Mastering care coordination

May 12, 2020

It takes a team to care for patients with chronic disease, but who should take the lead?

Patients with complex conditions require a multidisciplinary effort to optimize care and control costs. Care coordination is the goal, but getting there can be a challenge. What role should primary care physicians play in this process, and how can they do it without neglecting their patients? Experts provide insights below.

The primary care physician: leader or bystander?

Care coordination takes a team that involves physicians, case managers and ancillary caregivers. Outlining the physician’s role can be difficult, though, as the current system does not provide physicians with the time or compensation to thoroughly manage the ongoing care of patients with complex chronic diseases.

Sarahjane Rath, M.P.H., CHES, a trainer and curriculum development specialist for the health care policy and advocacy firm Primary Care Development Corporation, says while primary care physicians are important to the care coordination process, they should not be the process’s point person. “Their role is never going to be huge because they have such a time limitation. They really can’t spend that extra time with the patient,” she says.

Rath, who helped develop a weeklong, face-to-face training program on care coordination for physicians, pharmacists and other frontline caregivers, says physicians should focus on their strengths and let the care managers and other service providers carry on care management work. This includes following up with patients and managing ongoing lifestyle issues. If physicians have an understanding of what care management is and an understanding of the topics that it addresses, they will be more inclined to solidify and endorse the referral system so it falls not just on themselves but also on other caregivers, she says.

A good referral system is a strong foundation, and it isn’t limited to medical specialties. Physicians should make appropriate referrals to specialists as well as case managers and social or community service agencies to help patients meet their goals. If they instead take on that care themselves, they take time away from providing medical care, and that’s where they are really needed.

Many physicians say they simply don’t have time to address care coordination, Rath adds. “This is where face-to-face training on what care coordination is and who takes on what role in the process is ideal. Physicians and other caregivers can discuss the process openly and address issues and (identify) problems in the cycle. A dialogue is helpful among all the disciplines,” she says. “They need to understand the process of case management and acknowledge that it takes a team to address chronic disease. It’s not just chronic disease management; it’s the whole picture.”

A physician is key to diagnosing and developing a treatment plan, Rath says. It’s all the rest that they really can’t, or shouldn’t, take on. Making sure patients have access to their medications and glucometers, a ride to appointments, and help with making diet and lifestyle changes, improving health literacy and addressing social determinants of health - these are all time-consuming yet very important elements of chronic disease management.

“It really does take a village to look after a patient, so in turn, it takes a team to look after a patient,” Rath says.

Physicians have to keep in mind their role in the care coordination cycle, however, and problems in the cycle should become the job of them team to resolve. A case manager or advocate is best served as the point person for each patient and can see where things fall through and work with the team to address issues. A primary care physician who sees patients returning over and over again for the same issues is a sign that the cycle is broken, Rath says. At that point, a physician should make a referral to social and case managers to identify the problem in the cycle.
While this may seem like passing the buck, Rath says, this is where the open dialogue and training come into play.

“The physician needs to just do a referral here or there. The physician should know whom to refer to for the problem or barrier,” she says. “Having physicians in these face-to-face training sessions is invaluable because it helps them to understand their role.”

A matter of opinion or fact?

The notion of giving up the role that is the primary care physician’s namesake - as the primary clinician - can be difficult to resolve.
Samuel “Le” Church, M.D., M.P.H., a family physician in Gainesville, Ga., says while it’s true that primary care physicians are pressed for time and reimbursement to support care coordination, it’s also a critical part of their role.

Church, who has been working with the American Academy of Family Physicians and other stakeholders to improve reimbursement for care coordination efforts at the primary care level, disagrees that physicians should take on a secondary role in the care coordination process. He acknowledges, however, the challenges within the system that do not allow them to do this easily. The current coding and billing system in the United States has provided incentive for fragmented care, he says, adding that many primary care physicians already wear the hat of care coordinator without being compensated for it.

“I would wholeheartedly agree that coordinating referrals is something for the team to manage rather than the physician. It is also not uncommon for people to confuse case management with care management,” Church says. “Case management may be focused on one task, but care management explicitly addresses a comprehensive plan of care, something that family physicians are uniquely qualified for, and in many cases, (they are) the only providers willing to embrace this responsibility.”

Patients with intentional care coordination are less likely to end up in the emergency department or hospitalized, Church says, and a good primary care team is essential to helping patients avoid the hospital and achieve more efficient care. Despite the involvement of other caregivers, many patients, especially older patients and those in rural areas, turn to the primary care physician when they need something.

“If the patient perceives there is something going on with them outside the specialist, they still call me,” Church says, adding that specialists play a crucial role, but a central team leader often does not exist. Without someone patients trust to fill this role, they often begin self-referrals, and this can lead to waste.

“In a world of limited resources, how can we use these resources for more bang for our buck?” Church asks.

Two big pieces of this are addressing care management codes and providing physicians with the reimbursement they need to devote time to care coordination. Church has been at the forefront of helping to improve coding for these activities. Coding for chronic care management (CCM) used to be limited to just 20 minutes, with complex care allowing for 60 or 90 minutes. Additional codes now allow for add-ons for more time, Church says, and regulators have abandoned a previous requirement that care plans had to change anytime the complex CCM codes were used. Compensating for time spent, and providing physicians with training on how to make a good, comprehensive plan of care, will benefit the process and the patients.


“We’re not just your doctor at these visits. We want to encounter you throughout the year, and we want to be your doctor and team all the time,” Church says. “We don’t want you to wait until you need something. Both the patient and the system win when our care is proactive and intentional.”

Better coding can help move this forward and allow physicians to devote the time they need to achieve better outcomes for their patients and the health system as a whole.

“It can be beneficial for patients everywhere to have primary care physicians right in the middle of that. It’s not the expectation that they are trying to be a substitute for the specialist,” Church says. “But the primary care physician knows what is going on, and care can be less fragmented when the primary care physician plays an overview role. The more hands there are, the more there is a need for coordination.”

Being able to set a plan and monitor and support its progress in every respect is crucial for patients with chronic disease, and the primary care physician is uniquely positioned to do that, Church says.

“I think this is empowering for patients,” Church says. “It taps into the unique skill set of the primary care physician and improves efficiency and cost within the system without decreasing care quality. It also hits the fourth aim of the Quadruple Aim. The whole team is happier when we can be proactive in our care and improve outcomes.”

The case for a paradigm shift

Katie Coleman, M.S.P.H., director of the MacColl Center for Health Care Innovation and director of the Learning Health System Program at Kaiser Permanente Washington in Seattle, has focused her research on best practices for care coordination and says a lot of ambiguity exists in this area of health care. What isn’t up for debate, she says, is that the role of the primary care team is central in clinical care management.

“Repeatedly in the literature about the benefits of clinical care management, a healing relationship with the primary care physician is shown to be more cost-effective and satisfactory than other programs,” Coleman says.

The difficulty is that care coordination is a shared activity among the primary care physicians, community services and other clinicians, and navigating reimbursement is a challenge. While Coleman says the central role primary care physicians play in the care coordination process is important, she also agrees with Rath to some extent that they need to be participants - but not necessarily leaders - in the process.

“Good care coordination can’t be the responsibility of a given doctor. It’s the responsibility of a care team,” Coleman says. “That’s a concept that is not widely used in primary care practice.”

The biggest step involves the physician recognizing the need for care coordination and placing trust in the process, Coleman says. “The key is really about primary care practitioners deciding they want to improve care coordination, accepting that accountability and moving forward from there,” she explains, adding that physicians would need more than 24 hours a day to provide evidence-based care for a traditional panel of patients. “This is an impossible task if you’re asking the provider to do it themselves. It is entirely dependent on having a functioning team.”

A good team can help a patient stick to a plan developed by the primary care physician to avoid unnecessary visits, hospital stays and complications. This team can also save that patient stress and the health care system money by making sure the entire care team is involved in the patient’s journey, avoiding duplicate assessments, labs and tests, Coleman says.

“The health care system is overly complex and hierarchal when people are sick,” Coleman says, adding that duplicated, unnecessary care is a big issue facing health care and one that stems from poor care coordination. “This is really behind a lot of the value-based payment conversations that are happening.”

Practices need to change the way they view care coordination and building teams, Coleman further explains. New billing codes to reimburse for care coordination help, but health care has a long way to go before good care coordination becomes a standard in practice.

Brian Austin, who co-founded Kaiser’s MacColl Center in 1992 and is currently its associate director, shared several resources the center has developed to help the care coordination process. These include an implementation guide and the Improving Primary Care website, which offers three modules addressing self-management, referral management and care management. These resources can help a team assess its strengths and weaknesses and create an improvement plan.

“We’ve got to put an emphasis on the primary care team, not just the doctor,” Austin says.

To move forward in this, Coleman says, primary care practices have to truly be on board with integrating care coordination and becoming a care team. For this to happen, payments have to be in their favor, and referral tracking systems need to be in place.

“We need to organize teams to manage patients at every level. It’s really thinking of the whole team as owning the care of their panel of patients,” Coleman says, adding that this means that different clinical teams have systems set up to communicate about patients and share assessment data.

“It requires a combination of payment reform and practice changes, but this is a critical issue, and I think we can get there,” Coleman concludes.

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