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Patients wonder if there really is a health care system’
An elderly patient comes to the hospital with chest pain. She is immediately admitted and scheduled for bypass surgery. Who is in charge of her care? A cardiologist? A cardiac surgeon? A hospitalist? Or her own primary care physician?
Managed care promised to focus a patient’s care with one key provider — the primary care physician. But new specialties grew, including behavioral health "carve-outs" and urgent care centers. (See related articles, p. 112.)
Coordination of care is now gaining attention as an important factor in both clinical outcomes and patient satisfaction. Patients need to know who is responsible for their care, and they have a right to clear information and prompt follow-up, outcomes experts say.
"The absence of a coordinated health system is one of the most important reasons why people don’t trust health care right now," says Susan Edgman-Levitan, PA, president of The Picker Institute, a Boston-based nonprofit organization that focuses on health care quality improvement from the patient perspective.
"When you ask consumers about their perceptions of the health care system, universally, they start laughing," says Edgman-Levitan, referring to Picker-sponsored focus groups. "Even using the word system’ is an oxymoron. [They say,] There is no system up here. The only person who coordinates care is me. It is not done for me.’ There is a tremendous amount of cynicism about health care in general that is, in part, related to that [frustration]."
Coordination of care can involve everything from smooth discharge from a hospital stay to prompt communication about test results. "Patients want to know that things are happening that should be happening," she says.
Technology can play a major role in that smooth flow of information. At Kaiser Permanente in Oakland, CA, policies require hospitalists to notify primary care physicians within 24 hours of admission that their patient is in the hospital. The hospitalist is also responsible for sending a discharge summary to the primary care physician who is expected to contact or visit the patient during the hospitalization.
But each physician still generates a new paper record, which isn’t readily available to physicians at other sites. Kaiser hopes to rectify problem with an electronic medical record that includes firewalls, passwords, and other security measures to ensure confidentiality.
"As long as things are paper-based, there’s going to be a real problem in moving information around, which is a barrier to continuity of care," says Mike Ralston, MD, director of quality demonstration for The Permanente Medical Group in Oakland. "As patients move through these different areas of specialty, information about their care has to move along with them."
At Harvard Vanguard Medical Associates in Boston, a computerized medical record allows urgent care doctors to access records, inform primary care physicians of the encounter, and even schedule follow-up appointments with the patient’s regular doctor.
"I don’t miss a beat," says Steven Pearson, MD, MSc, an internist and urgent care physician. "If patients come in who don’t have a primary care provider, I can assign one on the spot and arrange for a follow-up."
While technology provides such benefits, coordination of care also relies on simple aspects of communication. For example, nurses or physicians may share the care plan with the patient or even hand over the medical chart for review, says Diane Miller, MBA, director of the collaborative on Improving Service in Health Care for the Institute for Healthcare Improvement (IHI) in Boston.
"That’s usually seen as something you don’t do, but it opens up a partnership," says Miller, who is director of organizational development at Virginia Mason Medical Center in Seattle.
In fact, sharing clinical pathways and guidelines improves patient satisfaction and gives patients realistic expectations, says Edgman-Levitan, who co-chaired the IHI collaborative. When patients don’t know what to expect from a hospital visit and discharge, "there is a cascade of problems that arise," she says. "They don’t know they’re going to need to set up a series of follow-up appointments, or they don’t have the equipment they need for home care."
Patients also need to be completely informed of who is responsible for their care. If a diabetic has questions about the insulin schedule, should she ask her patient educator, physician, or pharmacist? "Some teams developed a glossary of sorts of the different professionals you will see in the course of this illness, what they’re responsible for, and who is the final authority," says Edgman-Levitan.
In fact, she knows from her own experience as a breast cancer patient how confusing the team of specialists can be. "From my perspective as a patient, my experience of how my managed care organization manages and coordinates my care is mostly through the approval process for seeing specialists," she says. "It doesn’t facilitate my seeing the specialists. It just makes it possible for me to see the specialists."
Truly coordinated care eases patients through their health care experience and even reaches into their home environment, when necessary. At Cedars-Sinai Medical Center in Los Angeles, efforts to create a smooth hospital discharge begin within 24 hours of admission.
A case manager or social worker from the department of case management visits each patient, hands them an information sheet, and provides them with names and phone number of the case manager and social worker who cover that area. "In that brief intervention, you’re also able to determine whether this person has discharge-related needs," says David Esquith, LCSW, MPA, manager of medical social work.
To improve communication with attending physicians, the department of case management also faxes a sheet to their office briefly outlining the discharge plan. They need only respond if they have questions or concerns.
Just before discharge, a case manager or social worker again visits the patient and discusses any discharge needs, such as transportation, nutrition, psychosocial support, home care, or therapy. In many cases, the staff person simply says, "It did not appear there were any specific needs you would have when you were discharged. From your perspective, has anything changed?"
In cases of elective surgery, such as scheduled cardiac surgery, Cedars-Sinai is working with medical groups to begin discharge planning before the patient even enters the hospital. With extra time to plan, the social workers and case managers can better meet patients’ post-discharge needs.
The changes in discharge planning led to a surge in patient satisfaction, Esquith says.
Monitor progress with patient surveys
Medical groups and hospitals can monitor patients’ experiences with coordination of care just as they do satisfaction with access or communication, says Edgman-Levitan.
The Picker Institute ambulatory care survey contains questions about coordination of care, including questions about receiving test results and smooth referrals. (See sample questions, above left.) "It’s as important to send them the normal results as it is to send them abnormal results [of tests]," she says. "That becomes part of your quality control. If [patients] don’t hear from you, they will follow up."
For chronically ill patients, coordination is especially important as different physicians prescribe medications for different conditions. But even the healthy patient should have coordinated preventive care that includes reminders about screening tests or immunizations.
"Continuity is something patients have a right to expect," says Ralston.
[Editor’s note: A new collaborative on Improving Service in Health Care will begin in November. For more information, contact the Institute for Healthcare Improvement, 135 Francis St., Boston MA 02215. Telephone: (617) 754-4800. Fax: (617) 754-4848. Web site: www.ihi.org.
For more information on Picker surveys and services, contact The Picker Institute, 1295 Boylston St., Suite 100, Boston, MA 02215. Telephone: (617) 667-2388. Fax: (617) 667-8488. Web site: www.picker.org.]