Colorado's Family Physicians weigh in on care Coordination

By: Miranda Meadow

There is a lot of evidence that improved care coordination reduces rehospitalizations (and sometimes avoids hospitalizations in the first place). With than in mind, Healthy Transitions Colorado is interested in understanding issues related to care coordination for family practice docs in Colorado. To find out more about this issue, we worked with the Colorado Academy of Family Physicians to gather feedback on physicians' experiences with care coordination. Three key points surfaced as topics which warrant further exploration as we continue to seek ways to improve transitions in Colorado--read on to see what we learned.

Colorado's family docs report accuracy of discharge information as biggest barrier to care coordination

In general, timely access to accurate patient-level information continues to be a problem for physicians. More than half (51%) of physicians said that accuracy of discharge information is a barrier to coordinating care for their patients after discharge. This was followed closely by "getting access to patient records from visits to specialists" (46%) and "getting access to an up-to-date medication list" (42%). Of those who selected "other", the majority of comments focused on the lack of electronic medical records that are integrated between their practices, specialists, and hospitals.

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We compared rural and urban physicians to see if the barriers differed. The barrier cited most frequently by rural docs is getting reimbursement for time spent coordinating care (50%), followed by accuracy of discharge information (45%) and access to records from visits to specialists (41%).  It is worth noting that a larger proportion of rural docs cited lack of knowledge about non-medical services and supports for patients as a barrier to care coordination, though given the disparate sample sizes of rural and urban respondents it is difficult to draw comparisons. However, this may be important in informing the work of the Regional Health Connectors program, and others throughout Colorado who are focused on care coordination in rural areas.

Patients with a history of behavioral health and/or substance abuse most difficult group to coordinate care for

We also asked physicians to indicate the level of difficulty they have in coordinating care for certain groups of patients on a scale of 1 to 5 (with 1 being the most difficult to coordinate care for). Patients with a history of behavioral health and/or substance abuse and homeless adults are the hardest groups to coordinate care for (74% and 71% respectively), followed by patients with Medicaid as a distant third (59%). Hopefully the State Innovation Model's focus on integrating behavioral and physical healthcare may enable better care coordination for patients with behavioral and/or substance abuse issues. In the absence of social supports like housing and transportation, however, the homeless community will likely continue to face issues that impede effective care coordination.

Geriatric adults, people with multiple chronic conditions, and Medicare beneficiaries were reported to be among the easiest to coordinate care for. This may be due, in part, to the additions of Medicare Transitional Care Management and Chronic Care Management codes in recent years, though it is unlikely that reimbursement is solely responsible for this outcome.

53% of docs report providing in-home support to avoid sending patients to Emergency room

Finally, we sought to understand what resources outside of normal clinic visits family practice physicians are using to support their patients. The most common approach was providing patient education via telephone. Perhaps surprisingly, though, was the next most frequently cited support: in-home visits to avoid visits to emergency departments. More than half of physicians surveyed reported that in the last year they have provided in-home support to their patients. The percentage of physicians in rural areas was higher (14 out of 19, or 74%) compared to urban physicians (43 of out 98, or 49%). Whether these services were provided in a patient's own home or a residential facility was not reported.

Those who reported using other supports noted embedded case managers, patient navigators, and behavioral health support, same-day scheduling, and online patient portals as effective approaches.

In general, care coordination is a real barrier in primary care

What all of this tells us is that there are still large systemic barriers to improving care coordination (and thus reducing ER visits, hospitalizations, and readmissions). If physicians can't get the information they need from discharging hospitals, specialists, or pharmacies, their ability to follow their patients through multiple care settings will be greatly diminished. Similarly, without access to or knowledge of behavioral health supports, it will be difficult for physicians to engage patients with unmet behavioral health needs in self-care. This can contribute to unnecessary ER visits and prolonged illness episodes.

Current programs are underway at the national and state levels to address some of these problems. As mentioned above, the Colorado State Innovation Model has as a primary focus the integration of physical and behavioral health. And the Comprehensive Primary Care Plus (CPC+) program provides additional dollars to practices providing care coordination and care management. As a state, we need to continue to evaluate our efforts and adjust our approach to ensure we are heading towards the ultimate goal of better care leading to better health, at lower costs.


Special thanks to the Colorado Academy of Family Physicians for allowing Healthy Transitions Colorado to contribute some questions on their annual member survey!