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Care Coordination

Engaged patients lead to improved clinical outcomes. For example:

  • Patients who understand their doctors are more likely to acknowledge health problems, understand their treatment options, modify their behavior accordingly and follow their medication schedules.1
  • Patient-centered communication has a positive impact on important outcomes, including patient satisfaction, adherence to recommended treatment and self-management of chronic disease.2
  • Patient communication improves clinical outcomes in the management of diabetes, hypertension and cancer. 3

Survey Measures Background: What is CAHPS?

  • Typically mailed each year to plan members between March and June
  • Asks members about aspects of quality, such as provider communication skills and ease of healthcare services
  • Overseen by the Agency for Healthcare Research and Quality

Group Best Practices

  • Encourage patients to respond to survey.
  • Develop a new patient onboarding program that covers important access-to-care issues, including urgent care and referrals.
  • Have an after hour on-call system available (nurse advice line, physician on call).
  • Provide non-traditional care access options, such as an e-portal with self-service capabilities and a 24-hour nurse advice line.

CAHPS Asks Patients

In the last six months:

  • When you visited your personal doctor for a scheduled appointment, how often did he or she have your medical records or other information about your care?
  • How often did you and your personal doctor talk about the prescription medicines you were taking?
  • When your physician ordered a blood test, x-ray or other test for you, how often did someone from your personal doctor’s office follow up to give you those results?
  • When your personal doctor ordered a blood test, x-ray or other test for you, how often did you get the results as soon as you needed them?
  • How often did your personal doctor seem informed and up to date about the care you got from specialists?
  • Did you get the help you needed from your personal doctor’s office to manage your care among these different providers and services?

SCAN_5Star_CareCoordination_Fig01

PCP Best Practices

You probably know all relevant information about your patients’ medical history – but do your patients know you know? Make sure they do – it’s a quick way to improve patient satisfaction with doctor-patient  communication.

  • Ask if patients have seen any other If you are aware specialty care has occurred, mention it and discuss as needed.
  • Tell your patients when they should expect test results and who will give them the results – a staff member, your medical assistant, you?
  • Let patients know when test results are normal and tell your patients they can call your office if they still want to check results.
  • If your practice offers a patient portal, encourage web-savvy patients (or caregivers) to make use of it so they can stay on top of their care.
  • Encourage patients to bring in their medications to each visit.

Group Best Practices

  • Integrate PCP and specialist offices through electronic medical record or fax to get patient reports in a timely manner.
  • Identify high-risk patients and help coordinate care through case management and care navigation programs.

 

1Stewart MA. Effective physician-patient communication and health outcomes: a review. CMAJ. 1995;15(9):1423-1433.
2S, Kaplan S, Ware JE Jr.. Expanding patient involvement in care: effects on patient outcomes. Ann Intern Med. 1985;102(4):520–8.
3Doctor-patient communication and satisfaction with care in oncology. Curr Opin Oncol. 2005;17(4):351–4

 

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