One of the hallmarks of the patient-centered medical home (PCMH) is care coordination with members of its medical neighborhood — hospitals in particular. Because so many gaps in care can occur between primary and hospital care, the PCMH-Hospital Committee, convened by HealthTeamWorks, is working to identify and close those gaps and make patient “hand-offs” error-free.
By communicating with primary care physicians (PCPs), hospitals can improve care to patients in the emergency room by obtaining crucial health information. Medical practices can reduce patients’ emergency room and hospital visits — including re-admissions — through better care management, access and communication.
HealthTeamWorks established the PCMH-Hospital Committee in August 2009 with representatives of area hospitals, hospital systems, the Colorado Hospital Association, insurers and practices participating in the Colorado PCMH Pilot. It recently got renewed energy with the addition of Beth Neuhalfen, PCMH project manager for Westminster Medical Clinic (which participates in the HealthTeamWorks PCMH Pilot project), and Marsha Parker, MS, CPHQ, administrative director for quality and medical staff, St. Anthony Hospital North.
The committee aims to:
• Improve timely notification to PCMH practices when patients come to hospital emergency rooms or are admitted to the hospital so practices can act on the information; and
• Improve coordination and continuity of care through better communication between hospitals and PCMH practices, including determining the information that parties need to share.
“There are so many processes involved [between primary care and hospitals] that need changing,” Neuhalfen says. “It’s a journey of change. Our practice, as a PCMH pilot and model for other practices, can also be a model for working better with hospitals.”
“Hospitals have only looked at patients from when they enter our doors to when they leave,” Parker says. “Now, with a focus on partnership and coordination of care, we are starting to recognize a home-to-home perspective: What has the patient’s history been in other care settings, and how can the hospital assist in the patient’s care once they’ve gone home?”
The challenges facing the PCMH-Hospital Committee include:
• Resistance to change by hospital physicians, particularly those working under contract in the emergency room;
• Limited time for providers in primary care and the hospital to exchange information;
• Incompatibility between electronic health record systems;
• Patients’ inability to provide information about their PCPs; and
• Contracted physicians’ incentives to refer to care-givers outside a patient’s medical neighborhood.
“We’re identifying the information: who needs what, the best way to facilitate referrals to the emergency department, how hospital discharge advocates and primary-care coordinators can work together,” Neuhalfen says. “We have to include skilled nursing facilities and other kinds of services that reflect back to the PCP and reach out to the PCP.”
Neuhalfen and Parker both say that the committee is raising awareness of the importance of care transitions “We want to see what’s happening to people in the interim between providers.” Parker says. “A PCMH’s care coordinator can work with hospital care managers to make sure care never gets dropped. This eliminates a huge gap in care.”
“As someone who’s been involved in healthcare a long time, I know the incentives [for healthcare players] are misaligned,” she continues. “It’s very satisfying to see the focus coming back to the patient.”