By Richard Scott
March 27, 2012

The crucial aspect of information sharing among physicians may be a glaring weakness contributing to poor coordination of care across transitions, according to widespread data on communication trends between primary care physicians and specialists.This point became clear during Dr. R. Scott Hammond’s presentation, The Medical Neighborhood: A Primary Care Viewpoint, at the National Medical Home Summit in Philadelphia in late February.

A brief look at the data paints a dismal picture: half of referrals to a specialist had no information included; just 62 percent of primary care physicians receive “consultation reports” on a routine basis; and one-quarter specialist reports are received more than one month after the visit.

Dr. Hammond’s presentation detailed how the medical home can boost care coordination among physicians and other healthcare players. To learn more, Medical Home Today sits down with Dr. Hammond, who explains why physicians should take ownership of the medical home model and what barriers they can overcome to achieve improved patient outcomes.

When it comes to medical homes, what are the main barriers to success?

RSH: There is no new news here. It is time, money, willingness and, to some degree, trust. There are several studies and medical home pilot analyses that demonstrate the immense work in such transformational change. The trouble is that the work does not stop. It is incessant and there are considerable upstream and downstream costs. The major barrier to success is not in building the medical home but that it will be undervalued and underfunded, thereby jeopardizing sustainability. It requires carving-out time from patient care to make such change.

As a physician in a small practice, the cost in lost revenue is substantial and the cost in building teams and adding necessary technologies is significant. In order to make this commitment, the physician must be willing to acknowledge that he/she is part of the healthcare crisis and merge their vision for what good healthcare is with the reality of the care they currently deliver. Unfortunately, there is a disconnect between what the physician believes their performance to be and what it actually is. When performance data is presented to the physician, change will follow.

The management and staff also need to be willing to change. What is in it for them? We found that growing their passion (they are not working is a small clinic for big bucks), giving them autonomy to reach the top of their license, and giving them a voice in the process were key elements to change.

Finally, the healthcare industry needs to repair some bridges. After decades of false hopes and empty promises, why should the primary care physician believe this model will be any different from past failures to truly invest and support primary care? When this movement started, primary care was at the forefront and center of interest. Now that there is traction, numerous special interest groups want their piece of the action. This erodes the confidence of primary care physicians that this model will bring the economic and professional relief promised and fosters suspicion that the medical home, too, will be usurped by other powerful groups.

Where is care coordination perhaps lacking?

RSH: Wherever there is a transition of care in today's healthcare system, coordination of care is potentially lacking. The literature shows that essential medical information does not flow between primary care and specialist or between primary care and the ED/hospital.

We did a poll in Colorado that mirrored the results of two studies showing that, in such exchanges, specialists receive the information they need 35 percent of the time and PCP only 62 percent of the time. Information from hospitals is spotty at best and as, in a 2007 study shows, PCPs received discharge summaries less than 20 percent of the time within one week of discharge, 38 percent of these summaries had no lab results and 21 percent had no discharge meds. Nearly 20 percent of Medicare patients are readmitted within 30 days of discharge. Simple coordination activities have been shown to reduce that number to 11 percent.

Internally, how many practices track labs and referrals? If you do not, how can you say you coordinate anything? Coordination of care, however, is more than ensuring timely and complete bi-directional medical information flow and tracking referrals and tests. Are you accountable to the patient to ensure safe transition of care? Do you provide self-management support for the patient? Do you have agreements with other physicians and hospital outlining mutual responsibilities and accountabilities to ensure informational connectivity and safe, responsible transitions? These systems are costly in time and labor and require considerable energy to maintain. Few practices have these necessary resources or capabilities to coordinate such activities.

In my opinion, care coordination should be done by people who know the patient and have a long-term, personal relationship with them. We merged the duties of a care coordinator, disease case manager and patient navigator into one position and it has worked quite well.

What strategies can help overcome these barriers?

RSH: Unless you have an infrastructure to support broad change, it is best to tackle transformation in small steps. First, implement an EHR and search for a reliable and functional registry. Once you have worked out the kinks, start building teams. You will need a team to guide the overall process and smaller teams that effect the change. These teams must not be the traditional hierarchal type but more collaborative. We found that what physicians thought was good teamwork was little more than staff fulfilling their job description. Working together to effect change requires more than doing one's assignments. We found building teamwork to be the biggest challenge but also the one that leads to the greatest advance in transformation.

Once you have functional (and not dysfunctional) teams, the rest comes much easier. You need to adopt a method for change, such as the PDSA [Plan-Do-Study-Act] or RIA. We started with [a] recognition program and made sure that every one in the practice was involved in the process. This solidified our vision and engaged the staff. We then created several teams and assigned them the other standards depending on their interest and skills. Spreading the work decreased the negative impact on operations and ensured successful implementation over a reasonable length of time.

After successfully developing team care and operationalizing your policies and protocols, you are ready to tackle care coordination. Care coordination can be divided into internal and external coordination. Internal care coordination will identify high-risk patients in your practice (multimorbid patients, hospital discharges etc.). External care coordination defines and structures relationships with specialists and hospitals (the Medical Neighborhood).

For implementing coordination of care, The Safety Net Medical Home Initiative has good implementation guides. In addition, the Colorado Medical Society completed a two-year initiative on systems of care and posted, as freeware, the Facilitation Guide and Toolkit for Developing the Medical Neighborhood.

What’s the best way for physicians to get started on a medical home?

RSH: Take the Medical Home IQ test from TransforMed. This is a free survey tool that was a real wakeup call for us. Although we cared about our patients, we worked hard for them and we thought we delivered great care, we were woefully lacking when we saw the results from the survey. I took the test with my practice manager. When we finished, we knew we had a lot of work to do. This survey will give you a clear, concrete vision on how you want to deliver healthcare and what it looks like.

Next, try to visit a medical home in your area to see how it really operates. Chances are you will leave with a better idea of what you practice could become. If that is not possible, visit the following to read about practices that have made the transformation:

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