Continuity and Coordination of Care and Communication with the Primary Care Provider

Winter 2016/2017


High quality continuity and coordination of care can help maintain and improve a patient’s health through appropriate follow-up. Communication with the patient’s Primary Care Provider (PCP) following their visit to an Urgent Care Site or an Emergency Room, and when a patient is discharged from an inpatient facility, is a key aspect of continuity and coordination of care. Neighborhood Health Plan of Rhode Island’s (Neighborhood) claims data suggests there is room for improvement in communication with patients’ PCPs after an Emergency Room, Inpatient or Urgent Care Visit.

When a patient is discharged from these settings, we encourage providers to inform the patient’s PCP site about the patient’s plan of care. Additionally, explaining to the member why follow-up is necessary within a certain timeframe will motivate the patient to see their PCP. If the member does not have or know how to contact their PCP, the member can call Neighborhood Member Services for assistance connecting with their PCP. Members can find their Member Services phone number for their plan on their Neighborhood member ID card.