Coordinating Care for Safety and Value

In the U.S., there are many types and levels of health care. Examples include hospitalization, long-term skilled nursing, shorter-term rehabilitation programs, assisted living, home health, hospice, primary and specialty clinics, and community programs. There are multiple points of entry and providers of services. Having choices as to where to go, and who to see can be very positive for the consumer. At the same time, if the programs, institutions, and providers are not communicating with each other, or if they are conveying mixed messages, the consumer can become overwhelmed. Even worse, if the providers are not communicating, care can be compromised. Costs can also go up when care is not coordinated, as tests may be repeated unnecessarily, medications given that counteract, and recovery from an illness delayed due to confusion over the plan.

At the University of Washington Medical Center, part of UW Medicine, much effort is being put into coordinating care. Our pharmacists are working with physicians to reconcile medications that patients were prescribed in the community, with the medications we provide as part of our treatment plan. This will allow any potentially dangerous combinations of drugs to be recognized. We are electronically linking community physicians with our inpatient provider teams, so that the community physician knows when their patient is being admitted and discharged. We have introduced Nurse Care Coordinators on some of our busiest units to help ensure that all care providers are aware of the treatment plan and that any barriers to treatment, such as a lab or procedure delay, missed communication between the physicians, or need for patient education, be resolved as soon as possible. Our social workers communicate with their inpatient or outpatient colleagues at the time of a patient transfer to or from the hospital, so that existing services can be maintained as needed. Increasingly, when we are working with someone who has an especially complicated system of care, with multiple providers, we try to hold care conferences. This brings together the primary and specialty doctors, and the other members of the interdisciplinary team (pharmacist, rehab professionals, social workers, nurses, nutritionists) to ensure that everyone understands the treatment plan and goals of care.

Ideally, the individual patient should be the hub of the wheel, while all of the providers and services radiate around the patient and link with each other. At any point in time, everyone surrounding the patient should be aware of what the plan for the patient is, and who is involved in the care. Here is an example: Carol is a 65 year-old female who has insulin dependent diabetes, a history of breast cancer (two years prior, treated with radiation and chemotherapy), and a pacemaker. She is recovering from knee surgery, after a fall at home. Carol sees her primary care doctor, an oncologist, a cardiologist, and an endocrinologist on an ongoing basis, and temporarily will have some follow-up appointments with her knee surgeon. She has temporary in-home assistance arranged by the social worker that works in the primary care clinic, and home physical therapy through a local home health agency that was arranged by the social worker in the hospital. There is also a daughter in the area who wants to be involved in care.

At first glance, one would think that Carol is very well supported. She has five doctors involved in her care, as well as community services and family. If all these services are not coordinated however, the care may be inefficient, possibly affecting Carol’s health status. Many wonderful ingredients are necessary to make up a big pot of stew, but the ingredients do not jump into the pot on their own. If we were to serve as the care coordinator for Carol, here are some questions we would ask:

  • Who is in charge of the overall plan? Usually, it is the primary care physician, but this can change depending on what the predominant health issue may be.Someone has to be the lead.
  • How is information being relayed to the other providers? Is each provider sending reports to everyone, to some of the providers, to the designated lead, or is no one communicating?
  • Is each of the providers prescribing medications, and if so, are they reviewing with Carol and her daughter the current medications at each visit? Does Carol have an updated list of all her medications? For someone with this many providers, medications should be reviewed regularly.
  • Does each provider ask Carol to undergo the same lab tests? For example, endocrinologists request blood draws regularly, but then, so might the surgeon prior to conducting surgery, and the oncologist on an annual review. Granted, specialized tests may need to be done, but there is also the likelihood for redundancies. How many times must Carol give blood when another provider may already have the results needed? Some doctors, if not affiliated through one system, may insist on having their own tests done, but its always worth asking.
  • Do the community providers know the overall goals for Carol? Has the physical therapist communicated Carol’s physical limitations and exercise goals to the in-home caregiver and the daughter? Is one person asking Carol to try walking while the other is telling Carol to stay in her chair? Did the social worker know when requesting in-home assistance that home health was also in the home? These services offer different things, but the extent and frequency of the care will change based on other services being offered.

What can you do as a consumer to ensure coordinated care? If you are in a system of care that is linked structurally (i.e., the clinic is affiliated with the hospital), that can help, but don’t take it for granted that even internal systems talk to each other. Be your own advocate and educator. Let every provider know who else you are seeing. Bring to each visit your current medication list.Inform your providers of the community services you are utilizing. Be sure to have a durable power of attorney who can speak for you when you are not able to speak for yourself, and make sure that they know your health status and services. Ask that providers send reports to your other providers. As the health care system continues to work to improve coordination of care for greater safety and value, you can help by being your own care coordinator.