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Improving continuity of care


For patients to receive high quality care, healthcare providers must find ways to work together and ensure continuity of care between primary care physicians, specialists and hospitals. For a variety of reasons, continuity of care has not worked as advertised, but many physicians have ideas for how this collaboration can be improved.

Ernest Brown, MD, prides himself on staying on top of his patients’ care, whether he treats them personally at his Washington, D.C. office-or they see a specialist or an emergency room physician.

When they are admitted to hospitals, he says “I go with them and I advocate for them. I know the emergency room doctors. I make sure their care is thorough. I follow them until they are out of the hospital.”

Brown has time to play a role that is increasingly out of reach for primary care physicians because of the creative way he has structured his practice. He only does house calls and doesn’t take insurance, which enables him to avoid the time-consuming paperwork required.

“I have that luxury. I don’t have 30 patients to see in a day-and I’m mobile,” he says. He also has the freedom to see patients who are unable to pay.

Related:Becoming a PCMH

Brown’s approach isn’t for every physician, but it reflects the frustrations that many doctors feel at a time when delivering better continuity of care seems increasingly out of reach. “When you look at a clinic, you are talking about volume vs. value,” Brown says. “You’re talking about 10 to 15 minutes with the patient, whenever they happen to come in.”

The primary care quarterback

Few would disagree that when primary care doctors quarterback a patient’s care in a comprehensive way, quality improves and costs decline. A January 2014 study on patient-centered medical homes-where the family physician serves as the hub of the patient’s care-found that the approach decreased the cost of care, reduced the use of unnecessary or avoidable services, helped in controlling health indictors in the patient population such as blood pressure, improved access to care and boosted patient satisfaction. The study was done by the Patient Centered Primary Care Collaborative, a coalition of more than 1,200 patient centered medical homes.

But despite efforts by the federal government and private insurers to include continuity of care into evolving models of payment and care, the barriers to achieving it are mounting, say some physicians.

“There is no continuity of medical care,” says Thomas E. Bat, MD, a physician with 30 years’ experience who practices at North Atlanta Primary Care in Georgia, a patient-centered medical home with 23 physicians. “When a person leaves the sphere of family medicine or primary care and moves to the specialty arena for some chronic disease management issue or the emergency arena for acute care, each of these entities has their own team-based approach. The teams don’t communicate at all.”

The current system makes continuity of care so hard to achieve, says Bat, “there are days when I look at it that I feel like Don Quixote.”

Why is continuity of care slipping out of reach? In theory, primary care physicians’ work should be getting easier.

The Affordable Care Act brought more consistent access to care to millions of low-income Americans by expanding access to Medicaid. In the first half of 2014, the number of people covered by Medicaid grew by more than six million, with 71% gaining eligibility because of the ACA, according to an October 2014 estimate by the Heritage Foundation.

Meanwhile, the number of people receiving private insurance coverage increased by a little under 2.5 million in that same period, once the number of people who signed up under the ACA and the number of people who lost employer-sponsored coverage were factored in.


NEXT: Changes in technology


‘Zero feedback’

But one challenge for physicians, notes Bat, is that many moderate-income Americans who don’t qualify for Medicaid opt for the lowest-priced plans on the healthcare insurance exchanges. These “bronze” plans often have networks so narrow that it can be extremely difficult to find specialists to treat patients, he says.

With about 15% of his new patients covered by plans bought through the exchanges, Bat has found himself referring some who need a cardiologist to the emergency department for lack of any other option. And when he does that, he finds, communication is lacking.

“They made it difficult to tell us through these narrow networks who we can coordinate care with,” says Bat. “Then, when we do coordinate care with those people in the network, there’s virtually zero feedback from the people we coordinate with.

“Emergency rooms have no mechanism to communicate back to the primary care giver,” he adds. “They use a computer system to provide a summary report.” The reports may arrive within one to three days but sometimes can take more than a month, he says. “That’s not the same as one doctor talking to another about a patient,” he says.

Related:ACO or PCMH: Making a crucial decision

Recently, when he got a call from a cardiologist on a Sunday evening to discuss the continuation of a patient’s care, he was truly surprised. “I love that,” says Bat. “I thought, `We’re going to avoid keeping this person in the hospital.’”

That doesn’t happen very often in a market where most cardiology practices are owned by hospitals, he says. “They’ll never pick up the phone and call me on a Sunday night,” he says. “They’ll put them in the hospital and run $30,000 in tests on the patient.”

Of course, he adds, “It’s a two-way street.” Often the primary care physician won’t pick up the phone either. “The primary care guy goes, `I’ve got 15 minutes. I’ve got to move on to the next patient,’” he says.

Technology challenges

Another challenge for physicians is the transition to electronic health records (EHRs). Many physicians have done so to participate in the Physician Quality Reporting System (PQRS), Medicare’s pay-for-reporting program to encourage better quality care, and to avoid penalties for practices that don’t make meaningful use of certified EHR technology.

Rather than improving communication when a patient moves in and out of a hospital or nursing home, however, the new systems are making communication more difficult, because they don’t communicate with each other, says Joseph Barry, MD with Preventive Medicine Associations, a three-physician internal and geriatric medicine practice in Syracuse, New York, who followed his father into private practice in 1988.

“The advent of electronic medical records is creating great tumult and confusion and obfuscation of the medical record,” says Barry. When he does receive information from a patient’s chart, he often finds himself wading through boilerplate information from the EHR that is not relevant-while what he really needs to know is not included.

“Getting a full sheet of information about seatbelt safety is not helpful when the patient was admitted for pneumonia,” he says.

Even when the information he gets does pertain the patient’s case directly, critical facts often are missing. “It’s a mess,” he says. “When people leave the nursing home I get pages and pages of how many days of physical therapy they had–but not saying that on day eight, they had a blood clot and had to go back to the hospital.”


NEXT: Payer challenges


Payer challenges

Meanwhile, dealing with private insurers’ mounting paperwork requirements poses its own challenges, taking up time physicians might have used to call each other and catch up on a patient’s case.

“Everyone got very, very busy,” says Bat. “Everyone is entering data in a computer. When they finish that data entry, they are done.”

So what can physicians do to make sure they deliver continuity of care? “The problem is fixable if doctors take a leadership position on this,” says Barry. To that end, he says, he has written to four local hospitals suggesting ways to improve record keeping that he finds dangerous and inadequate.

“I’ve always been a believer in the one piece of paper rule,” he says. “Everything that is important to a patient can be put on one piece of paper.”

Updating payment models, so that specialists have more incentive to follow up with primary care physicians on the care they have delivered is also important, physicians say. “When I worked the emergency room, you used to get paid extra money on the day of discharge to do a discharge summary,” says Barry.

Some relief was expected to come at the start of the year under Medicare’s new fee schedule, when physicians doing chronic care management became eligible for a separate fee. Medicare has started paying $42.60 per billing to doctors who provide in-office support to patients with at least two chronic conditions-even if the support is not delivered face-to-face with patients. However, Bat anticipated that the “tedious” procedures to get the reimbursement would make it hard to actually obtain it.

Including physician assistants (PAs) on a medical team can help boost communication and prevent rehospitalizations, says Dawn Morton-Rias, president and chief executive officer of the National Commission on Certification of Physician Assistants (NCCPA) and a certified PA.

Using PAs has helped Bat’s practice, where about 15% of the patients are covered by Medicare. The practice relies on a team that includes PAs to keep the practice running smoothly while Bat recently spent a long visit with a 70-year-old alcoholic patient who has numerous chronic conditions including diabetes, osteoarthritis and renal failure.

Related:Patient-centered medical home: Making care coordination work for your practice

“She was my partner’s patient,” says Bat. “This doctor had backed up three or four deep in patients. He had both PAs jumping in with other stuff, so we could spend time with this patient. That’s how an office functioning like a team works.”

Physicians should also include caregivers in conversations about patient care, says Peter Rosenberger, author of Hope for the Caregiver and host of a Nashville radio show for caregivers. “They would be well-served to at least engage with the caregiver,” says Rosenberger. “The caregiver can become a real asset to doctors.”

Rosenberger has been caregiver for his wife for three decades. While in college she suffered a disabling car accident and later lost both legs due to complications related to two pregnancies. Along the way she has had 78 operations-often with Rosenberger doing the legwork to keep her doctors informed of what has happened in her case before.

“I know my wife’s history,” he says. “I know her chart. You can’t discount the person who is engaging with the patient day in and day out.”

Many physicians believe it starts with them. “We all operate in our silos,” says Bat. “How are we going to reform healthcare if we don’t come out of our silos?”


NEXT: Getting paid for care transitions


Getting paid for care transitions

Streamlining the transition of care process need not be an unreimbursed expense to your practice.

In 2013, two Current Procedural Terminology (CPT) codes were introduced to cover transitional care management (TCM). The codes are selected based on the complexity of the patient.

The codes require you to communicate with the patient and/or caregiver (through direct contact, telephone, or electronically) within two business days of the patient’s discharge, and conduct a face-to-face visit within seven to 14 days post-discharge, depending on the patient’s complexity level.

Select the proper CPT code based on the level of medical decision-making and the timing of the face-to-face visit. The codes and descriptions are:

  • 99495: Transitional care management services: Communication (direct contact, telephone, or electronic) with the patient and/or caregiver within two business days of discharge; medical decision making of at least moderate complexity during the service period; and a face-to-face visit within 14 calendar days of discharge.

  • 99496: Includes the transitional care management services included in 99495, and medical decision-making of high complexity and a face-to-face visit within seven calendar days of discharge.

The codes are billable at the end of the 30-day period, can be used by only one physician or provider, and may be reported only once during the 30-day period, even if the patient is re-admitted. While any physician or other qualified healthcare professional may use both the discharge code and appropriate TCM code, a TCM code cannot be used by a physician who also reports a service to the patient within a global period of 10 or 90 days.

NEXT: Managing continuity of care


Managing continuity of care

Continuity of care requires careful management of care transitions between providers and healthcare settings. You can build a rigorous transition of care process that makes a difference for your patients and your practice.

One way to get started is to follow these strategies:

Formalize your inbound referral process

List the information you need to manage the care of patients you accept from other providers. If your electronic health record (EHR) doesn’t provide an electronic consult request form, create one. Make sure that the form is in a format the transferring facility or provider can easily view, such as a text file or Excel spreadsheet. Design it in the form of a checklist of all critical elements that you want before or during the patient’s visit.

Develop a timeline that runs from when a patient referral is made to the appointment day. Include time for your staff to process the referring physician’s data.

Focus on the logistics of external referrals

When you refer patients for care outside of your office walls, focus on the logistics. How does the information travel from your practice to the physicians, hospitals, or those other resources involved in your patient’s care? Importantly, understand the information that the other provider or facility has requested to always receive-hold staff accountable for always including that information when a patient’s records and treatment plan are transferred.

Likewise, develop processes to ensure that your practice’s contact at the receiving institution knows what information you want regarding your patient’s condition and the current course of his or her care, and when you need it. Provide a telephone number or a secure, web-based email box for physicians, the hospital’s case managers, or discharge planning team members to reach you.

Pursue collaboration

Care transitions can be an opportunity for you and your practice’s care team to find common goals with the other physicians and facilities that provide care to your patients.

These goals can include:

  • educating patients about the care plan and the signs of a worsening condition,

  • offering patients clear instructions about follow-up care, and

  • identifying the resources the patient should contact with questions and concerns.

While you probably won’t be at patients’ bedsides when they are discharged, you’d still like to know what discharging physicians and facility staff communicate to the patients and their caregivers.

Look also to how the care team provides the information to the patient. Do instructions and other knowledge come in multiple formats such as printed hard copies, web-based information, and/or instructional videos? Do those materials seem like they would be understandable and engaging to your average patient and his or her caregivers?

Focus on prevention

Learn about your own readmissions before investing in more prevention techniques such as care and case outreach, 24-hour nurse triage hotlines to answer patients’ questions, and patient education materials that are appropriate to the patient’s education level, language, and culture.

Those all have potential, but first, look for patterns in your readmitted patients. Key points to determine and assess are the readmitted patient’s diagnosis, last visit date with your practice, and most recent communication with your practice-even the time of day and day of the week.

Once you have your data, look for opportunities to prevent future readmissions. After addressing the communication roadblocks or accountability failures within your practice, look for opportunities to collaborate with other providers in the community. Addressing these barriers creates value for patients, and the healthcare system.

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