Care Coordination
One strategy for reducing health care costs while improving quality is increasing the coordination of services provided by different members of the health care team. In the absence of care coordination, patients may get duplicate or otherwise unnecessary tests, receive medications that are contraindicated by other aspects of the treatment regimen, fail to obtain services that each of the treating physicians thought had been provided by one of the other members of the health care team, etc. There are a number of different strategies for increasing the coordination of care, from utilizing electronic health records and health information exchanges designed to ensure that each treating physician has access to the patient’s most current medications, lab and imaging results, consults, etc., to adopting concierge medicine, where a physician may literally accompany the patient to each visit to a specialist.
Following is information on several care coordination strategies that physicians may wish to consider implementing:
Under the PCMH model, each patient maintains an ongoing relationship with a personal physician who coordinates all of the patient’s care. Patient care is coordinated and/or integrated across all elements of the health care system (e.g., specialty care, hospitals, nursing homes, home health agencies, etc.), with the goal of improving the quality and safety of care. For more information, access the Centers for Medicaid and Medicare Services (CMS) report on medical home for care coordination.
Along with public and private payers launching Medical Home pilots, Bridges to Excellence (BTE) partnered with the National Committee for Quality Assurance (NCQA) to offer an incentive program for physicians that is based on the Medical Home model. To learn more about PCMHs, refer to the AMA resource, “Achieving medical home recognition.”
Defined in the 2010 Affordable Care Act, ACOs are intended to be a new delivery platform for Medicare services. One of the hallmarks and major goals of ACOs is care coordination, which in turn is expected to lead to improvements in the quality and efficiency of care.
The American Medical Association (AMA) is committed to helping doctors help their patients. To fulfill this goal, the AMA produces innovative resources designed to bridge gaps in the delivery of medical care. The “Physician resource guide to patient self-management support” introduces patient self-management support concepts and presents selected resources and practice implementation tools.
The resource guide builds on existing information in the field of patient self-management. It is organized to direct physicians to resources that will help them implement cost-effective techniques at various levels of the health care system in order to help patients achieve better health outcomes and increase their quality of life.Caregivers are often so concerned with caring for their relative’s needs that they lose sight of their own wellbeing. The “Caregiver Health Self-assessment Questionnaire” will help caregivers analyze their own behavior and health risks and, with their physician's help, make decisions that will benefit both the caregiver and the patient. The “Caregiver Self-assessment Questionnaire (Spanish version)” will enable physicians to identify and provide preventive services to an at-risk but hidden population and improve communication and enhance the physician-family caregiver health partnership.
Physicians can keep better track of their patients' care from hospital to home with an updated and expanded resource. Medical Management of the Home Care Patient: Guidelines for Physicians, 4th edition helps physicians identify and oversee the wide range of medical and social services available to assist their patients at home. Careful utilization of appropriate services can prevent unnecessary rehospitalizations, emergency department visits and poorer than expected health outcomes.
