Key Changes and Resources for
Care Coordination
(Reducing Care Fragmentation in Primary Care)
MacColl Institute for Healthcare Innovation
Group Health Research Institute
http://www.improvingchroniccare.org
The Patient-centered Medical Home
Key Features:
1. Engaged leadership
2. Quality improvement strategy
3. Empanelment
4. Patient-centered interactions
5. Organized, evidence-based care
6. Care coordination
7. Enhanced access
8. Continuous, team-based health
relationships
http://www.improvingchroniccare.org
Defining Care Coordination
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.
(McDonald, 2007)
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http://www.improvingchroniccare.org
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What constitutes a high quality referral or transition?
Institute of Medicine’s (IOM) report Crossing the Quality Chasm:
A New Health System, for the 21st Century:
Safe
Planned and managed to prevent harm to patients from medical or
administrative errors.
Effective
Based on scientific knowledge, and executed well to maximize their
benefit.
Timely
Patients receive needed transitions and consultative services
without unnecessary delays.
Patientcentered
Responsive to patient and family needs and preferences.
Efficient
Limited to necessary referrals, and avoids duplication of services.
Equitable
The availability and quality of transitions and referrals should not
vary by the personal characteristics of patients.
http://www.improvingchroniccare.org
The Care Coordination Model
http://www.improvingchroniccare.org
Key Changes
Assume accountability
Provide patient support
Build relationships & agreements
Develop connectivity
http://www.improvingchroniccare.org
Assume Accountability
• Providers, especially
primary care clinics,
decide to improve
care coordination.
• Develop a
referral/transition
tracking system.
http://www.improvingchroniccare.org
Resource #1
NCQA Patient-Centered Medical Home 2011
Standards
• Test tracking and follow up
• Referral tracking and follow up
• Coordinate with facilities and care transitions
http://www.improvingchroniccare.org
Resource #2
Measuring care coordination from
patient’s perspective:
• ACES
• Picker
• PACIC
• CAHPS
• CYSNCN
• Press Ganey
 Also check out AHRQ’s Care Coordination
ATLAS
http://www.improvingchroniccare.org
Resource #3
Referral Tracking Guide
• How-to guide to setting up your own referral
tracking system
– Use existing practice management (or billing)
system
– Use paper tracking grid
• Describes how to use the data to inform
practice
http://www.improvingchroniccare.org
Provide Patient Support
• Organize the practice team to
support patients and families
during referrals and transitions.
• Logistical “referral” coordinator:
– Tracks all referrals and
transitions
– Provides patient (and family)
with information about referral
– Addresses barriers to referrals
– Follows up on missed
appointments
http://www.improvingchroniccare.org
Patient Support ≠ Case Management
Case Load
High-risk, multimorbid patients
Clinical Care Management
Logistical Clinical Monitoring
Self Mgmt Support Medication Mgmt
Patients with
common chronic
illnesses
All patients in
panel who are
involved in
referral or
transition
process
Clinical Follow-up Care
Logistical Clinical Monitoring
Self Mgmt Support
Care Coordination
Logistical
©MacColl http://www.improvingchroniccare.org
Institute for Healthcare Innovation, Group Health Research Institute 2011
Resource #4
Referral “Logistical” Coordinator Job Description
• Based on our review of relevant jobs
Questions for group:
• Do your clinics have someone filling this role?
• How is the role different/similar to our generic
job description?
http://www.improvingchroniccare.org
Resource #5
Referral “logistical” coordinator training
includes:
• Why job is important
• How role interacts with the rest of the team
• How to liaison with other facilities
• Use and utilize the tracking system
• Understand medical chart
• Understand insurance processes
• Provide pro-active patient support
http://www.improvingchroniccare.org
Resource #6
Patient preparation for referral visit:
• Informs patients about logistics including what they
need to do beforehand, what to bring, and where to
go.
• Prepares patients by describing expectations (reason
for visit, goals of visit, next steps in treatment).
•Empowers patients to ask questions during specialist
appointment.
http://www.improvingchroniccare.org
Resources #7-9
Evidence-based program for managing
transitions:
• Foster greater engagement of patients/families
• Elevate status of family caregivers
• Implement performance measurement
• Build competency in care coordination
• Explore use of technological solutions to
communicate between settings
• Align financial incentives
©
2007 Care Transitions Program; Denver, Colorado. All rights reserved.
http://www.improvingchroniccare.org
©
2007 Care Transitions Program; Denver, Colorado. All rights reserved.
http://www.improvingchroniccare.org
Coleman E. The Post-Hospital Follow-Up Visit: A Physician Checklist to Reduce Readmissions, CA Healthcare Foundation, Oct 2010
http://www.improvingchroniccare.org
Build Relationships & Agreements
• Develop agreements to:
– Standardize information
– Set expectations
– Build relationships
http://www.improvingchroniccare.org
Medical Neighborhood
• ARHQ White Paper (Resource #10)
– Defines the medical neighborhood
– Describes potential approaches to overcoming
barriers to high-functioning medical
neighborhoods
Taylor EF, Lake T, Nysenbaum J, Peterson G, Meyers D. Coordinating care in the medical neighborhood: critical
components and available mechanisms. White Paper (Prepared by Mathematica Policy Research under
Contract No. HHSA290200900019I TO2). AHRQ Publication No. 11-0064. Rockville, MD: Agency for Healthcare
Research and Quality. June 2011.
http://www.improvingchroniccare.org
Resource #11
Compact: Primary Care - Specialty Care Compact
• Pre-consultation
• Formal consultation (in-person referral)
• Transfer of care from PCP → specialist
• Co-management
• Emergency care
 Main goal of Colorado’s compact is to develop
mutually agreed upon expectations
http://www.improvingchroniccare.org
Resource #12
Approaches to strengthen PCP ↔ Specialist
interface:
• Case studies
– Guidelines for referrals
– Forms (important info to include)
– Agreements/co-location/co-management
http://www.improvingchroniccare.org
Service Agreement Example
• Case Study: Family Care Network in WA
agreement with local cardiology group
describes who/when/how for each:
– Emergency referrals
– Emergency testing
– Routine consultation
– Follow-up care
– Re-referral
– Inpatient care
http://www.improvingchroniccare.org
Resources #13-14
• Berta W et al
– Article #1: 24 key components to include in
referrals
– Article #2: 15 key components to include in
consultative report
http://www.improvingchroniccare.org
http://www.improvingchroniccare.org
Resource #15
• Reichman M
http://www.improvingchroniccare.org
Develop Connectivity
• Develop and implement an
information transfer system.
• Standardize information.
• Key elements of system:
– Integrates information needs and
expectations (per agreements)
– Assures that information transmits to
correct destination
– Key milestones in the referral process
can be tracked
– Referring clinicians and consultants can
communicate with each other
http://www.improvingchroniccare.org
Resource #16
• O’Malley et al describe the principal tasks for effective care
coordination as:
– Maintaining patient continuity with the PCP/primary care team.
– Documenting and compiling patient information generated within and
outside the primary care office.
– Using information to coordinate care for individual patients and for
tracking different patient populations within the primary care office.
– Referrals and consultations (initiating, communicating and tracking).
– Sharing care with clinicians across practices and settings.
– Providing care and/or exchanging information for transitions and
emergency care.
• New paper by O’Malley also work checking out:
– “Referral and Consultation Communication Between Primary Care and
Specialist Physicians” Arch Intern Med. 2011;171(1):56-65.
http://www.improvingchroniccare.org
Resource #17
• CA HealthCare Foundation: Bridging the Care
Gap by Metzer and Zywiak
– Details e-referral systems
http://www.improvingchroniccare.org
E-Referral Case Studies
• Doc2Doc system in OK
• Humboldt County, CA
• San Francisco, CA
Humboldt County’s workflow
http://www.improvingchroniccare.org
E-Referral Improves Specialty Access
http://www.improvingchroniccare.org
E-Referral Improves Referral Tracking
PCPs’ ratings of attributes of electronic referrals compared to prior
referral methods
Source: Kim Y, Chen AH, Keith E, Yee HF, Kushel MB. Not Perfect, but Better: Primary Care Providers’ Experiences with Electronic
Referrals in a Safety Net Health System. Journal of General Internal Medicine. Vol 24(5),614-619.
http://www.improvingchroniccare.org
Contact us:
www.improvingchroniccare.org
Thank you
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