013). As suggested by Merriam and
Tisdell (2015), there are several ways to protect the integrity of qualitative research.
Triangulation of data was realized through the use of interviews and document analysis to allow
various patterns and themes to emerge. I analyzed notes kept in a researcher log and a researcher
reflective journal to ensure that data and personal experiences are kept in perspective. I ensured
that there was saturation of the data, collecting information until realized a pattern of repeated
information on several occurrences. I conducted an external audit by asking an outside evaluator
(one of my mentors and a practicing scholar of academic research in the nonprofit arena) to
conduct a peer review of my coded transcripts and conclusions and provide feedback me in
writing the strengths and weaknesses of my research. I specifically asked this individual to be
attentive to what Maxwell (2013) refers to as researcher bias as it relates to my subjectivity and
the notion of how my values and expectations reflect in the research outcomes. Finally, I was
conscientious of Maxwell’s concept of researcher reactivity, by avoiding leading questions and
not influencing how the interviewee responds to my research questions. As a result, research
findings produced reality behind what was really happening as it related to providers’ knowledge
and motivational influences and how they interacted with RCHC in the design of care
coordination models that include the perspectives of older adults.

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Appendix E: Ethics
To address gaps in the literature with respect to providers including the perspectives of older
adults in their care coordination models, I employed the method of qualitative research. A semi-
structured interview was designed and data obtained through conversational partnerships.
According to Rubin and Rubin (2012) conversational partnerships are built on mutual trust and
respect and as the researcher, I accepted great responsibility in ensuring that no harm came to my
research participants, no deception was involved and that I adhered to all promises made.
Additionally, coercion was not used against anyone who felt uncomfortable answering interview
questions.
I explained to research participants that the study was submitted through the University of
Southern California’s Institutional Review Board (IRB) process to ensure that their rights and
welfare were protected as human subjects throughout this study. My philosophical nature is that
research participants have certain rights and as such, these rights were detailed through
Introduction to the Interview Protocol, as I described the purpose of the study, the use of the
results, and how these results may impact their lives (University of Southern California [USC],
2017; Creswell, 2014; Glesne, 2011). Additionally, I explained that participation was voluntary
and that they may decide to withdraw from the study at any time with no repercussions. I
promised that information obtained would be kept confidential, (utilizing pseudonyms or other
non-identifying labels throughout the study), and that all records will be stored and secured in a
locked cabinet in my home office. I ask research participants if they were comfortable with me
shredding all data at the conclusion of the study. Finally, asked for their agreeance for me to
record our qualitative interviews once they commenced. I asked my research participants if they
had any questions or concerns before I commenced with the interview.
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My study focuses on the providers of care coordination activities within a community
clinic that provides healthcare to those who are uninsured or under-insured. I decided to conduct
my study within an organization that I have no relationship with and thus, have no interest in the
results but to help the organization improve upon its performance outcomes for its older adult
patients. Albeit the case, I was not so naïve as to think that I did not have biases as it relates to
data collection, analysis and reporting activities. To address my biases as an African American
female who grew up in poverty not having access to healthcare, I reflected on my personal,
practical and intellectual goals through a researcher identity memo that helped me discover any
potential concerns that my identity and experiences may create (Maxell, 2013). Additionally, I
constantly reflected on Glesne’s (2001) descriptions of the roles researchers can assume and my
potential to serve as Intervener/Reformer, Advocate, or Friend by noting my reflections in a
researcher journal. As a qualitative researcher conducting conversational interviews, I was
attentive to actively discovering any potential biases, ensuring the integrity of my research study.

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Appendix F: Limitations and Delimitations
There are limitations that may have a possible impact on the study’s outcome. First, this
problem of practice focused on only a singular community health clinic located in the
Southeastern region of the United States. Findings cannot be generalized to community health
clinics that are subject to different contextual circumstances. Second, this study focused on the
perspectives of several individuals who served in different roles in initiating care coordination
models for older adult patients. Also, there were time limitations with respect to the study that
limited additional methods from being analyzed, such as focus groups. Additionally, document
analysis would ideally include policies and procedures manuals, a Standards of Operating
Procedures manual, partnership agreement and internal memos or emails. There were limited
documents provided for this study, which impacts the interpretation of the data. A fourth
limitation was the nature of qualitative research which allows for subjectivity. Also, I trusted
that the responses of interviewees were answered honestly and truthfully, based on their
experiences.
There are delimitations of this study that need to be mentioned. First, I chose a
healthcare organization who served lower income older adults because this population is steadily
rising and they typically face multiple barriers in addressing chronic illnesses. Second, I chose
to study healthcare providers and not older adult patients because providers are the first point of
contact in initiating care coordination activities. Provider beliefs and biases towards the design
of care coordination models are critical in how they enact care for their older adult patients.
Also, there were complex Health Insurance Portability and Accountability Act (HIPAA) laws
that needed to be overcome with regard to interviewing patients. Time constraints of the study
would not allow patient interviews to happen. Finally, the qualitative research design was
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chosen because I wanted to uncover the meanings behind why providers enacted care in the way
that they did, within the context of organizational influences. Although a small focus groups
may have further validated data received from the interviews, time constraints on behalf of the
providers would not allow for meetings to occur. Document analysis was performed instead to
understand organizational culture and commitment to the design of care coordination models that
include older adult perspectives.

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Appendix G: Implementation and Evaluation Plan
To aid in the process of change efforts for RCHC, a training program will be
implemented for providers and organizational leaders. An effective way of measuring training
programs and their value to the organization is the New World Kirkpatrick Model (2016). The
New World Kirkpatrick Model was chosen because planning starts with the outcomes that need
to be accomplished, automatically focusing on what is important in a training program.
According to Kirkpatrick and Kirkpatrick (2016), there are four levels that demonstrate training
effectiveness. This discussion begins with Level 4, which measures Results and the degree to
which outcomes occur as a result of training. Leading indicators are a way to determine whether
behaviors are on track to meeting desired outcomes. Next is Level 3, which measures Behaviors
and the degree to which employees apply what they learned as a result of training. Required
drivers are policies, processes and systems to monitor, reinforce, encourage and reward critical
behaviors on the job. The New World Kirkpatrick Model starts with the end in mind to ensure
that training programs are effective in accomplishing program outcomes, which is critical in this
era of scare time, money and resources.
Organization Purpose, Need and Expectations
Royal Community Health Center (RCHC) is a 501(c)(3) community-based organization
whose mission is to provide the highest quality, medical, dental and mental health services for
low-income and underserved individuals who lack access to health care. The organizational goal
is that by October 2019, RCHC will implement a care coordination model for its older adult
patients. Organizational leaders set this goal because they wanted to exceed the minimal
requirements of the Federally Qualified Health Center (FQHC) with regards to the provision of
care coordination activities that will facilitate the provision of primary and specialty medical care
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for those who are uninsured or under-insured. Second, feedback from the independent
evaluation prompted RCHC to desire an innovation that will reduce healthcare costs and increase
patient satisfaction for their older adult patients. Measures to track achievement of this goal will
be developed and monitored by the RCHC’s Quality Improvement Team.
The stakeholder providers’ goal is that by March 2019, a care coordination model will be
designed that includes the feedback of RCHC’s older adult patients. The stakeholder goal was
determined because providers are the first point of contact in initiating care coordination models
and will need to understand the critical elements of designing such models. Implementing
recommendations from this study will ensure that RCHC will remain in compliance with federal
health mandates that require care coordination in order to provide services through the Centers
for Medicare Services. Additionally, it is expected that desired outcomes will increase patient
satisfaction and reduce healthcare costs associated with providing care for RCHC’s older adult
population.
Level 4: Results and Leading Indicators
Leading indicators are short term observations and measurements that inform an
organization about critical behaviors and whether they are on track to creating positive impacts
towards meeting desired results (Kirkpatrick & Kirkpatrick, 2016). External outcomes measure
constituent feedback and responses; whereas, internal outcomes measure individual, team,
departmental and organizational outcomes. Table 6 below lists the outcomes, metrics and
methods for RCHC’s external and internal outcomes.

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Table 6
Outcomes, Metrics, and Methods for External and Internal Outcomes

Outcome Metric(s) Method(s)
External Outcomes
1. RCHC’s Board will
approve the initiation of
designing care
coordination models that
include older adult
feedback.

By January 2019, the Board will approve
RCHC’s initiative to design care
coordination models.
Board meeting minutes.
2. RCHC’s Board will
approve the design of the
new care coordination
model for older adults.
By March 2019, the Board will make a
formal announcement to the community
via press releases that RCHC.
A press release.
Employee newsletters.
3. Improved relationships
in the community.
3a. An increase in opportunities to
partner with local and regional health
organizations.

3a Compare the number
of partnerships
agreements from FY
2019 against the last
fiscal year.

3b. An increase in grant and private
funding opportunities from local and
regional funders.

4. Positive feedback
from older adult patients
indicating approval of
the care coordination
model.
By July 2019, satisfaction surveys will
be administered to get feedback on the
care coordination model and its potential
to influence health outcomes.
Survey results

Internal Outcomes
4. Providers will be
identified to lead the
design of a care
coordination model that
includes older adult
perspectives.
By January 2019, provider members of
the Quality Control team will be
identified, representing medical and non-
medical disciplines.
Provider meeting
minutes will identify
QC team members.
5. Provider monthly
meetings will include
discussions on how to
incorporate feedback for
older adult patients.
The first 30 minutes of weekly provider
meetings will discuss care coordination
models that are informed by older adult
patients.
Provider meeting
minutes will provide
summarize discussions.
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6. Critical elements of a
care coordination model
will be identified by the
Quality Control Team.

In February 2019, the critical elements a
care coordination model will be voted
and approved by consensus among
providers.
A draft visual job aid
will be available that
explains the care
coordination model.
7. Providers will design a
care coordination model
for older adults.
By March 2019, critical elements of the
refined care coordination model will be
voted and approved by consensus among
providers.
A final visual job aid
will be presented that
details the care
coordination models for
older adults.

Level 3: Behavior
Critical behaviors. Critical behaviors are the few, key observable behaviors that
employees must perform to have the biggest impact on desired results (Kirkpatrick &
Kirkpatrick, 2016). In the case of this study, critical behaviors will demonstrate providers’
commitment to designing care coordination models that include older adult patient feedback. The
first critical behavior is that providers enhance their knowledge on the concept of care
coordination. Second, providers will volunteer to serve on the Quality Control committee for the
purposes of designing a care coordination model. The third critical behavior is that providers
will set aside time each day to brainstorm on the critical components of care coordination
models. The specific metrics, methods, timing for each of these outcome behaviors appears in
Table 7 below.

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Table 7
Critical Behaviors, Metrics, Methods, and Timing for Evaluation
Critical Behavior Metric(s)
Method(s)
Timing
1. Providers will
enhance or update their
knowledge on the
PCMH model and care
coordination models.
models.
At least 50% of RCHC
providers will enroll in a
professional development
training that focuses on care
coordination models.
Pre-post tests will be
administered gauges
knowledge around care
coordination models.
Every
month
2. Providers will
volunteer to serve on the
Quality Control
committee to facilitate
the design of the care
coordination models.
Five providers from at least
three disciplines will agree to
serve on the Quality Control
Committee.
The Quality Control
Committee will be
determined via an
internal email.
Within
30 days
3. Providers will set
aside time each day to
brainstorm on the
critical components of
care coordination
models.
Providers will set aside 30
minutes a day or 1.5 hours
per week to decide which
critical components are
necessary based on their
medical and non-medical
experiences.
An internal Google Doc
will capture the
feedback from providers
about the critical
components of care
coordination model.
Every
month

Required drivers. Required drivers are processes and systems that reinforce,
encourage, monitor and reward critical behaviors that are necessary to ensure that employees
stay on track (Kirkpatrick & Kirkpatrick, 2016). In this case of this study, required drivers will
ensure that providers learn the concepts of care coordination and able to design care coordination
models as a result of their training. Providers must have a consensus definition around the
concept of care coordination that embodies the mission of the organization. This could be
reinforced through job aids which detail the critical elements of care coordination models.
Providers will also feel as though they can influence the health outcomes of their older adult
patients as they are given the freedom to do so and incorporate specific criteria for their older
adult patients.
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Providers must have the confidence that their organization is committed to designing care
coordination models that include older adult patient feedback. Confidence can be increased in
several ways. First, there must be opportunities for training and planning in formal and informal
settings. Also, strategic meetings should be held with staff to align the structure of the
organization with key business processes. Next, communication between leadership and
providers should increase. Confidence can also be increased when providers notice that the
organization is partnering with healthcare clinics, medical facilities or other community
organizations to acquire the necessary funding, resources, equipment and technologies necessary
to implement such models. Additionally, when the organization ties provider incentives
outcome-related care coordination activities that reduce health costs and increase patient
experiences, providers will be more supported and motivated towards the design of care
coordination models for their older adult patients.
Table 8 below outlines the knowledge, motivation and organizational influences necessary to
achieve stakeholder outcomes.
Table 8
Required Drivers to Support Critical Behaviors
Method(s) Timing
Critical
Behaviors
Supported
1, 2, 3 Etc.
Reinforcing

A job aid will be developed or the CCH utilized to train
providers on care coordination models.
March
2019
1
Provide information on the definitions of care coordination and
the definition that best suits the provider/patient relationship at
RCHC.
Weekly 1
Focus on modeling, role-playing and practice to gain feedback
from their peers on whether they are designing care coordination
models that include older adult feedback.
Weekly 1, 2, 3
Encouraging

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Focus on modeling, role-playing and practice increase
confidence in designing care coordination models that include
older adult feedback.
Weekly 1, 2, 3
Allow providers the freedom to incorporate strategies they
believe will contribute to the healthy outcomes of their older
adult patients on a case-by-case basis.
Daily 2, 3
Monitoring

Advocate for resources on behalf of the organization locally and
regionally for additional funding and mutually beneficial
partnerships to design care coordination models that include
older adult patient feedback.
Ongoing 2, 3
Rewarding

Provide incentives that align organizational incentives with care
coordination models for older adults.
Monthly 2, 3

Organizational support. To ensure that drivers are implemented on a continuous basis,
RCHC will enact behaviors that will demonstrate organizational accountability. First, there
needs to be buy-in from the Board and from top management that create strategies for constantly
reminding employees that care coordination models are valuable to the organization. This will
be illustrated in the form of a highly visible local and regional campaign about RCHC’s
commitment to improving healthcare outcomes among its older adult population. Along with
this commitment, RCHC will encourage others to join them in committing mutually beneficial
resources to their new venture. For example, RCHC will recommend that the local Housing
Authority form a partnership with them to offer on-site care for its older adult residents. This
partnership would provide additional resources in the form of grant funding and office space to
serve new and current RCHC older adult patients. Internal to the organization, RCHC’s
accountability to its employees will be demonstrated in the form of weekly emails that remind
employees of the benefits of such models to their patients and to the organization. Also, top
management will provide monthly examples of best practices within the healthcare field that
demonstrate the success RCHC wants to mirror for its organization.
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Second, organizational accountability will include new ways of measuring provider
success for their older adult patients. Incentives will be aligned with organizational priorities as
it relates to designing care coordination models. An incentive package will be developed based
on provider feedback of what encourages them to design such models. Outcome measures will
be developed around feedback from older adult patients about specific provider strategies around
designing interactive care coordination strategies that met their specific healthcare needs.
Third, a feedback loop will be designed to ensure that employees and their departmental
leaders are able to monitor the successes, as well as make adjustments along the way as it relates
to supporting critical behaviors. Feedback loops may be established through monthly surveys,
one-on-one meetings with management, or a confidential employee hotline for those who may
feel uncomfortable with stating their concerns. Getting buy-in from top management,
developing a new incentive packing that rewards different outcomes based on patient feedback
and seeking and welcoming employee feedback will ensure that organizational leaders are held
accountable to enforcing and rewarding critical behaviors.
RCHC will support provider’s critical behaviors in a couple of ways. First, a new
performance appraisal system will be developed that links incentives to care coordination
activities for older adults. Currently, providers have no incentives that motivate or reward them
for decreasing health care costs or increasing patient healthcare outcomes. Feedback from
providers will inform organizational leaders about incentives that are appropriate in encouraging
them to design care coordination models that include older adult feedback. Second, provider
critical behaviors will be supported by providing them with resources needed to design such
models. Resources will be obtained by identifying additional grant-funded sources. Also,
partnerships will be made with other healthcare organizations or nonprofit groups in developing
A CARE COORDINATION MODEL 123
mutually beneficial partnerships that will provide the funding and additional staff needed to
design care coordination models. RCHC will be intentional in ensuring that critical behaviors
are supported within the organization.
Level 2: Learning
Learning is the degree to which participants obtain the intended knowledge, skills,
attitude, confidence and commitment after their participation in a training program (Kirkpatrick
& Kirkpatrick, 2016). Because there are multiple definitions of care coordination, providers
need to agree on a consensus definition of care coordination that will guide their practice.
Additionally, by attending monthly meetings to discuss care coordination strategies and being
allotted additional time to practice with each other and their older adult patients, providers will
learn the steps in implementing care coordination models.
Learning goals. Following completion of the recommended solutions; the RCHC
Providers will be able to:
1. Define care coordination for older adults.
2. Plan and collaborate with their peers to identify specific components of care coordination
models for older adults.
3. Classify and interpret the different models of care coordination and the different contexts
in which they can be useful to influence care for older adults.
4. Describe the value of care coordination models specifically for older adults.
5. Indicate confidence that they can influence the health outcomes of older adults within the
context of the RCHC.
6. Understand how to plan and monitor their time with older adult patients to ensure that
patient feedback is incorporated in the design or their care coordination model.
A CARE COORDINATION MODEL 124
The program recommended to RCHC that will support the achievement of provider goals
is one that will be informed by the Care Coordination Handbook (CCH) mentioned earlier in the
study. Also utilized will be Medicare’s Coordinated Care Demonstration Project. Developed in
2015, this project demonstrated promise in decreasing healthcare costs and improving healthcare
outcomes for older adult patients (CMS, 2015). RCHC’s Provider Care Coordination Training
module will provide the knowledge and skills needed to design care coordination models for
older adult patients. By providing this training, RCHC will demonstrate its commitment to the
design of care coordination models for their older adult patients. Providers will then become
motivated to designing such models because they will gain the confidence that they can influence
the health outcomes of their older adult patients. Finally, this training will be able to generate
the resources necessary to designing these models because when this program is evaluated in
2021, the results will demonstrate improved health outcomes and decreased healthcare costs of
patients. The training module has the promise of being the “gold standard” of professional
development programs within the field of healthcare for aging adults, resulting in innovative
partnerships that will leverage community assets.
The RCHC’s Provider Care Coordination training model be facilitated by a healthcare
trainer who is considered the expert on the design of care coordination models from the Center of
Medicare Services. The training will be modified to adapt to the contextual environment of
RCHC and will last for approximately eight weeks.
Program. The Provider Care Coordination Training model will include information
basic information about the concepts of care coordination and the design of models that include
older adult patient feedback which will allow for group discussion and dialogue. These modules
will be broken down into eight modules:
A CARE COORDINATION MODEL 125
1. What is the Definition of Care Coordination?
2. The Essentials of Care coordination models.
3. Effective Planning, Prioritizing and Designing Care coordination models.
4. Overcoming Challenges in the Design of Care coordination models.
5. Developing Confidence in Designing Care coordination models for Older Adult
Patients.
6. Importance of Designing Care Coordination Models that are Driven from Older
Adult Patient Perspectives.
7. Commitment to Designing Interactive Care Coordination for Older Adult Patients.
8. Applying Interactive Care Coordination Activities with Older Adult Patients.
Evaluation of the components of learning. The providers involved in the training will
be those who initiate care coordination activities for older adults and will include primary care
providers, dentists, nurse practitioners, behavioral health specialists and social workers. Once
the training is completed, an evaluation tool will be used to measure the effectiveness of the
training. Table 9 lists the methods and activities that will be used to evaluate the learning goals.
Table 9
Evaluation of the Components of Learning for the Program
Method(s) or Activity(ies) Timing
Declarative Knowledge “I know it.”

Knowledge checks using multiple choice

Ongoing and after
Pre- and post-tests on how to incorporate feedback from older adult
patients.
Before, during and
after
Practice with peers to share ideas on care coordination models Ongoing

Procedural Skills “I can do it right now.”

Role playing and practice designing care coordination. Ongoing
A CARE COORDINATION MODEL 126
Attitude “I believe this is worthwhile.”

Checklist of observation During the training
Discussions of interest in the design of the care coordination model.

Ongoing
Confidence “I think I can influence health outcomes within the
RCHC.”

Survey items using scaled items. Ongoing
Discussions following practice and feedback During the training.
Introspective documentation in work journal Ongoing
Commitment “I will do it on the job.”

Survey items using scaled items Ongoing
Discussions and documentation at the end of trainings During the training.
Self-reports of progress
Retrospective pre- and post-test assessments
After the course

Level 1: Reaction
Reaction is the degree to which participants are satisfied by the training as evidenced by
their level of engagement in the training, as well as its relevance to their job duties (Kirkpatrick
& Kirkpatrick, 2016). To measure participants engagement in the training, they will be asked to
document the information in a journal related to program objectives, course materials and
relevance to what they do. They will also be strongly encouraged to ask at least one question
during the program. Customer satisfaction will be measured through formative surveys that are
completed at the end of each module, as well as a summative survey upon program completion.
Table 10 below list the methods used to determine how participants will react to the learning
events.
Table 10
Components to Measure Reactions to the Program
Method(s) or Tool(s) Timing
Engagement

Attendance records At the beginning of each
workshop.
A CARE COORDINATION MODEL 127
Document reactions in a work journal. During
Asking meaningful questions

During
Completion of exercises During

Relevance

Informational survey and/or discussion Before and after breaks during
training.
Anonymous survey At the end of training.
Customer Satisfaction

Observer who listens intently and engage in discussion;
notice body language
During
Anonymous survey At the end of each workshop.

Evaluation Tools
Immediately following the program implementation. Once the training is conducted,
data will be gathered as it relates to the providers’ engagement of program materials. After each
training module providers will be asked about the knowledge and skills obtained during the
training and the relevance of the material to the design of care coordination model of older
adults. Specifically, Level 1 data will measure participants’ reaction to the training program and
Level 2 data will demonstrate the degree of learning that occurred as a result of the training.
Please see Appendix H for the immediate evaluation instrument.
Delayed for a period after the program implementation. Approximately 90 days
after the training, leaders will conduct a survey that includes open-ended and closed ended
questions using Kirkpatrick and Kirkpatrick’s (2016) Blended Evaluation approach that will
monitor, measure and report findings of the evaluation to improve providers’ performance in
designing care coordination models for older adults. The report will measure the Providers’
reaction to the training and learning and performance as a result of the training. Additionally, it
will measure how new knowledge is applied in the design of care coordination models for older
adults and the patient and organizational outcomes as a result of applying this new knowledge.
Please see Appendix I for the delayed evaluation instrument.
A CARE COORDINATION MODEL 128
Data Analysis and Reporting
Likert scaled items will be analyzed through an Excel spreadsheet. The means and
standard deviation will also be calculated. A Training Evaluation Report will be produced that
reports findings and summarizes how the training was received, its impacts on learning outcomes
and recommendations that will inform future needs as it relates to designing care coordination
models that include older adult feedback. The report will initially be presented to organizational
leaders. Subsequently, the researcher will follow instructions on releasing the information to staff
and subsequently to Board Members. The data will display nominal and ordinal level data
demonstrating the value the training has to the participants and the organization in designing care
coordination models that include older adult feedback.
Summary
The New World Kirkpatrick Model is beneficial in planning, implementing and
evaluating knowledge, motivational and organizational recommendations for RCHC to optimize
achieving the stakeholder and organizational goal. This model is beneficial because it will allow
the researcher to focus on the desired learning outcomes of the training for participants,
reinforced by critical behaviors and monitored by required drivers which promotes program
success (Kirkpatrick and Kirkpatrick, 2016). Also, it allows for monitoring of training contents
because of formative assessments that are collected throughout the training program. Monitoring
of training contents allow for adjustments in the program, which increases learned behavior. If
learned behavior increases job performance, it increases organizational effectiveness. For these
reasons, the researcher’s expectation for utilizing the New World Kirkpatrick Model is highly
probable, as it demonstrates training effectiveness, which shows the value of the intervention to
the organization.
A CARE COORDINATION MODEL 129

A CARE COORDINATION MODEL 130
Appendix H: Immediate Evaluation Instrument
Level 1: (Reaction)

1. The training is relevant to what I do on a day-to-day basis as a provider who delivers care
coordination to older adult patients.
Strongly Agree
Agree
Disagree
Strongly Disagree

2. The activities helped me to learn and retain information on how to design care coordination
models for older adults.
Strongly Agree
Agree
Disagree
Strongly Disagree

3. I was able to relate my learning to the training course objectives.
Strongly Agree
Agree
Disagree
Strongly Agree

Level 2: (Learning)

4. How committed you are to designing care coordination models for older adult patients?
Very Committed
Committed
Somewhat Committed
Not Committed at all

5. The knowledge and skills learned will help me to care coordination models for my older adult
patients.
Strongly Agree
Agree
Disagree
Strongly Disagree

6. As a result of the training, I know the steps in designing care coordination models for older
adult patients.
Strongly Agree
Agree
Disagree
Strongly Disagree
A CARE COORDINATION MODEL 131

7. I am confident that I can design care coordination models for older adult patients.
Highly Confident
Confident
Somewhat Confident
Not Confident at All

8. As a result of the training, my attitude towards the value of designing care coordination
models for older adults.
Strongly Agree
Agree
Disagree
Strongly Disagree

A CARE COORDINATION MODEL 132
Appendix I: Delayed Evaluation Instrument
Level 1: (Reaction)

1. The training was relevant to what I do on a day-to-day basis as a provider who delivers care
coordination to older adult patients.
Strongly Agree
Agree
Disagree
Strongly Disagree

2. The activities helped me to learn and retain information on how to design a care coordination
model for older adults.
Strongly Agree
Agree
Disagree
Strongly Disagree

3. I was able to relate my learning to the training course objectives.
Strongly Agree
Agree
Disagree
Strongly Agree

Level 2: (Learning)

4. How committed you are to designing care coordination models for older adult patients?
Very Committed
Committed
Somewhat Committed
Not Committed at all

5. The knowledge and skills learned will help me to a care coordination models for my older
adult patients.
Strongly Agree
Agree
Disagree
Strongly Disagree

6. As a result of the training, I know the steps in a designing care coordination model for older
adult patients.
Strongly Agree
Agree
Disagree
Strongly Disagree
A CARE COORDINATION MODEL 133

7. I am confident that I can design care coordination models for older adult patients.
Highly Confident
Confident
Somewhat Confident
Not Confident At All

8. As a result of the training, my attitude towards the value of designing care coordination
models for older adult patients.
Strongly Agree
Agree
Disagree
Strongly Disagree

Level 3: (Behavior)
9. I was able to apply the information learned from the training directly to my role in designing a
care coordination model.
Strongly Agree
Agree
Disagree
Strongly Disagree

10. The information I learned help me to improve my performance on the job as it related to me
designing a care coordination model for older adults.
Strongly Agree
Agree
Disagree
Strongly Disagree

Level 4: (Results)

11. The overall level of care increased for my older adult patients as a result of information learned
from the training.
Strongly Agree
Agree
Disagree
Strongly Disagree

12. Medicaid costs have decreased for my older adult patients as a result of the information learned
in the training.
Strongly Agree
Agree
Disagree
Strongly Disagree

Abstract (if available)

Abstract Care coordination, or coordination of healthcare services, has emerged as a promising solution to an increasing older adult population who are living longer with higher incidences of chronic illness (Institute of Medicine, 2001

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Asset Metadata

Creator Caughman, Corsha Samuel (author)

Core Title Designing a care coordination model for older adults

School Rossier School of Education

Degree Doctor of Education

Degree Program Organizational Change and Leadership (On Line)

Publication Date 02/15/2019

Defense Date 12/19/2018

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag care coordination,coordination of care,OAI-PMH Harvest,older adults

Format application/pdf (imt)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Seli, Helena (committee chair), Hirabayashi, Kimberly (committee member), Jason, Kendra (committee member), Lincoln, Karen (committee member)

Creator Email caughman@usc.edu,corwave@gmail.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c89-123149

Unique identifier UC11676807

Identifier etd-CaughmanCo-7082.pdf (filename),usctheses-c89-123149 (legacy record id)

Legacy Identifier etd-CaughmanCo-7082.pdf

Dmrecord 123149

Document Type Dissertation

Format application/pdf (imt)

Rights Caughman, Corsha Samuel

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA