We all know that the delivery of healthcare today is far from perfect, but  it is important for us to remember that our primary focus is the patient. One of the best ways we can ensure that we are delivering quality care is to improve coordination. 

Coordination of care seems to be one of the most challenging aspects of patient care which is mostly due to a lack of communication and effort on the part of the involved providers. Why is coordination of care so difficult to master? Ownership. It is easy for a patient to go to their primary physician for a visit and then go to the pharmacy for a prescription. But once that patient needs to be admitted to the hospital or referred to a specialist, the ownership of their care starts to become confusing. Then you add in the many complexities of insurance and the lines of responsibility really start to blur.

I recently read a study by the Center for Studying Health System Change (HSC)  where they documented strategies that a range of physicians used to coordinate patient care. The study validated that although there is not a perfect method of coordinating care, there are strategies that can help make the process stay effective.

Through this study,  I learned there were essentially 5 ways to improve the coordination of patient care.

1. Designate qualified staff

Coordination of care involves both clinical and non-clinical tasks and more often than not staff members are not qualified to handle all aspects of the process. It is important that the individual responsible has enough clinical training to understand the needs of the patient. The referral coordinator, as often referred to, should, at the minimum, be able to coordinate authorizations for care, assess patient education needs, setup care with other providers and counsel the patient on next steps. This role can also be delegated to several individuals and those roles need to be clearly defined so that information does not fall through the cracks.

2. Provide or request for sufficient referral information

As a home health care provider,  I have often received referrals with little or no background information such as previous history. It is critical that you include referral information in their process to ensure the receiving providers get all the information necessary to transition care. Typically this information would include items such as reason for the referral, a history and physical, patient demographic information, medication profile and allergies, discharge or referral instructions, and physician contact information.

3. Provide specific discharge or referral  instructions

Once you refer or discharge a patient , both the patient and receiving provider should understand exactly what you want done to ensure that miscommunication does not exist. Referral instructions should also include follow ups such as summary reports to ensure you know exactly what is going on with your patient.

4. Establish relationships with other providers

It is also good idea to start making relationships with other providers. This will enable you to obtain information more efficiently once you communicate your preferences and processes. Once you become familiar with another provider, the transfer of information becomes smoother.

5. Involve the patient

It sounds simple but it is so often ignored. The patient is your key to effective coordination. Your staff can be flawless; however if your patient does not understand what needs to be done, the process comes to a halt. Communicate your expectations and next steps to the patient to make them responsible for their own care. Once they feel responsible, they are more likely to carry out your instructions. So, EDUCATE, EDUCATE, EDUCATE!

Coordination of care, for all providers, is difficult because there are so many of us involved in the process. There are several strategies you can adopt to help make it run smoother, but the most important factor is communication. We all have a responsibility to communicate with each other to ensure our patients are getting the care they deserve.

What are other strategies that have worked for you?