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

Continuity of care is a defining attribute of primary care and a core element of the Institute of Medicine’s definition of primary care. Continuity is generally recognized to have three dimensions: continuity in information; in management; and the physician-patient relationship. Relationship continuity is the ongoing interaction of a patient with one physician, which results in increased knowledge of patient preferences, better communication, and improved trust.

Such outpatient continuity has shown to be associated with improved patient satisfaction, increased use of appropriate preventive health services, greater medication compliance, lower hospitalization rates, more appropriate end of life care, and lower 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 crucial 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, an Urgent Care or Inpatient 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 specific 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.