Family Care Network: Developing Agreements between Primary Care and Specialty Groups 
The Family Care Network is a family practice in Northwestern Washington state with approximately 75 providers including physicians, nurse practitioners and physician assistants. With 12 clinics throughout the county, their providers aim to understand their patients’ lives and develop trusting provider-patient relationships.
AccountabilityA few years ago, the practice held a series of focus groups with their patients. They were surprised to learn that the main patient concern was being unable to navigate across the silos of their medical care. Specifically, patients expressed difficulty coordinating care when they were referred out to a specialist. Each physician they saw would change medications and when the patient experienced problems, they didn’t know which doctor to contact. With this finding, Dr. Berdi Safford, the Network’s Medical Director, decided to improve their patients’ care coordination.
After brainstorming solutions, Dr. Safford decided to try to establish service agreements with the key specialty groups they worked with frequently. According to Dr. Safford, the goals of these service agreements were to:
  • Improve communication between the provider groups, and
  • Develop “seamless handoffs” for patients.
Dr. Safford champions service agreements, not because they formalize a process but because through her experience, they create a vehicle for critical conversations between primary and specialty care to occur. For example, a common complaint from specialists is that patients are referred to them without a clear understanding of the clinical question. Likewise, primary care providers often state that a consultation report does not meet their needs. To counter this finger pointing, Dr. Safford has learned to start conversations about agreements by discussing the best care for a typical patient case. In addition, she keeps the following in mind during some agreement conversations: 
  • Find common goals and work on them
  • Assume all providers have the best intent for the patient’s care
  • Avoid confrontation
  • Focus on the system and not the people
Relationships & AgreementsThe practice’s first effort in developing service agreements was with their local cardiology group. The agreement took about one year to develop, which is not an uncommon timeframe. The group of 12 cardiologists was often referring patients to additional specialists and not keeping the primary care provider in the loop. The situation was further complicated because the cardiology group was setting up a heart failure center, which many PCPs opposed because it blurred the lines between specialist and primary care responsibilities. Under Dr. Safford’s leadership, the service agreement was developed and a cooperative relationship between the two groups has formed.
The agreement with the cardiologist group focuses primarily on how to access a cardiologist for curbside consultations and how to co-manage and return patients to primary care. Here are the specific elements of their service agreement:
1.)     Emergency Referrals
         a.       How will the Cardiology Group provide consultations and admissions? 
i.      A just-in-time consult phone list includes each cardiologist by specialty and phone number
b.       What patient information will the primary care group provide to cardiology group?
2.)     Emergency Testing 

         a.       How and who will order emergency testing?
         b.       Who is responsible for further urgent care? 
         c.       What are the time expectations for sending information back to primary care group?
3.)     Routine Consultation
a.       What patient information will primary care group submit with referral?
b.       How will appointments be booked?
c.       Referral will indicate if cardiology group is to:
          i.      Consult only (two visits)
          ii.      Assume care of cardiac disease
          iii.      Assume management of care until patient is stable
d.       Expectation that cardiology group will not refer patient for tests or services outside the scope of cardiovascular health
e.       Who will fill out insurance information about referral?
f.         Who will follow up with patients about tests ordered by cardiology group?
g.       How will information be sent back to primary care group?
4.)     Follow-up Care:
a.       When patient is referred to cardiology group to:
          i.      Have consult only
1.       How will appointments be booked back with primary care group?
2.       Who is responsible for ongoing prescription refills?
          ii.      Assume care of cardiac disease
1.       Who is responsible for testing and follow-up?
2.       How will primary care group be kept abreast of patient care?
          iii.      Assume management of cardiac care until patient is stable
1.       Who is responsible for primary cardiology care and for how long?  
5.)     Re-Referral
a.       Who is responsible for ongoing medications?
b.       How is the patient’s cardiac care managed once transferred back to the primary care group?
6.)     Inpatient Care
a.       How will cardiology group alert primary care group of hospital admission?
b.       What will be included in discharge summary (including follow-up) and how will that information be transferred to primary care group?
7.)     Ongoing Relationship and Education
a.       How regularly will primary care group and cardiology group meet to review service agreements?
b.       How will cardiology group provide education to primary care group?
8.)     Insurance Referral Requests
a.       How will insurance logistics be handled by both groups?
It was important for the process that the service agreements focus on types of patients and lay out who (primary care or cardiology group) is responsible for specific details such as ordering procedures, booking appointments and filling out insurance information. Time expectations for consultative reports were also included.
Dr. Safford and the cardiology group continue to meet every three months to maintain their dialogue. This ongoing relationship has been able to quell problems that would have lingered and potentially created further problems without communication. For example, there was a recent technical glitch that occurred when an insurance company changed their referral paperwork. After it was communicated, the problem was quickly resolved with a new data entry process. This new process was written into their service agreement. The collaboration has also led to continuing medical education courses provided by the cardiology group.
Although insurance does not pay for the effort and time to develop and maintain this service agreement, Dr. Safford believes it has improved her patients’ care. She believes that developing linkages with her specialist counterparts has broken down the silos of care her patients used to experience.