Care Coordination and Communication Needed Between Transplant Providers and Primary Care
By Melinda Young
Cirrhosis affects a small percentage of the U.S. population. But it is a highly complex disease that leads to high hospital readmission rates and a higher cost per patient than found in heart failure and COPD. It also is the fifth leading cause of death for people ages 45 to 64 years in the United States.1
Investigators found care coordination and efficient communication between providers can optimize care. Telehealth can help patients, particularly for return visits.1
“Cirrhosis is very costly and has high morbidity and high mortality,” says Marina Serper, MD, MS, lead study author and an assistant professor of medicine in the division of gastroenterology and hepatology, department of medicine at the University of Pennsylvania Perelman School of Medicine. “It has two forms: compensated and decompensated. Both can result in mortality over time; the decompensated form is what is costly.”
Patients with decompensated cirrhosis experience fluid overload, mental confusion, kidney failure, and infections that send them in and out of the hospital, Serper says.
A major barrier to managing their disease well is inadequate care coordination between primary care and specialty care. Sometimes, primary care is not involved in managing complex liver disease, and providers may have trouble accessing patients’ records. There also could be large distances between community-based clinics and the hospital where patients are treated.
Referrals and care coordination between referring centers and transplant centers also is an issue. There could be long delays in providers obtaining needed records.
Care coordination improves if nurse navigators are involved. It works most seamlessly when a health system is integrated with community clinics where patients receive primary care services. Other facilitators to optimal care include telehealth, interdisciplinary collaboration, and electronic health records.
“The issue is who takes care of patients with cirrhosis. It’s mostly done by general practitioners in the United States because there are not enough gastroenterologists or hepatologists to meet the needs of our population,” Serper explains. “Doctors are clustered in high population areas.”
The same trend is true for specialists treating other patients with chronic illnesses, including heart failure. “People want to live in densely populated areas, but rural adjacent areas do not have specialists,” Serper adds.
People who live along a coastline or in a high-population metro area may have access to a gastroenterologist or hepatologist, but these specialists may not be available in other communities. Managing this complex care is challenging for primary care providers.
“There’s a lot to know,” Serper notes. “Primary care providers have to deal with a lot of things: very short patient visits, insurance denials, and increasingly complex disease management.”
While primary care providers may be receptive to learning more about care for patients with liver disease, they still need dedicated time that is not always possible under fee-for-service reimbursement models. One way to improve care would be for primary care providers to meet with specialists via videoconferencing to present their medical cases and learn tactics to manage the more complex cases.
In large health systems like the Veterans Administration (VA), it is possible for primary care providers to contact VA specialists in other states for their perspective. “Another aspect is telemedicine, which can bridge the gaps and improve access to specialty care and help manage these patients,” Serper adds. “Telemedicine could offer timely access when there isn’t a specialist within 100 or 200 miles.”
Serper and colleagues found providers thought telehealth was useful for symptom management, but some were unsure of whether telehealth visits were a sufficient substitute for in-person visits. Plus, some sites may lack broadband internet and digital literacy to adequately engage in telehealth.
Case managers can improve care coordination by ensuring patients are transitioned to their community setting with follow-up primary care appointments. “We know that access to early, timely, post-hospital discharge care is associated with lower mortality,” Serper says. “There could be provider-to-provider communication, telemedicine, or a call to discuss the patient’s case.”
Case managers could ensure timely follow-up within 30 days of an ED visit or hospitalization. “Some of these patients need transplant referral, and they’re not being referred enough because [their disease progression] is not recognized in a timely manner,” Serper notes.
Another potential model is a day hospital. This model does not yet exist in the United States but has been used elsewhere. “A person with cirrhosis needs imaging, endoscopy, blood tests, and medication adjustments, so a [cirrhosis] day hospital could do all of that in one day,” Serper explains. “A study from Italy showed it can reduce hospital days and mortality and is very effective.”1,2
In the United States, health systems with value-based models could arrange for all the specialist visits with the patient during a long medical appointment. That is a similarly innovative model of care.
“Bring the clinic to the patient,” Serper says.
- Serper M, Agha A, Garren PA, et al. Multidisciplinary teams, efficient communication, procedure services, and telehealth improve cirrhosis care: A qualitative study. Hepatol Commun 2023;7:e0157.
- Morando F, Maresio G, Piano S, et al. How to improve care in outpatients with cirrhosis and ascites: A new model of care coordination by consultant hepatologists. J Hepatol 2013;59:257-264.
Cirrhosis affects a small percentage of the U.S. population. But it is a highly complex disease that leads to high hospital readmission rates and a higher cost per patient than found in heart failure and COPD. Investigators found care coordination and efficient communication between providers can optimize care. Telehealth can help patients, particularly for return visits.
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