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How to Develop Better Care Coordination


Research reveals reporting discrepancies between primary-care and specialty practices. How can you improve the lines of communication?

With the Affordable Care Act's focus on improving health and managing costs, industry leaders are giving the coordination-of-care their full attention. The ability to seamlessly share information between primary care physicians and specialists is critical to successfully accomplishing this objective.

Research from JAMA Internal Medicine reveals reporting discrepancies:

• Between 25 percent and 50 percent of referring physicians are not aware if their patients actually were seen by the specialist they were referred to.

• Only 35 percent of the time specialists claim they have received the patient's history and reason for the visit, even though primary care doctors claim a history or reason for the referral was provided 70 percent of the time.

• 80 percent of the time the specialty practice states they sent a report following the consultation, but the primary care physicians report receiving this information only 60 percent of the time.

Four steps to improve coordination-of-care:

1. Develop a coordination relationship. Find who the go-to-person to manage referrals in both the primary care and specialty practice.  Cultivate tools to improve communication and reporting between parties, and set reasonable time standards for post visit response;

2. Prepare and maintain referral agreements and patient-care plans;

3. Improve access to specialty care by establishing scheduling templates that ensure patient access is not delayed when the primary care physician indicates the patient needs prompt attention;

4. Expand access to information (preferably electronically) between the providers and caregivers to improve ability to track care between physicians across patient encounters. This will increase the ability to manage medications and ensure tests have been completed and follow up care takes place.

How coordination-of-care can becomes a reality:

• Strive to strengthen the patient-clinical practice relationship;

• Promote communication about things that matter to the patient;

• Help patients understand more about their health conditions; and the choices they can take to improve their health;

• Facilitate patients' and caregiver involvement in the choices they can take to improve their health; and

• Commit to creating a practice-wide patient-centered program. Make the commitment a reality by setting program goals, establish standards, and tracking progress.

A good starting point:

Investigate opportunities to become certified in either a patient-centered medical home program for those providing primary care or the patient-centered specialty practices recognition program for specialists seeking to improve coordination-of-care and focus on improving the patient relationship. Patient satisfaction along with better coordination-of-care is expected to contribute to better patient compliance and improved health outcomes through prevention and early intervention. This will impact the ability to reach the goals of the reform law, improving the healthcare of the population while reducing the cost-of-care in the United States.

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