Improving care coordination in primary care

Abstract

Background: Although coordinating care is a defining characteristic of primary care, evidence suggests that both patients and providers perceive failures in communication and care when care is received from multiple sources.

Objectives: To examine the utility of a newly developed Care Coordination Model in improving care coordination among participating practices in the Safety Net Medical Home Initiative (SNMHI).

Research design: In this paper, we used correlation analysis to evaluate whether application of the elements of the Care Coordination Model by SNMHI sites, as measured by the Key Activities Checklist (KAC), was associated with more effective care coordination as measured by another instrument, the PCMH-A.

Measures: SNMHI measures are practice self-assessments based on the 8 change concepts that define a PCMH, one of which is Care Coordination. For this study, we correlated 12 KAC items that describe activities felt to improve coordination of care with 5 PCMH-A items that indicate the extent to which a practice has developed the capability to effectively coordinate care. Practice staff indicated whether any of the KAC activities were being test, implemented, sustained, or not on 4 occasions.

Results: The Care Coordination Model elements-assume accountability, build relationships with care partners, support patients through the referral or transition process, and create connections to support information exchange-were positively correlated with some PCMH-A care coordination items but not others. Activities related to the model were most strongly correlated with following up patients seen in the Emergency Department or discharged from hospital.

Conclusions: The analysis provides suggestive evidence that activities consistent with the 4 elements of the Care Coordination Model may enable safety net primary care to better coordinate care for its patients, but further study is clearly needed.