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


Continuity of care has been conceptualized as a fundamental aspect of primary care since the resurgence of family practice more than 3 decades ago.

There is evidence for a positive effect of continuity of care on both physician and patient satisfaction with care and patient adherence to medical regimens, emergency department and hospital utilization, overall service utilization and cost.

Communication with the patient’s Primary Care Practitioner (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 (NHPRI) 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. Also we encouraged collaboration between the care team,   aftercare provider prior to discharge, medication reconciliation; enhanced patient education and empowerment; home visits or telephone calls by clinical providers, transitional care managers and early post-discharge follow-up. Patient instructions should take into account the patient’s cognitive status, health literacy, and other barriers to self-care. Multiple concurrent interventions may be more effective than single components.

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 Service phone number for their plan on their Neighborhood card.

All of these initiatives have shown promise in minimizing readmission and increase patient satisfaction.