Improving Care Coordination in Your Practice

Practices are spending more and more time discussing how to control the rising costs of healthcare reform while caring for an ageing population. Yet with the advent of quality reforms like Patient-Centered Medical Homes, there has been a rise in the amount of effort needed at the practice level to actively coordinate and manage patients' care.

One way to corral the ever-growing list of patient care tasks is effective care coordination. Coordinating care involves things like recalling patients to ensure that they receive appropriate and timely care, tracking referrals to specialists, and connecting patients to resources that will help drive better outcomes.

• Setting up processes

So where do you begin? Start by identifying the conditions that you spend the most time on, or the patient population that demands the most care coordination. Once you understand the needs of these patients, you can begin to develop print educational materials and online interactive tools that will make your job easier.

Care coordination should begin during the patient's office visit. Once you establish clear goals for patient care during the exam, you can provide patients with the educational materials that you've prepared to help them manage their own conditions.

Keep a list of community resources and actively refer your patients to local health programs. There are often many programs available in any community - from smoking cessation to nutritional counseling - that can benefit your patients.

• Obtain commitments

Another way to maximize your time is to set up referral agreements with specialists in your community. These agreements are an effective way to ensure that when you refer a patient out for care, you will receive the report in a timely manner. Simply state that the specialist will see your patients within a certain period of time and will send you the findings of that visit within X number of business days. If a specialist fails to comply, send a letter stating that while you would like to continue to refer patients, it is not possible to do so without a commitment to collaborate effectively.

• Utilize hospital referral programs

Hospitals and specialists are taking proactive roles and building "response times" into their referral loops, ensuring that providers receive the information they need in a minimum amount of time. So take advantage of any referral programs that your local hospital may be offering. Many now offer sophisticated programs where the referring provider only needs to call a single phone number to request an appointment with a specialist. The hospital will handle the rest of the work, ensuring that the patient is contacted and follows through with the appointment and the report is sent back within a defined period of time. If your local hospital does not already have a referral program, start the process by asking them for one!

• Third-party services

With a growing need to effectively manage chronic conditions, many tools and services have sprung up to help make things a little easier. There are companies that manage and track patient referrals, others that will help you recall overdue patients, and EHR modules that can help you track various data points on patients with specific conditions. If you are short on staff and heavy on chronically ill patients, you might consider outsourcing care coordination to companies that specialize in this type of work.

• Wellness and disease-management programs

Payers too are playing a key role in coordinating care. National insurers have developed "Ask a Nurse" telephone lines and care-management programs for costly chronic diseases. In some cases, payers require their network providers to sign agreements promising to refer patients to those resources. Investigate what is available within your payer networks, and see how these programs can help you manage your patients' care. Some payers are even willing to send case managers to work with your practice to help manage their sickest members.

Also, don't hesitate to ask patients about any wellness programs they may have at work. Encourage them to utilize these programs, and offer to provide your contact details so that program coordinators can keep you up to date on their progress.

In coordinating care for your patients, don't forget to utilize every resource you can to help support the care you give. It will go a long way toward keeping your costs down and keeping your patients healthy.

Susanne Madden, MBA, is founder and CEO of The Verden Group, a consulting and business intelligence firm that specializes in practice management, physician education, and healthcare policy. She is also COO, National Breastfeeding Center, and cofounder, Patient Centered Solutions. She can be reached at madden@theverdengroup.com or by visiting www.theverdengroup.com.