Conversations and Collaborative Agreements

Collaborative agreements are verbal or written compacts between a Primary Care Provider and a referral source that specify the types of patients referred, types of referral, consultation, or co-management arrangements available.
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

    Collaborative agreements are verbal or written compacts between a Primary Care Provider and a referral source that specify the types of patients referred, types of referral, consultation, or co-management arrangements available. They further define testing to be completed prior to referral, availability for “curbside consults”, and who is accountable for which processes and outcomes of care. These agreements also outline post-consultation care expectations, as well as those regarding the information content requirements and the frequency and timeliness of bi-directional information flow. When applicable, collaborative agreements spell out how secondary referrals are to be handled along with in-patient processes, including notification of admission, data exchange, and transfers into and out of the hospital. To ensure their continued relevance and accuracy, collaborative agreements should also include a mechanism for regular review of their terms and a mechanism for all persons to periodically evaluate each other’s cooperation with the terms of the agreement.

    Collaborative Agreements are 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

    The Steps Towards Collaborative Agreements

    Select Referral Partners

    Identify specialists, hospitals and community service agencies that the practice and patients use most and who have been a good track record as a referral partner. Select one or two to begin the conversation and strengthen the relationship.

    Engaging in Conversation and Refining Collaborative Agreement

    Discuss each party's preferences and expectations about which patients to refer, the information to send and care arrangements after consult. Consider the following:
    Referrals
    • Does the specialty provider have existing protocols for the types of patients they will see?
    • Are their other referral guidelines that provide guidance?
    • Is there an interest to develop specific educational guidelines between PCPs/Specialists to support the referral process?
    • How will secondary referrals to another specialist take place?
    Types of Management (See Step 3 Below)
    • Are there additional types of Care Management Roles that should be included?
    • How is clear designation of care responsibility and accountability expressed in the progress notes?
    • Are there changes to be made so all parties interpret their roles the same way?
    Patient Communication
    • Does the patient have a specific set of needs or plan for the visit?
    • Does a system exist to identify issues or barriers that prevent the patient from following through on care recommendations?
    • How will the patient be prepped for their next visit?
    • How will the provider parties communicate patient wishes?
    Patient Transition Record
    • What items/elements of the clinical record will be shared?
    • What information transfer modality will be used?
    Timeliness of Patient Appointment. Example:
    Emergent:

    Within 24 hours

    Urgent:

    Within 1 week

    Priority:

    Within 2 weeks

    Routine:

    Within 8 weeks

    Elective:

    Before next visit

    Verbal and Written Communication
    • What is an acceptable period of time to receive verbal and/or written communication?
    • Timeliness of follow-up conversations and reports.

    Define Care Management Role for Each Provider

    Define the different roles for care management between the Primary Care Provider and the referral source. 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.

    Draft a Collaborative Agreement

    Here's an example of a general collaborative care agreement.
    A structured list titled "Sample Care Coordination Agreement – Referrals, Consults, Co-Management: General: for all patients" outlining responsibilities of the Primary Care Practice. It includes sections on preparing the patient, providing referral details, indicating urgency, and communicating with specialists.
    A continuation of the care coordination agreement titled "Subspecialty/Specialty (Neighbor) Practice Agrees to," listing expectations for triaging referrals, sharing information, managing secondary diagnoses, and notifying the referring primary care practice.

    Periodically Review and Improve the Process Between the Entities

    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. .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, or PDSA, for more information).

    Key Takeaway

    Collaborative agreements enhance communication, clarify roles, and streamline care coordination between primary care providers and referral sources, leading to more timely referrals, improved patient outcomes, and reduced service duplication.

    Some questions to consider:

      • Who will be responsible for maintaining and reviewing the terms of your collaborative agreements?
      • How can you work to ensure timely and bi-directional information exchange with referral partners?

    How Can We Help Your Team Work?