Do health systems respond to the quality of their competitors?

OBJECTIVES: Some large employers and healthcare analysts have advocated for retail competition that relies on providers competing on performance metrics to improve care quality. Using publicly available performance measures, we determined whether health systems increased the quality of diabetes care provided by their clinics based on performance relative to competitors. STUDY DESIGN: Our analysis examined publicly reported performance measures of diabetes care from 2006 to 2013 for clinics in Minnesota health systems. METHODS: We obtained data for 654 clinics, of which 572 publicly reported diabetes care performance. Because some clinics did not report performance, we estimated a Heckman selection model. First, we predicted whether or not clinics reported performance. Second, we estimated the effect of relative performance (a clinic's performance minus the mean performance of clinics in competing health systems) on clinic performance using the results of the reporting model to control for selection into the sample of reporting clinics. RESULTS: Although diabetes care performance improved during our study, health systems did not differentially improve the diabetes care performance of their clinics performing worse than clinics in competing systems. This result indicates divergence between high-performing and low-performing clinics. This result does not appear to be due to risk selection. CONCLUSIONS: Publicly reporting quality information did not incentivize health systems to increase the performance of their clinics with lower performance than competitors, as would be expected under retail competition. Our results do not support strategies that rely on competition on publicly reported performance measures to improve quality in diabetes care management.

Do Health Systems Have Consistent Performance Across Locations and Is Consistency Associated With Higher Performance?

This study addresses whether health systems have consistent diabetes care performance across their ambulatory clinics and whether increasing consistency is associated with improvements in clinic performance. Study data included 2007 to 2013 diabetes care intermediate outcome measures for 661 ambulatory clinics in Minnesota and bordering states. Health systems provided more consistent performance, as measured by the standard deviation of performance for clinics in a system, relative to propensity score-matched proxy systems created for comparison purposes. No evidence was found that improvements in consistency were associated with higher clinic performance. The combination of high performance and consistent care is likely to enhance a health system's brand reputation, allowing it to better mitigate the financial risks of consumers seeking care outside the organization. These results suggest that larger health systems are most likely to deliver the combination of consistent and high-performance care. Future research should explore the mechanisms that drive consistent care within health systems.

Is Anyone Paying Attention to Physician Report Cards? The Impact of Increased Availability on Consumers' Awareness and Use of Physician Quality Information.

OBJECTIVE: To determine if the release of health care report cards focused on physician practice quality measures leads to changes in consumers' awareness and use of this information. PRIMARY DATA SOURCES: Data from two rounds of a survey of the chronically ill adult population conducted in 14 regions across the United States, combined with longitudinal information from a public reporting tracking database. Both data were collected as part of the evaluation for Aligning Forces for Quality, a nationwide quality improvement initiative funded by the Robert Wood Johnson Foundation. STUDY DESIGN: Using a longitudinal design and an individual-level fixed effects modeling approach, we estimated the impact of community public reporting efforts, measured by the availability and applicability of physician quality reports, on consumers' awareness and use of physician quality information (PQI). PRINCIPAL FINDINGS: The baseline level of awareness was 12.6 percent in our study sample, drawn from the general population of chronically ill adults. Among those who were not aware of PQI at the baseline, when PQI became available in their communities for the first time, along with quality measures that are applicable to their specific chronic conditions, the likelihood of PQI awareness increased by 3.8 percentage points. For the same group, we also find similar increases in the uses of PQI linked to newly available physician report cards, although the magnitudes are smaller, between 2 and 3 percentage points. CONCLUSIONS: Specific contents of physician report cards can be an important factor in consumers' awareness and use of PQI. Policies to improve awareness and use of PQI may consider how to customize quality report cards and target specific groups of consumers in dissemination.

Evaluating a complex, multi-site, community-based program to improve healthcare quality: the summative research design for the Aligning Forces for Quality initiative.

OBJECTIVE: The Aligning Forces for Quality (AF4Q) initiative was the Robert Wood Johnson Foundation's (RWJF's) signature effort to increase the overall quality of healthcare in targeted communities throughout the country. In addition to sponsoring this 16-site complex program, RWJF funded an independent scientific evaluation to support objective research on the initiative's effectiveness and contributions to basic knowledge in 5 core programmatic areas. The research design, data, and challenges faced during the summative evaluation phase of this near decade-long program are discussed. STUDY DESIGN: A descriptive overview of the summative research design and its development for a multi-site, community-based, healthcare quality improvement initiative is provided. METHODS: The summative research design employed by the evaluation team is discussed. RESULTS: The evaluation team's summative research design involved a data-driven assessment of the effectiveness of the AF4Q program at large, assessments of the impact of AF4Q in the specific programmatic areas, and an assessment of how the AF4Q alliances were positioned for the future at the end of the program. CONCLUSION: The AF4Q initiative was the largest privately funded community-based healthcare improvement initiative in the United States to date and was implemented at a time of rapid change in national healthcare policy. The implementation of large-scale, multi-site initiatives is becoming an increasingly common approach for addressing problems in healthcare. The summative evaluation research design for the AF4Q initiative, and the lessons learned from its approach, may be valuable to others tasked with evaluating similarly complex community-based initiatives.

The Aligning Forces for Quality initiative: background and evolution from 2005 to 2015.

OBJECTIVE: The Robert Wood Johnson Foundation's (RWJF's) Aligning Forces for Quality (AF4Q) program was the largest privately funded, community-based quality improvement initiative to date, providing funds and technical assistance (TA) to 16 multi-stakeholder alliances located throughout the United States. This article describes the AF4Q initiative's underlying theory of change, its evolution over time, and the key activities undertaken by alliances. STUDY DESIGN: Descriptive overview of a multi-site, community-based quality improvement initiative. METHODS: We summarized information from program documents, program meetings, observation of alliance activities, and interviews with RWJF staff, TA providers, and AF4Q alliance stakeholders. RESULTS: The AF4Q program was a dynamic initiative, expanding and evolving over time. The underlying theory of change was based on the notion that an aligned, multi-stakeholder approach is superior to independent siloed efforts by stakeholders. Participating alliances developed or strengthened programming to varying degrees in 5 main programmatic areas: (1) measurement and public reporting of healthcare quality, patient experience, cost, and efficiency for ambulatory physician practices and hospitals; (2) efforts to engage consumers in health, healthcare, and alliance governance (consumer engagement); (3) adoption and spread of effective strategies to improve care delivery; (4) advancing healthcare equity; and (5) integration of alliance activities with payment reform initiatives. CONCLUSION: The AF4Q initiative was an ambitious program affecting multiple leverage points in the healthcare system. AF4Q alliances were provided a similar set of expectations, and given financial support and access to substantial TA. There was considerable variation in how alliances addressed the AF4Q programmatic areas, given differences in their composition, market structure, and history.

Summative evaluation results and lessons learned from the Aligning Forces for Quality program.

OBJECTIVE: To report summative evaluation results from the Aligning Forces for Quality (AF4Q) initiative, the Robert Wood Johnson Foundation's (RWJF's) signature effort to improve quality of care from 2005 to 2015. METHODS: This was a longitudinal mixed methods program evaluation (ie, multiphase triangulated evaluation) of 16 grantee "alliances" from across the country, funded by RWJF as part of the AF4Q initiative. Grantees were selected in a nonexperimental manner and were charged with deploying interventions in 5 main programmatic areas to improve health and healthcare in their communities. RESULTS: Except for a small proportion of outcomes, there were no major differences in the rate of longitudinal improvement in AF4Q communities, compared with control communities, on quantitative outcomes related to the Triple Aim. Although the majority of the measures improved in both AF4Q and non-AF4Q communities, there were some exceptions to this improving trend, most noticeably in the cost of care and population health. There was also considerable heterogeneity across communities in terms of programmatic areas and the scale and scope of interventions in these areas. Although a number of AF4Q alliances implemented robust interventions in specific areas, often advancing strategies useful for others in the field, no AF4Q alliance pursued and aligned all 5 AF4Q programmatic areas in a robust way. In addition, whereas all alliances were able to garner the participation of multiple stakeholders initially, sustaining this participation and securing new sources of funding after RWJF support ended proved challenging for many alliances. Conclusion and Policy and Practice Implications: While the AF4Q program did not attain the ambitious community-level changes predicted by its sponsor at the program's outset, it did produce pockets of success on some dimensions for particular alliances. A number of factors explain the less-than-expected impact of the AF4Q initiative on community health and the observed variation in alliance sustainability and intervention strength. These include differing acceptance of the AF4Q initiative's theory of change, variation in the experience and capacity of the alliance communities selected for the program, differences in alliances' local healthcare market context, and the changing programmatic requirements for alliances participating in the AF4Q initiative. The variation in AF4Q program outcomes offers important lessons for those engaged in regional health improvement work.

The longitudinal impact of Aligning Forces for Quality on measures of population health, quality and experience of care, and cost of care.

OBJECTIVE: To summarize the results from the quantitative analyses conducted during the summative evaluation of the Aligning Forces for Quality (AF4Q) initiative. STUDY DESIGN: Longitudinal design using linear difference-in-difference (DD) regression models with fixed effects. Outcomes were selected based on the AF4Q program logic model and organized according to the categories of the Triple Aim: improving population health, improving quality and experience of care, and reducing the cost of care. DATA: Two primary data sources: the AF4Q Consumer Survey and the National Study of Physician Organizations (NSPO); and 4 secondary data sources: the Dartmouth Atlas Medicare claims database, the Truven Health MarketScan commercial claims database, the Behavioral Risk Factor Surveillance System (BRFSS), and the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). RESULTS: In total, 144 outcomes were analyzed, 27 were associated with improving population health, 87 were associated with improving care quality and experience, and 30 were associated with reducing the cost of care. Based on the estimated DD coefficients, there is no consistent evidence that AF4Q regions, over the life of the program, showed greater improvement in these measures compared with the rest of the United States. For less than 12% of outcomes (17/144), the AF4Q initiative was associated with a significant positive impact (P ≤.05), although the magnitude of the impact was often small. Among the remaining outcomes, with some exceptions, similarly improving trends were observed in both AF4Q and non-AF4Q areas over the period of intervention. Conclusion and Policy and Practice Implications: Our quantitative findings, which suggest that the AF4Q initiative had less impact than expected, are potentially due to the numerous other efforts to improve healthcare across the United States, including regions outside the AF4Q program over the same period of time. The limited overall impact may also be due to the variability in the "dose" of the interventions across AF4Q regions. However, these results should not be interpreted as a conclusive statement about the AF4Q initiative. More nuanced discussions of the implementation of interventions in the specific AF4Q programmatic areas and their potential success (or lack thereof) in the participating communities are included in other articles in this supplement.

Reporting provider performance: what can be learned from the experience of multi-stakeholder community coalitions?

OBJECTIVES: This analysis assessed the evolution of public reporting of provider performance in Aligning Forces for Quality (AF4Q) alliances, contrasted alliances that stopped reporting with those that plan to continue, and drew insights from alliance public reporting efforts for the national transparency movement. METHODS: Combined with document review, qualitative research methods were used to analyze interview data collected, over a nearly 10-year period, from the 16 participating alliances. RESULTS: AF4Q alliances made their greatest contributions to provider transparency in reporting ambulatory quality and patient experience measures. However, reporting ambulatory cost/efficiency/utilization measures was more challenging for alliances. Alliances contributed the least with respect to measures of inpatient performance. Six alliances ceased reporting at the end of the AF4Q program because of their inability to develop stable funding sources and overcome stakeholder skepticism about the value of public reporting. Insights provided by alliance leaders included the need to: focus on provider, rather than consumer, responses to public reports as the most likely avenue for improving quality; address the challenge of funding the reporting infrastructure from the beginning; explore collaborations with other entities to increase public reporting efficiency; and develop a strategy for responding to efforts at the national level to increase the availability of information on provider performance. CONCLUSION: The AF4Q initiative demonstrated that a wide variety of voluntary stakeholder coalitions could develop public reports with financial and technical support. However, the contents of these reports varied considerably, reflecting differences in local environments and alliance strategies. The challenges faced by alliances to maintain their reporting efforts were substantial, and not all alliances chose to report. Nevertheless, there are potential roles for alliances going forward in contributing to the national transparency movement.

From rhetoric to reality: consumer engagement in 16 multi-stakeholder alliances.

OBJECTIVE: A key component of the Aligning Forces for Quality (AF4Q) program was engaging consumers in their health and healthcare. We examined the extent to which the alliances embraced 4 areas of consumer engagement: self-management, consumer friendliness of reports of healthcare provider quality, involvement of consumers in alliance governance, and the integration of consumers into quality improvement teams. METHODS: We used a largely qualitative approach. The evaluation team conducted 1100 in-depth interviews with alliance stakeholders. Two authors reviewed the consumer engagement data for each alliance to assess its level of embrace in the 4 consumer engagement areas. For consumer friendliness of public reporting websites, we also assessed alliance public reports for reading level, technical language, and evaluable displays. Population-level effects were also examined for self-management and public reporting. RESULTS: Consumer engagement was new to most alliances, and few had staff with consumer engagement expertise or existing consumer constituencies. For each area of consumer engagement, some alliances enthusiastically embraced the work, other alliances made a concerted but limited effort to develop programs, and a third group of alliances did the minimum work required. Integrating consumers into governance was the area most often embraced, followed by making public reports consumer friendly. Two alliances strongly embraced both self-management and integrating patients into quality improvement efforts. The AF4Q program did not have greater population level effects from self-management or public reporting than were those observed in a national comparison sample. CONCLUSION: The AF4Q program sparked a few alliances to develop robust consumer engagement programming, while most alliances tried consumer engagement efforts for the first time and developed an appreciation for integrating consumer perspectives into their work.

Referrals to integrative medicine in a tertiary hospital: findings from electronic health record data and qualitative interviews.

OBJECTIVE: To examine patterns of, and decision-making processes, informing referrals for inpatient access to integrative medicine (IM) services at a large, acute care hospital. DESIGN: Retrospective electronic health record review and structured qualitative interviews. SETTING: A 630-bed tertiary care hospital with an IM service available to inpatients. PARTICIPANTS: IM referrals of all inpatients aged ≥18 years between July 2012 and December 2014 were identified using the hospital's electronic health record. Fifteen physicians, 15 nurses and 7 administrators were interviewed to better understand roles and perspectives in referring patients for IM services. RESULTS: In the study hospital, primary sources of referrals for IM services were the orthopaedic and neuroscience/spine service lines. While the largest absolute number of IM referrals was made for patients with lengths of stay of 3 days or fewer, a disproportionate number of total IM referrals was made for patients with long lengths of stay (≥10 days), compared with a smaller percentage of patients in the hospital with lengths of stay ≥10 days. Physicians and nurses were more likely to refer patients who displayed strong symptoms (eg, pain and anxiety) and/or did not respond to conventional therapies. IM referrals were predominantly nurse-initiated. A built-in delay in the time from referral initiation to service delivery discouraged referrals of some patients. CONCLUSIONS: Conventional providers refer patients for IM services when these services are available in a tertiary hospital. Referral patterns are influenced by patient characteristics, operational features and provider perspectives. Nurses play a key role in the referral process. Overcoming cultural and knowledge differences between conventional and IM providers is likely to be a continuing challenge to providing IM in inpatient settings.

Health System Consolidation and Diabetes Care Performance at Ambulatory Clinics.

OBJECTIVE: We addressed two questions regarding health system consolidation through the acquisition of ambulatory clinics: (1) Was increasing health system size associated with improved diabetes care performance and (2) Did the diabetes care performance of acquired clinics improve postacquisition? DATA SOURCES/STUDY SETTING: Six hundred sixty-one ambulatory clinics in Minnesota and bordering states that reported performance data from 2007 to 2013. STUDY DESIGN: We employed fixed effects regression to determine if increased health system size and being acquired improved clinics' performance. Using our regression results, we estimated the average effect of consolidation on the performance of clinics that were acquired during our study. DATA COLLECTION/EXTRACTION METHODS: Publicly reported performance data obtained from Minnesota Community Measurement. PRINCIPAL FINDINGS: Acquired clinics experienced performance improvements starting in their third year postacquisition. By their fifth year postacquisition, acquired clinics had 3.6 percentage points (95 percent confidence interval: 2.0, 5.1) higher performance than if they had never been acquired. Increasing health system size was associated with slight performance improvements at the end of the study. CONCLUSIONS: Health systems modestly improved the diabetes care performance of their acquired clinics; however, we found little evidence that systems experienced large, system-wide performance gains by increasing their size.

Practitioner Perspectives on Delivering Integrative Medicine in a Large, Acute Care Hospital.

Background. We describe the process and challenges of delivering integrative medicine (IM) at a large, acute care hospital, from the perspectives of IM practitioners. To date, minimal literature that addresses the delivery of IM care in an inpatient setting from this perspective exists. Methods. Fifteen IM practitioners were interviewed about their experience delivering IM services at Abbott Northwestern Hospital (ANW), a 630-bed tertiary care hospital. Themes were drawn from codes developed through analysis of the data. Results. Analysis of interview transcripts highlighted challenges of ensuring efficient use of IM practitioner resources across a large hospital, the IM practitioner role in affecting patient experiences, and the ways practitioners navigated differences in IM and conventional medicine cultures in an inpatient setting. Conclusions. IM practitioners favorably viewed their role in patient care, but this work existed within the context of challenges related to balancing supply and demand for services and to integrating an IM program into the established culture of a large hospital. Hospitals planning IM programs should carefully assess the supply and demand dynamics of offering IM in a hospital, advocate for the unique IM practitioner role in patient care, and actively support integration of conventional and complementary approaches.

Are healthcare quality "report cards" reaching consumers? Awareness in the chronically ill population.

BACKGROUND: Significant investments have been made to provide comparative healthcare quality information (CQI) to the public, but whether these efforts are increasing awareness of CQI is unknown. OBJECTIVES: To provide regional estimates of change in awareness of CQI among the chronically ill population residing in 14 geographic regions of the United States between 2008 and 2012. Additionally, to examine its correlation with the changes in the availability of quality reports. STUDY DESIGN: Data from 2 waves (2008 and 2012) of a random-digit dial survey of 11,896 adults with chronic illness. METHODS: Regression-adjusted change in the percentage of respondents aware of physician and hospital CQI, and Pearson correlations between regional change in awareness of CQI and regional change in availability of quality reports. RESULTS: While the number of reports on both hospital quality and physician quality increased between 2008 and 2012, there was significant change in awareness of only physician CQI (12.8% to 16.2%, regression-adjusted change of 3.7 percentage points; P < .05). No significant correlation was found between the change in awareness of CQI and the change in availability of hospital quality reports or physician quality reports. CONCLUSIONS: Awareness of physician CQI among the chronically ill increased modestly between 2008 and 2012, but no significant increase in awareness of hospital quality was observed. As efforts to report CQI accelerate, more attention to approaches to dissemination may be warranted in order to increase awareness in the chronically ill population.

Public reporting and the evolution of diabetes quality.

We address three questions related to public reports of diabetes quality. First, does clinic quality evolve over time? Second, does the quality of reporting clinics converge to a common standard? Third, how persistent are provider quality rankings across time? Since current methods of public reporting rely on historic data, measures of clinic quality are most informative if relative clinic performance is persistent across time. We use data from the Minnesota Community Measurement spanning 2007-2012. We employ seemingly-unrelated regression to measure quality improvement conditional upon cohort effects and changes in quality metrics. Basic autoregressive models are used to measure quality persistence. There were striking differences in initial quality across cohorts of clinics and early-reporting cohorts maintained higher quality in all years. This suggests that consumers can infer, on average, that non-reporting clinics have poorer quality than reporting clinics. Average quality, however, improves slowly in all cohorts and quality dispersion declines over time both within and across cohorts. Relative clinic quality is highly persistent year-to-year, suggesting that publicly-reported measures can inform consumers in choice of clinics, even though they represent measured quality for a previous time period. Finally, definition changes in measures can make it difficult to draw appropriate inferences from longitudinal public reports data.

What is the cost of quality for diabetes care?

Increasing the quality of care and reducing cost growth are core objectives of numerous private- and public-sector performance improvement initiatives. Using a unique panel data set for a commercially insured population and multivariate regression analysis, this study examines the relationship between medical care spending and diabetes-related quality measures, including provider-initiated processes of care and patient-dependent quality activities. Empirical evidence generated from this analysis of the relationship between a comprehensive set of diabetes quality measures and diabetes-related spending does not lend support for the assumption that high-quality preventive and primary care combined with effective patient self-management can lead to lower costs in the near term. Finally, we find no relationship between adjusted spending and intermediate clinical outcomes (e.g., HbA1c level) measured at the clinic level.

The dynamics of community health care consolidation: acquisition of physician practices.

CONTEXT: Health care delivery systems are becoming increasingly consolidated in urban areas of the United States. While this consolidation could increase efficiency and improve quality, it also could raise the cost of health care for payers. This article traces the consolidation trajectory in a single community, focusing on factors influencing recent acquisitions of physician practices by integrated delivery systems. METHODS: We used key informant interviews, supplemented by document analysis. FINDINGS: The acquisition of physician practices is a process that will be difficult to reverse in the current health care environment. Provider revenue uncertainty is a key factor driving consolidation, with public and private attempts to control health care costs contributing to that uncertainty. As these efforts will likely continue, and possibly intensify, community health care systems now are less consolidated than they will be in the future. Acquisitions of multispecialty and primary care practices by integrated delivery systems follow a common process, with relatively predictable issues relating to purchase agreements, employment contracts, and compensation. Acquisitions of single-specialty practices are less common, with motivations for acquisitions likely to vary by specialty type, group size, and market structure. Total cost of care contracting could be an important catalyst for practice acquisitions in the future. CONCLUSIONS: In the past, market and regulatory forces aimed at controlling costs have both encouraged and rewarded the consolidation of providers, with important new developments likely to create momentum for further consolidation, including acquisitions of physician practices.

Multistakeholder perspectives on composite measures of ambulatory care quality: a qualitative descriptive study.

The development of composite measures of ambulatory care quality is an area of growing practice and policy interest. Using 29 semistructured interviews, this study describes the opinions of stakeholders related to the use and development of composite measures in a multistakeholder setting. Research experts working in multistakeholder settings need to understand the perspective of various stakeholders, many of whom have varying levels of research expertise, in order to develop useful and acceptable composite measures. Findings from this study suggest that to achieve maximal stakeholder buy-in, research experts should focus on clinical area-specific composites that are designed and constructed in a simple and transparent manner. However, composite measures are not a panacea for improving the utility of public reporting. Performance measure and report card creators should continue to investigate other ways to improve the user-friendliness of their reports and to address other barriers that prevent more extensive use of reports.

Care guides: an examination of occupational conflict and role relationships in primary care.

BACKGROUND: Improving the efficiency and effectiveness of primary care treatment of patients with chronic illness is an important goal in reforming the U.S. health care system. Reducing occupational conflicts and creating interdependent primary care teams is crucial for the effective functioning of new models being developed to reorganize chronic care. Occupational conflict, role interdependence, and resistance to change in a proof-of-concept pilot test of one such model that uses a new kind of employee in the primary care office, a "care guide," were analyzed. Care guides are lay individuals who help chronic disease patients and their providers achieve standard health goals. PURPOSE: The aim of this study was to examine the development of occupational boundaries, interdependence of care guides and primary care team members, and acceptance by clinic employees of this new kind of health worker. METHODOLOGY/APPROACH: A mixed methods, pilot study was conducted using qualitative analysis; clinic, provider, and patient surveys; administrative data; and multivariate analysis. Qualitative analysis examined the emergence of the care guide role. Administrative data and surveys were used to examine patterns of interdependence between care guides, physicians, team members, and clinic staff; obtain physician evaluations of the care guide role; and evaluate the effect of care guides on patient perceptions of care coordination and follow-up. FINDINGS: Evaluation of implementation of the care guide model showed that (a) the care guide scope of practice was clearly defined; (b) interdependent relationships between care guides and providers were formed; (c) relational triads consisting of patient, care guide, and physician were created; (d) patients and providers were supported in managing chronic disease; and (e) resistance to this model among traditional employees was minimized. PRACTICE IMPLICATIONS: The feasibility of implementing a new care model for chronic disease management in the primary care setting, identifying factors associated with a positive organizational experience, was shown in this study.

Care coordination for the chronically ill: understanding the patient's perspective.

OBJECTIVE: To identify factors associated with perception of care coordination problems among chronically ill patients. METHODS: Patient-level data were obtained from a random-digit dial telephone survey of adults with chronic conditions. The survey measured respondents' self-report of care coordination problems and level of patient activation, using the Patient Activation Measure (PAM-13). Logistic regression was used to assess association between respondents' self-report of care coordination problems and a set of patient characteristics. RESULTS: Respondents in the highest activation stage had roughly 30-40 percent lower odds of reporting care coordination problems compared to those in the lowest stage (p < .01). Respondents with multiple chronic conditions were significantly more likely to report coordination problems than those with hypertension only. Respondents' race/ethnicity, employment, insurance status, income, and length of illness were not significantly associated with self-reported care coordination problems. CONCLUSION: We conclude that patient activation and complexity of chronic illness are strongly associated with patients' self-report of care coordination problems. Developing targeted strategies to improve care coordination around these patient characteristics may be an effective way to address the issue.