Closing the loop on communication and care coordination to improve health and safety

The challenge

Though medical errors can happen when care is delivered by a single provider, the opportunities for serious mishaps increase when multiple providers are involved. Specialty providers may not get the information they need from referring providers to be able to offer high-quality care. Primary care teams may not be notified when their patients are seen in an emergency room or admitted to the hospital. These failures in communication and care coordination among participants involved in a patient’s care — typically referred to as “care fragmentation” — can have devastating consequences for patients.

To help solve this problem, the MacColl Center for Health Care Innovation (now the ACT Center) worked with The Commonwealth Fund and 15 partner organizations across the country to improve care coordination by creating a model for high-quality referrals and transitions for providers and patients. Care coordination is a set of activities that is needed to minimize the dangers of care fragmentation. Those activities include explicitly assigning accountability for coordinating care, actively supporting patients, and assuring that all providers involved in a patient’s care have clear, shared expectations about their roles.

The work

• Convene an expert panel of physicians, researchers, patients, and nurses who excel at coordinating care to guide the effort
• Examine the research literature and best practices for care coordination
• Partner with high-performing practices to identify the best strategies for making care coordination routine in practice
• Use those learnings to develop a model and comprehensive toolkit including case studies and hands-on resources to ensure providers, institutions, and patients have the information and tools they need to optimize care and reduce fragmentation 
• Share the model and toolkit as part of an organized learning collaborative and coaching intervention to support primary care practice improvement in 5 states

What we learned

Coordinating care in our current health care environment is difficult, and it starts with primary care practices assuming responsibility for that work as part of becoming a patient-centered medical home. The comprehensive set of tools compiled in Reducing Care Fragmentation: A Toolkit for Coordination Care can help. The toolkit includes the Care Coordination Model, change package, case studies, and additional tools and resources. 

Elements of the model include: 

• Assuming accountability
• Providing patient support
• Building relationships and agreements among providers (including community agencies) that lead to shared expectations for communication and care
• Developing connectivity via electronic or other information pathways that encourage timely and effective information flow between providers (including community agencies)

Impact

The Care Coordination Model and toolkit provide a clear roadmap for creating lasting relationships and agreements among providers (including community agencies) that lead to shared expectations for communication and care. Especially helpful have been cases studies based on patient experiences of the harms caused by fragmented care, as well as several case studies that illustrate what high-performing primary care practices are doing to forge stronger electronic and personal links between community providers.

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Wagner EH, Sandhu N, Coleman K, Phillips KE, Sugarman JR. Improving care coordination in primary care. Med Care. 2014 Nov;52(11 Suppl 4):S33-8. doi: 10.1097/MLR.0000000000000197. PubMed

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Reducing Care Fragmentation: A Toolkit for Coordinating Care