Background

Why is care coordination so difficult?

  1. Accountability for the process is shared, which contributes to ambiguity as to who is responsible for making it work well.  
  2. Many†primary care physicians†(PCPs) no longer have the personal relationships with consultants and hospitals that make communication easier.
  3. The added time and effort required to achieve an effective referral/consultation or transition is generally not reimbursed.
  4. Most primary care practices do not have the dedicated personnel or information infrastructure to coordinate care effectively.
A slowly growing body of literature and reports from innovative practices and care systems are beginning to clarify the elements associated with more effective care coordination and more successful referrals and transitions. (5)

One of the primary goals of care coordination efforts is a high-quality referral or transition. A referral occurs when a patient requires additional, specialized care by a medical consultant or community agency, and a transition is when a patientís overall care is being transferred between institutions, such as from the hospital back to primary care. What constitutes high quality? In our view, all patient referrals and transitions should meet the six Institute of Medicine (IOM) aims of high-quality health care. (9) From this perspective, referrals and transitions should be:

Timely: Patients receive needed transitions and consultative services without unnecessary delays.

Safe: Referrals and transitions are planned and managed to prevent harm to patients from medical or administrative errors.

Effective: Referrals and transitions are based on scientific knowledge, and executed well to maximize their benefit.

Patient-centered: Referrals and transitions are responsive to patient and family needs and preferences.

Efficient: Referrals and transitions are limited to those that are likely to benefit patients, and avoid unnecessary duplication of services.

Equitable: The availability and quality of referrals and transitions does not vary by the personal characteristics of patients.

The†IOM aims appropriately define high-quality health care from a patientís perspective.† But, transitions and referrals should also meet the needs and expectations of the involved providers to be fully successful. A patient may have a very satisfying encounter with a specialist, but if the PCP fails to send relevant information or the specialist fails to communicate with the referring provider, care for that patient or others with similar problems may well suffer.