Co-Management – Primary & Specialty Care Shared Patients

Co-Management is the act of collaborating in the delivery of care for shared patients between the Primary Care Provider and Specialty Care Provider(s) when the necessary care and treatment is beyond the scope of the Primary Care Provider.
Resource Type: 
  • Guide
Topic(s): 

    REFERENCES

     

    American College of Physicians. The Patient-Centered Medical Home Neighbor: The Interface of the Patient-Centered Medical Home with Specialty/Subspecialty Practices. Philadelphia: American College of Physicians; 2010: Policy Paper. (Available from American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106.)  https://www.acponline.org/system/files/documents/acp_policy/policies/pcmh_interface_subspecialty_practices_2010.pdf

     

    Cardwell D, Richmeier, S. (2011).  Patient-Centered Medical Home Care Coordination Workbook: Part of the Transformation Series. MGMA and TransforMED publishers

    Care Coordination.  AHRQ.  https://www.ahrq.gov/professionals/prevention-chronic-care/improve/coordination/index.html  Accessed 05 Dec 2017

    Care Coordination Implementation Guide.  Reducing Care Fragmentation in Primary Care. (2013).  Safety Net Medical Home Initiative.  http://www.safetynetmedicalhome.org/sites/default/files/Implementation-Guide-Care-Coordination.pdf.  Accessed 05 Dec 2017.

    Clinical Referral Protocol Guide: Definitions and Templates for Referrals with the Accountable Care Collaborative (2014).  Developed by RCCOs across the state of Colorado. http://ichpcolorado.com/providers/pdfs/Clinical-Referral-Protocols-Guide.pdf

    Coordinating Care in the Medical Neighborhood: Critical  Components and Available Mechanisms..  PCMH Resource Center.  AHRQ https://pcmh.ahrq.gov/page/coordinating-care-medical-neighborhood-critical-components-and-available-mechanisms

    Greiner A. White space or black hole: What can we do to improve care transitions. American Board of Internal Medicine Issue Brief #6. 2007. Accessed at www.abimfoundation.org/~/ media/Files/Publications/F06-05-2007_6.ashx accessed 13 December 2017

    Institute for Healthcare Improvement / National Patient Safety Foundation. Closing the Loop: A Guide to Safer Ambulatory Referrals in the EHR Era. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2017. (Available at www.ihi.org)

    Mehrotra, Ateev, Christopher B Forrest, and Caroline Y Lin. “Dropping the Baton: Specialty Referrals in the United States.” The Milbank Quarterly 89.1 (2011): 39–68. PMC. Web. 13 Dec. 2017.

    Primary Care Team Guide. A program of the Primary Care Team Leap. http://www.improvingprimarycare.org/work/referral-management.  Accessed 06 Dec 2017

    Royer, Richard, (May, 2015).  Transforming Care Coordination.  Hospitals and Health Networks.    https://www.hhnmag.com/articles/3067-employees-raise-a-half-million-dollars-to-build-rural-replacement-building

    Snow, V., et al.  Transitions of Care Consensus Policy Statement: American College of Physicians, Society of General Internal Medicine, Society of Hospital Medicine, American Geriatrics Society, American College of Emergency Physicians, Society of Academic Emergency Medicine. J Hosp Med. 2009 Jul;4(6):364-70. doi: 10.1002/jhm.510.

    REFERENCES

    Introduction

    This co-management process is useful to:

    • Ensure appropriate and timely consultations and referrals between the Primary Care Practice and referral sources.
    • Ensure effective communication and coordination between the Primary Care Practice and referral sources.
    • Improve the flow of necessary patient and care information
    • Improve patient-centered care, enhanced care access and high levels of quality and safety.
    • Achieve better health outcomes.
    • Reduce duplication of healthcare services.

    Successful co-management requires persons within the practice dedicated to patient referral management and a referral tracking system (preferably electronic and connected to the EMR). However, a manual/paper system can be utilized. You will also need lists and relationships with different providers and service organizations within the community. The knowledge of how these providers and resources send and receive patient information gathered through development of collaborative care agreements, care compacts and/or co-management protocols is also necessary.

    Starting Co-Management of Shared Patients:

    Adopt Conceptual Model for Transitions of Care

    Adopt the guiding principles for Care Transition, Flow of information and the Care Collaborative Agreements. Adapted here from the Transitions of Care Consensus Conference – TOCCC and Stepping up to the Plate SUTTP Alliance Initiative
    Diagram showing a linear care coordination process with four stages—Send/Sender, Key Information, Receive/Receiver, and Act—surrounded by an oval labeled “Care Coordination Hub.” Additional banners highlight Provider Accountability at the top and Active Patient/Family Engagement at the bottom.

    Reach Consensus with Referral Sources

    Assure that all referral sources agree to abide be these principles.
    • Respect the patient’s hub of coordination of care. This is provided by the Primary Care Provider unless total care has been transferred to another provider
    • Accountability. At all times, a personal physician must be accountable for ensuring that patients of all ages experience effective transition between locations of care through the timely exchanges of appropriate information.
    • Clear and direct communication of treatment plans and follow-up expectations. Appropriate communication should be direct and specific clearly stating what is needed and why, and the expected follow-up.
    • Timely feed-forward and feedback of information. Information should be exchanged as quickly as possible.
    • Agreement on informational elements that should be included in an “ideal transition record." These include:

    Clear Identification of PCP and Hub of Coordination

    Assessment of Caregiver Status

    Med List Reconciliation, Including Over-the-Counter & Herbal Supplements

    Ongoing Treatment and Diagnostic Plan

    Advance Directives, Powers of Attorney, Consents

    Test Results and Pending Results

    Prognosis and Goals of Care

    Emergency Plan and Contact Number and Person

    Planned Interventions Such as DME, Wound Care, etc.

    Patient’s Cognitive State

    Principle Diagnosis and Problem List

    Known Allergies and Drug Interactions

    • The involvement and awareness of the patient and family member, unless inappropriate, in all steps. Patients and families need to know who is responsible for their care at any given point and know who and how to contact them.
    • Establishing national standards. National standards should be established for transitions and implemented at the practice level. (See Developing Protocols for more information).
    • Measurement – Standardized measures related to these standards should be used to continuously improve quality and accountability. (See Step 6 below).

    Clarifying the Transition of Care Interaction Between Sender and Receiver

    Table comparing the roles of senders and receivers in transitions of care, across seven categories: Who, What, To Whom, When, Verify/Clarify, Act Upon, and How Documented. Both roles involve the accountable provider and patient and rely on documentation through paper records, EHRs, and checklists.

    Adapted from Transitions of Care Measures. (2008).  NTOCC Measures Workgroup.  www.NTOCC.org

    Define Care Management Role for Each Provider

    The American College of Physicians defines the following models of co-management:
    A vertical series of seven labeled semicircle gauges representing progression of co-management in care: from “No coordination” to “Fully Integrated Care,” showing increasing levels of engagement and collaboration.
    Pre-Consultation:

    Pre-consultation serves to expedite and prioritize care. It is used to answer a clinical question and/or to determine if  a formal consultation is necessary, facilitate timely access and determine the urgency for specialty referral or facilitate in the diagnostic evaluation of a patient prior to a specialty assessment. This category includes establishment of general referral guidelines and to help expedite timeliness and appropriateness of referrals as well as defining what qualifies as an “urgent” request and the manner to address them.

    Formal Consultation:

    Formal Consultation is an option when dealing with a discrete question or procedure. In this model, a request for an opinion and/or advice with a discrete question regarding the patient’s diagnosis, diagnostic results, procedure, treatment or prognosis. A detailed report and discussion of management recommendations would be provided to the PCP. The patient will be transferred back to the Primary Care Practice after the initial visits.

    Co-Management with Shared Management:

    In situations requiring shared management for the disease, the specialist provides guidance and ongoing follow-up of the patient for the specific condition in the form of expert advice, guidance and periodic follow-up for a specific condition. Both parties, primary care provider and specialist, define and agree on mutual responsibilities of care however the specialist does not manage the illness on a day-to-day basis.

    Co-Management with Principal Care for the Condition:

    In cases calling co-management with principal care for the disease, both the PCP and the specialist are concurrently active in the patient’s treatment. The specialist  assumes responsibility for the long-term, comprehensive management of a patient’s referred medical/surgical condition. The Primary care provider continues to receive consultation reports and provides input on secondary referrals and quality of life/treatment decision issues. The PCP continues to care for all other aspects of care and new or other unrelated health problems and remains the first contact for the patient

    Co-Management with Principal Care of the Patient for a Consuming Illness for a Limited Period:

    In this model, the specialist  temporarily becomes the first contact for care until the crisis or treatment has stabilized or completed. The PCP receives on-going treatment information, retains input on secondary referrals, and may provide certain, well-defined areas of care.

    Transfer of Patient to Specialty Medical Home for the Entirety of Care:

    In these cases, the specialist assumes the total care of the patient after consultation with the PCP and approval of the patient. The specialist provides first contact, ready access, continuous care and comprehensive and coordinated medical services with links to community resources.

    Enter into a Collaborative Agreement

    See Conversations and Collaborative Agreements for more information.

    Track Referral

    When patients are referred, continually track the referral through all steps to assure continuity of care (See Managing Referrals for more information).

    Review and Improve Care Coordination Process

    Periodically review and improve the process between the PCP and referral sources. Designate an interdisciplinary team representing all entities to agree on acceptable measures and tracking methods. Suggestions of areas to improve include:
    SIPOC diagram divided into three columns—Structure, Process, Outcome—listing key components such as accountable providers, care team processes, and patient health outcomes.

    Adapted from Transitions of Care Measures. (2008).  NTOCC Measures Workgroup.  www.NTOCC.org

    Care Team Processes:

    • Care planning (including advance directives)
    • Medication reconciliation (this process includes patient and family)
    • Test tracking (laboratory, radiology, and other diagnostic procedures)
    • Tracking of referrals to other providers or settings of care
    • Admission and discharge planning
    • Follow-up appointment tracking
    • End-of-life decision making

    Information Transfer & Communication:

    • Timeliness, completeness, and accuracy of transferred information
    • Protocol of shared accountability in effective transfer of information

    Patient & Family Education and Engagement:

    • Patient and/or family preparation for transfer
    • Patient and/or family education for self-care management
    • Patient and/or family agreement with the care transition (active participation in making informed decisions)
    • Appropriate communication with a patient with limited English proficiency and health literacy

    Once your care coordination protocols are defined conduct Quality Improvement analysis, such as Plan-Do-Study-Act, on areas needing improvement. (See Plan-Do-Study-Act PDSA for more information).

    Key Takeaway

    Co-management is a collaborative approach where primary care providers and specialty care providers work together to deliver comprehensive care for shared patients, especially when the patient’s needs exceed the primary care provider’s scope.

    This ensures timely consultations, effective communication, and coordinated care to improve patient outcomes, reduce service duplication, and enhance the overall quality and safety of care.

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