Today's health care executives are managing fragmented patient care in a disjointed health care system made up of primary care physicians, specialists, hospitals and long-term care facilities.

As the shift toward value-based care continues, better care is expected at lower costs. Despite efforts through the Affordable Care Act and readmission reductions programs, the rate of readmissions continues to rise. To date, the penalty for hospitals with high readmission rates is approximately 3 percent of each payment.

Executives must start looking at the bigger picture and involve all providers. We're slowly moving toward a model in which the payer wants to pay the providers — a system of home health caregivers, pharmacists, physicians, hospitals and nursing homes — as a group. The accountable care organization movement is a classic example. All of those entities have to work collaboratively to demonstrate to the payer how well they are taking care of their patients.

Putting a good care coordination program in place will remarkably improve quality of care, patient satisfaction and the bottom line. From assigning accountability to developing agreements to maximizing electronic health records, C-suite executives can use this handy checklist to begin coordinating patient care effectively.

Assign Accountability

Too often, lack of communication leaves patients unclear as to why they are being referred to a specialist and specialists unsure of the reasons for the referral or which tests have been administered. Furthermore, primary care physicians often are not told what happened in the referral visit or notified when their patient is seen in the emergency department or hospital. Lack of communication hurts patient care, can lead to unnecessary and duplicate tests, and confuses the patient who may be receiving conflicting information from different doctors.

A 2007 study of information transfer at hospital discharge (JAMA 2007; 297[8]:831–41) found that direct communication between hospital-based and primary care physicians was uncommon at the time, occurring in only 3 to 20 percent of discharges. To improve accountability and prevent care from becoming fragmented, executives should consider five key steps:

  • Assign a dedicated team to be accountable for managing patient care.
  • Define the extent of responsibilities for key activities such as following up on test results, communicating information to other physicians, etc.
  • Establish when specific responsibilities should be transferred to other care providers — whether that means specialty physicians, long-term care facilities or home care providers.
  • Share background information and findings about patients who are in the hospital.
  • Ensure that referrals to specialist physicians are made and completed.

Improve Referral Systems

Referrals are a constant. The likelihood of being referred to a specialist nearly doubled from 1999 to 2009 with doctors sending their patients to other providers 9.3 percent of the time in 2009 compared with 4.8 percent in 1999 (Arch Intern Med 2012; 172[2]:163–170). Tracking referrals is essential to ensuring the best medical care possible. This is especially critical for conditions such as cancer, which require early diagnosis and treatment for the best outcome. Executives who manage referrals should consider the following actions to make sure the process is streamlined for everyone involved:

  • Develop a referral tracking system to internally track and manage referrals and transitions, including consultations with specialists, hospitalizations and ED visits, and referrals to community agencies.
  • Generate periodic reports by physician, including type of specialist referred to, patient name and diagnosis.
  • Establish referral guidelines for all physicians.
  • Inform primary care physicians when inappropriate referrals are made to prevent future recurrences and unnecessary appointments leading to increased costs.
  • Ensure that providers adequately prepare their patients for their referral visit and for what to expect afterward.
  • Implement a system that allows transparency between physicians post-visit regarding findings, next steps and treatment plans (including notifications of no-shows and cancellations).

Build Relationships and Agreements

Hospitals, primary care physicians, specialists and long-term care providers need to have agreements on the specific roles they will play in providing care. Care coordination agreements have been associated with decreased costs and increased quality of care as they reduce unnecessary referrals, avoid duplicate assessments and provide optimal care (see, for example, "Principles of Service Agreements for the Patient Centered Medical Home" from the American College of Physicians, May 2012). Establishing clear agreements and relationships with other providers can be achieved by:

  • setting clear expectations and guidelines on how providers will share information;
  • implementing a standard communication protocol among primary care physicians, hospitals and specialists to keep all parties informed of any clinical developments;
  • providing the primary care physician with the specialist's direct contact information for urgent cases that require an open line of communication during treatment;
  • establishing which medical information is necessary to circulate with long-term care and home care providers;
  • documenting all agreements in writing to ensure compliance.

Provide a Patient Support System

Problems can develop when patients are not adequately prepared to manage their own care after being discharged from the hospital or moved to a long-term care facility. The C-suite must ensure that the process is properly managed to avoid unclear discharge instructions, conflicting information from different providers, and duplicate or conflicting medications. Providing the right amount of patient support during transitions will lead to improved patient satisfaction and better health outcomes. To improve quality of care, executives should consider:

  • setting up a practice team whose duties will be to support patients and their families;
  • making sure patients are informed and understand why they are being referred to outside specialists or care facilities, what they can expect and what resources are available to them;
  • ensuring that staff follow up with patients after they complete their referral visit or transition to a hospital or long-term care facility;
  • giving a discharge checklist to patients preparing to leave a hospital or long-term care facility;
  • communicating patients' needs and preferences to all staff providing care;
  • identifying problems and intervening when patients fail to keep a referral appointment.

Maximize EHR Systems

Electronic health records can integrate patient health information such as current medications and lab and imaging results; they also can distribute important medical data instantly to all medical specialists involved in a patient's care. This is especially significant for patients who are under multiple specialists, receiving treatment in emergency settings and moving between care settings. EHRs facilitate communication between specialists and reduce unnecessary tests or medical errors.

The use of EHRs is growing rapidly. According to a data brief from the National Center for Health Statistics (No. 143, January 2014), 78 percent of office-based physicians used EHR systems in 2013, up from just 18 percent in 2001. For managers to make their EHR systems more efficient, they must consider:

  • establishing an EHR system that can share information so that accurate and updated patient data can be sent easily to other providers;
  • enabling live data-sharing so that physicians can immediately see changes to medications and test results;
  • sending out alerts to all key care providers, such as primary care physicians and specialists, when one of their patients has been seen in the hospital so that they can follow up;
  • allowing secure messaging between physicians within the EHR system;
  • designating an on-site staff member who will be an expert in the EHR system and can troubleshoot problems;
  • opening communication with other providers about patients as a way to follow up on information received through EHRs.

Improve Communication

Effective communication is the foundation of any health care team. Communication errors can have grave consequences in health care settings and are often the leading cause of preventable adverse events. According to the Journal of the American Medical Informatics Association, almost half of all health care-related communication errors occur during handoffs between care providers (Oct. 22, 2011; 28–37). It is paramount that health care executives address the following to prevent errors and maximize communication:

  • standardizing communication by using structured forms to ensure that primary care providers, specialists and long-term care providers all have the same and necessary information;
  • ensuring that a patient's preferences and goals are communicated to all providers involved in that patient's care;
  • asking yourself what you know that others need to know, and sharing that information with the patient's care team;
  • developing a protocol for filling out patient charts in a standard way so that they are easy to interpret and key elements are not overlooked;
  • using communication tools like SBAR (situation, background, assessment, recommendation) to improve communication between physicians and other providers.

Implement Changes

Everyone in the health care community has a role to play by working together to achieve exceptional care coordination. Care providers who continue to hang on to their broken systems will be left behind by those who see the need for change and implement it. Reputations depend on excellent outcomes, and those practicing effective care coordination programs will see huge benefits as a result.

Richard A. Royer is the CEO of Primaris in Columbia, Mo. He is active in a number of statewide health care initiatives and serves as board treasurer for the Excellence in Missouri Foundation.