• Research Points to Five Lessons for Ensuring Seamless Health Care

    FOR IMMEDIATE RELEASE: Tuesday, Sept. 15, 2015

    Leslie Champlin
    Senior Public Relations Strategist
    (800) 274-2237, Ext. 5224

    WASHINGTON, DC — The promise of creating a seamless health care system depends on patient care coordination services that establish a strong relationship with both patients’ medical teams and that share real-time data between inpatient settings and physicians.

    Those are two of the five lessons gleaned from a review of Centers for Medicare & Medicaid Services care coordination demonstrations, published in the September-October issue of the Journal of the American Board of Family Medicine. 

    Winston Liaw, MD, MPH, researcher with the Robert Graham Center for Policy Studies in Family Medicine and Primary Care, and his colleagues looked at the processes and outcomes of CMS care coordination demonstrations over the past 10 years. Not all demonstrations produced anticipated efficiency results, but several programs did succeed, Liaw reported in “Lessons for Primary Care from the First Ten Years of Medicare Coordinated Care Demonstration Projects.”

    Liaw and his coauthors studied the characteristics of the successful demonstrations and distilled them into five lessons:

    • Foster relationships with both physicians and patients
    • Track patients across all medical settings in real time
    • Minimize expenses by sharing resources and avoiding cost-ineffective interventions
    • Concentrate on the most complex patients who are at high risk of using intensive services
    • Extend rather than duplicate the efforts of primary care practices

    Although health care providers can control costs by sharing care coordination services with other practices and facilities, successful programs stressed the importance of having coordinators in the physician office, according to Liaw’s research.

    “A lot of places foster good relationships with patients but not necessarily with the providers,” Liaw said in an interview. “Our review found the demonstrations that did the best had integrated the coordinators into the physician office” because personal and ongoing communication with doctors and nursing staff ensured the coordinators had a complete understanding of complex patients’ needs. Moreover, such communication ensured that coordinators knew when follow-up services have been provided and avoided duplicating the work already completed by the physician and office staff.

    Equally important, Liaw said, was real-time communication among physicians, hospitals, long-term care facilities and other settings.

    “This means (the health care system) must have interoperable electronic health records,” Liaw said. “A lot of the projects started in the early 2000s. They didn’t have EHRs, and of those that did, most weren’t interoperable. So the physicians had no access to their patients’ hospital records. If their patient was admitted to the hospital, they often didn’t know about it until after the fact – sometimes as long as a few months later.”

    Equally important is ensuring that care coordination services are targeted to patients who have the greatest need and use the most services, according to Liaw.

    “Care coordination holds great promise,” Liaw said. “In order to harness the potential of care coordination, we need to look at these five lessons that we took from successful pilots. When these five principles are in place, care coordination will be successful.



    About the Robert Graham Center

    The Robert Graham Center for Policy Studies in Family Medicine and Primary Care works to improve individual and population health by enhancing the delivery of primary care. The Center staff generates and analyzes evidence that brings a family medicine and primary care perspective to health policy deliberations at local, state, and national levels.

    Founded in 1999, the Robert Graham Center is an independent research unit affiliated with the American Academy of Family Physicians (AAFP). The information and opinions contained in research from the Center do not necessarily reflect the views or policy of the AAFP.