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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?


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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