Need better care coordination? There’s a toolkit for that.

acp new logoA guest column by the American College of Physicians, exclusive to KevinMD.com.

Care coordination seems to be the rage these days. It is mentioned in most discussions of new delivery and payment models such as the patient-centered medical home (PCMH) and accountable care organizations. The concept is not a new one; primary care physicians have been coordinating care for decades.

Making referrals to other physicians, reviewing consultant reports, and getting patients to follow through with referrals have been part of the job description of the primary care physician for a long time. What is “new” about care coordination is that other stakeholders appreciate its importance in improving quality and controlling costs as well as the key role of the primary care physician. They are also holding primary care physicians more accountable for coordinating patients’ care and in many cases are willing to pay for the time and effort of doing it right.

As long as we have been coordinating care, we’ve been doing it implicitly, without any written “rules” for how to do it. Relationships between referring physicians and consultants develop based on several factors including friendships developed during training, hospital staff affiliation, geography, insurance participation, ease of access, patient feedback, and perceived quality, to list a few. If a referring physician is happy with the consultant, they continue to refer, and if not happy, they send their patients elsewhere.

As a primary care physician, I can’t speak for the consulting physicians, but I suspect that while they appreciate the business, they find that some physician referrals are easier to see than others. I’m sure that some referred patients show up with no information for the consultant and no idea why they were referred, while other patients arrive knowing the reason for the visit, with relevant data sent ahead by the referring physician to make it easier for the consultant.

While the perception might be that the old system was working just fine, studies on referrals paint a different picture. A recent review of the specialty referral process reported that in more than 50 percent of cases, the referring physician did not communicate with the consultant, while the consultant did not report back to the referring physician up to 45 percent of the time. When a report was sent, it was not always timely. In addition to these shortcomings, there are issues such as inappropriate referrals, patients’ not keeping referral appointments, and lack of clarity regarding follow up care after the referral.

With the evidence showing that care coordination can be improved, plus the greater attention paid to it by stakeholders and the increasing importance of high quality coordination for an older and sicker patient population, there is a need for tools to help us coordinate care better.

Earlier this year, the American College of Physicians (ACP) released the High Value Care Coordination (HVCC) Toolkit. It is a library of resources designed to address the gaps in the referral process that I described and much more.

The HVCC Toolkit was developed by internal medicine specialists and subspecialists. It includes a collection of Pertinent Data Sets for specific common clinical conditions listing information that should be provided at the time of referral, tests that should and should not be performed prior to the referral, and other recommendations that will make the referral more effective and valuable. There are model checklists for outpatient referrals and responses from consultants. The Toolkit also contains a patient education guide for the referral process. Two Care Coordination Agreements that explicitly define the responsibilities and expectations for the relationship between the primary care physician and subspecialist or hospital care team, based on the ACP’s Patient-Centered Medical Home Neighbor policy paper, are also provided.

What distinguishes care coordination 2.0 from version 1.0 is that it is more explicit and comprehensive than what we’ve been doing for years. It acknowledges the needs of both the referring physician and the consultant and it more fully involves the patient in the process.

Some will criticize all of this as another “mandate” by insurers, the government, and professional societies. However, there are potential benefits to the physician practice from taking a more explicit approach to care coordination beyond providing better care. Developing systems to handle referrals similar to those described in the toolkit will help a practice to achieve PCMH recognition. It may also satisfy quality improvement requirements for maintenance of certification. Some insurers include care coordination in their incentive programs.

If that is not enough, the recently released final rule for the 2015 Medicare Physician Fee Schedule includes payment for chronic care management. The covered service includes “Management of care transitions within health care, including referrals to other clinicians, follow-up after the patient’s visit to an emergency department, and follow-up after discharges from hospitals, skilled nursing facilities, or other health care facilities.”

Most importantly, doing care coordination well benefits our patients.

Yul Ejnes is an internal medicine physician and a past chair, board of regents, American College of Physicians. His statements do not necessarily reflect official policies of ACP.

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