Tools to improve coordination in primary care

By | July 28, 2016

pexels-photo-29596Last month, I left readers with a bit of cliffhanger.

I had written about a potential magic bullet in primary care; the one thing that health care systems and providers could focus on together that would make care more efficient, higher quality and altogether better for patients.  Despite the obvious risk of appearing to sell snake oil, I wrote that care coordination might just be that one thing.  If health care systems could help their providers better organize and communicate about complicated care, and if providers could lead efforts to make this care feel more rational and meaningful for patients, we all might benefit.

Health systems have not been sitting on their hands.  

Care coordination is hard because medicine is hard.  Particularly medicine delivered in a fragmented health care system; one that has a lot of highly specialized providers, competing incentives, and lots of middlemen.  It takes energy, time and resources, and the physical and financial costs of doing this are often footed by providers working largely in primary care.  This is why, despite years of trying to promote care coordination, progress is very slow.

The recent Chartbook on Care Coordination by the Agency for Healthcare Research and Quality (AHRQ) that tracks quality of care as part of the National Healthcare Quality and Disparities Report gives us some evidence.  It shows, for example, that about 1 in 5 people under age 65 in the U.S. say their regular doctor does not usually ask about medications and treatments from other doctors (see page 23 of the report). The challenge is big and, according to the report, further hampered by the lack of regular and consistent care coordination measurement over time.

Back to the cliffhanger.  How do we actually improve care coordination?  Last time, I suggested there were some great ideas, and now it’s time to delve into three promising strategies.

1. Individualize and Personalize the Electronic Medical Record (EMR)

The shift from paper to electronic records has really picked up over the past five years, in part because of the Affordable Care Act, which provided incentives for transitioning.  By then end of 2014, more than 80% of all physicians (and nearly 90% of those in primary care) were using an EMR.  Among the many goals of going digital was enhancing care coordination by making it easier for doctors to get access to and share information.

The days of faxing the results of specialist consultations or mailing imaging results are now mostly over, speeding up decision-making about patient care.  Creating a “care plan”, which is ideally a collaborative activity between primary and specialty care in more complex cases, can be facilitated by an easily accessible and shared record.

However, it seems the ideal EMR has yet to arrive.  According to congressional testimony by Ann S. O’Malley, MD, MPH, one of the country’s leading experts on care coordination, most EMRs only help within-office communication, allowing providers to pull up their own patients’ data quickly.  They do not yet widely support coordination across offices and are not designed to support planning or tracking care for the patient.  Rather, she argues, they are primarily designed to support billing and administration.

One major step forward would be improving interoperability so that EMRs can generate and track referrals and present the results.  This is partly a technical challenge, but one that EMR vendors are overcoming.  Google Docs, for example, is already used by millions of collaborators to edit the same paper or spreadsheet in real-time on lots of different operating systems.  With the right privacy protections, EMRs should just as easily facilitate shared work on patient care.

The bigger challenge is enabling good communication in the face of lots of data.  Dr. O’Malley, and others, suggest that EMRs should develop a standard communication space and template.  She offers the Continuity of Care Record (essentially a voluntary standard for summarizing patient information in EMRs) as one example.  Another example is the use of management “dashboards” for each patient and for groups of patients that would help providers more quickly cut through the fog of data.

This thoughtful article by Dr. Gordon Schiff and Dr. David Bates about including free-text narrative in the EMR is worth a read.  They argue that EMRs need to balance the checkboxes that serve as critical care reminders for providers with ways to narrate patients’ evolving medical history and ongoing assessment.

2. Fix the Hospital Discharge Process

When hospitals discharge patients, they return to the care of their usual primary care providers and specialists.  But that process of discharging patients has not been seamless, and many patients who need to return to their usual care fall through the cracks.  Patients may not understand their next steps. Medical tests and advice that should reach the patient’s primary care physician may arrive late or never. Confusion about conflicting medication regimens can arise.  As a result, patients may not recover well.  In fact, 1 in every 5 Medicare patients returns to the hospital within 30 days.

One idea supported by AHRQ and tested by researchers at Boston University is the idea of a redesigned and standardized patient discharge process.  The result was the Re-engineered Discharge (RED) Toolkit.  It includes step-by-step instructions to create an After Hospital Care Plan with each patient, describing how discharge educators should discuss discharge plans with each patient, and how to carry out follow-up phone calls with patients to check appointments, medications, and what to do if non-emergency medical issues arise.

An evaluation of the RED Toolkit suggested that it can help cut hospital readmissions by 30%, and reduce costs of care for each RED patient by about 34%.  With nearly 40 million hospital admissions per year, these savings could be tremendous.  The toolkit has been comprehensively tested and made freely available.  Example discharge forms are available in both English and Spanish.  And AHRQ offers five case studies of how to use the toolkit, giving real-world examples for providers interesting in trying it.

3. Make It a Part of Normal Practice to Measure Care Coordination

AHRQ has taken a leadership role in testing and promoting care coordination ideas.  In addition to releasing extensive thought pieces on coordination in the primary care medical home and care management strategies for coordination, they developed the most comprehensive measure of coordination available and made it freely available.  This toolkit, called the Care Coordination Quality Measure of Primary Care (CCQM-PC), fills a big gap in measuring this essential element of care.  It evaluates patient perceptions of their care coordination experiences.  It was cognitively tested and piloted in 13 diverse primary care practices.  To encourage providers and organizations to adopt this measure, they give all the necessary tools to administer it and allow providers to customize the tool without any extra permission from AHRQ.

Now the caveats.

Some big questions remain unanswered: Who will pay for these changes? How quickly will providers and organizations adopt new skills and behaviors? Will such initiatives have a reasonable return on investment? But for those seeking a magic bullet in primary care, these ideas to promote care coordination are worth considering.

Gregory Stevens
Gregory D. Stevens, PhD, MHS is a health policy researcher, writer, teacher and advocate. He is an Associate Professor of Family Medicine and Preventive Medicine at the Keck School of Medicine of the University of Southern California. He received both his masters and PhD from the Johns Hopkins University Bloomberg School of Public Health, with a focus on health care policy. He has focused his research on primary health care, children’s health, health disparities and vulnerable populations. He is an author of the book Vulnerable Populations in the United States and you can find his peer reviewed papers in Medical Care, Health Services Research, Journal of General Internal Medicine, and American Journal of Public Health, among other journals.
Gregory Stevens

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