Instant Replay—A Quarterback`s View of Care Coordination

The
NEW ENGLA ND JOURNAL
of
MEDICINE
Perspective
august 7, 2014
Instant Replay — A Quarterback’s View of Care Coordination
Matthew J. Press, M.D.
A
s a general internist, I often serve as the quarterback for my patients’ care — helping them
navigate the system, advocating on their behalf,
and coordinating their evaluation and treatment.
But for one of my patients, the
game was played on a whole different level.
Mr. K. was a stoic 70-year-old
with a few minor medical problems. His care was fairly straightforward — I was the only doctor
he saw regularly — until the day
he came into my office with flank
pain and fever. A CT scan of his
abdomen revealed a kidney stone
— and a 5-cm mass in his liver,
which a subsequent MRI indicated was probably a cholangiocarcinoma.
Over the 80 days between when
I informed Mr. K. about the MRI
result and when his tumor was
resected, 11 other clinicians became involved in his care, and he
had 5 procedures and 11 office
visits (none of them with me). As
the complexity of his care increased, the tasks involved in coordinating it multiplied. I kept a
running list and, at the end, created an “instant replay” of Mr. K.’s
care (see diagram; also see animation, available with the full text of
this article at NEJM.org). In total,
I communicated with the other
clinicians 40 times (32 e-mails and
8 phone calls) and with Mr. K. or
his wife 12 times. At least 1 communication occurred on 26 of the
80 days, and on the busiest day
(day 32), 6 communications occurred.
This instant replay offers a
chronicle of the coordination that
was required to help ensure that
Mr. K.’s ambulatory care was delivered safely and effectively. Care
coordination is now a high priority in health care and is the backbone of new models of care, such
as accountable care organizations,
that aim to improve quality and
reduce costs. But it remains an
abstract concept to many people
who are not on the front lines of
clinical care, as well as to some
on the front lines who lack (or
don’t want to have) the quarterback’s view of the field. In replaying the highlights, we can learn
some important lessons about
care coordination.
The first is that care coordination is not just a value proposition
(higher quality, lower costs) but a
patient-safety issue. Patients can
be harmed when the many moving parts of their care are out of
sync.1 We owe it to them to coordinate the care we provide and
n engl j med 371;6 nejm.org august 7, 2014
The New England Journal of Medicine
Downloaded from nejm.org on November 20, 2016. For personal use only. No other uses without permission.
Copyright © 2014 Massachusetts Medical Society. All rights reserved.
489
PERS PE C T IV E
Instant Replay — a view of Care Coordination
Phone call
E-mail
Procedure
Office visit
Surgeon
Hematologist
Neurologist
Urologist
PCP
Patient
Gastroenterologist
Interventional
radiologist
Lab
Social worker
Oncologist
Cardiologist Pathologist
Ambulatory Care Coordination for One Patient.
Over an 80-day period, 12 clinicians were involved in the care of the patient. The patient’s primary
care physician (PCP) communicated with the other clinicians 40 times (32 e-mails and 8 phone calls)
and with the patient (or his wife) 12 times. The patient underwent 5 procedures and had 11 office
visits (none of them with his PCP). (An animated “instant replay” is available with the full text of
this article at NEJM.org.)
prevent this type of medical error.
For example, on day 32 of Mr.
K.’s care, a Friday, I noticed some
new electrolyte abnormalities on
laboratory tests done before an
interventional radiology procedure. First I called the cardiologist who had seen Mr. K. earlier
that week, after I learned from
An animation
the electronic medical
is available at
record (EMR) that he
NEJM.org
had prescribed a new
antihypertensive. Then I called Mr.
K. to arrange to have his electrolytes rechecked, which had to be
done at an outside laboratory because by then it was the weekend
(this took two calls to the laboratory — one to schedule and one
for the results). On Sunday, I had
Mr. K. change medications and on
Monday asked the interventional
radiology nurse practitioner to recheck the labs again before the
procedure (two more calls). On day
490
36, she did, and the electrolytes
had normalized.
The second lesson is that the
way we’ve viewed health care
teamwork in the past (in single
clinical settings, such as operating rooms, intensive care units,
and primary care offices) needs
an update. Given changes in the
way health care is delivered and
financed, teamwork today must
encompass multiple clinical settings, where team members might
not see or know each other. For
example, on day 76 of Mr. K.’s
care, I sent an e-mail to his urologist (cc-ing his surgeon) to alert
him about kidney stones on a recent CT scan and about Mr. K.’s
upcoming tumor resection. On
day 79, the urologist let me know
that he and the surgeon had communicated and made a plan to
stage their procedures (first ureteral stent placement, then re-
n engl j med 371;6
nejm.org
section). Both procedures went
smoothly on day 80, and Mr. K.
did well postoperatively.
Teamwork spanning health
care settings is particularly challenging. Research from the field of
organizational science has shown
that conflict is greater within
“distributed teams” than within
co-located teams because their
members are less familiar with
one another and don’t necessarily
have a shared context or shared
norms.2 Overcoming these challenges requires a system designed
to support and facilitate collaboration.3 Health information technology (e.g., shared EMRs and
electronic messaging) is part of
the solution (I used e-mail far
more often than the phone), but
it is not a panacea. Similarly, assigning care coordination to nonphysician staff members, such as
care managers, is appropriate for
some tasks and may benefit patients, but in many instances —
including my e-mail to Mr. K.’s
urologist and surgeon — communication must be physician to physician. Therefore, our workflow
needs to be structured to allow
time for communication with each
other, and our reimbursement system should recognize the value
of this aspect of care. I was able
to play the role I did in Mr. K.’s
care largely because, as a clinician-researcher, I had a patient
panel about one tenth the size of
the average primary care panel.
The goal should be to make coordination and collaboration feasible
for full-time clinicians, too.4
But even a perfectly designed
system will not make up for one
ingredient that’s essential to effective teamwork across care settings:
relationships. Having a relationship with another clinician makes
it easier to communicate because
the social barrier is lower and
august 7, 2014
The New England Journal of Medicine
Downloaded from nejm.org on November 20, 2016. For personal use only. No other uses without permission.
Copyright © 2014 Massachusetts Medical Society. All rights reserved.
PE R S PE C T IV E
opportunities to communicate are
more frequent. But some changes
in health care may be causing relationships to deteriorate. EMRs
and the use of hospitalists probably have led to fewer personal
interactions among physicians,
and the consolidation of physician practices and changes in insurance participation can affect
referral networks.
I did not have relationships
with most of Mr. K.’s other clinicians when his care began, so
I reached out to them early and
often to establish connections. I
believe these connections instilled
a sense of mutual accountability,
helping to mitigate the potential
for a bystander effect.5 Part of
Instant Replay — a view of Care Coordination
my job as quarterback is to make
sure the other players know
where the ball is and what routes
each player is running. But everyone has to come to the huddle
willingly. Fortunately, providing
care collaboratively is more enjoyable than staying alone in our
silos. I considered it a mark of
successful teamwork when Mr.
K.’s surgeon sent me an e-mail
on day 80 saying, “Tumor is out!”
No one knows for sure how Mr.
K.’s case would have played out
without effective care coordination. But this instant replay reveals that there is only one way
for physicians to confront the
perilous nature of complex care:
together.
Disclosure forms provided by the author
are available with the full text of this article
at NEJM.org.
From the Departments of Healthcare Policy
and Research and Medicine, Weill Cornell
Medical College, New York.
1. Improving America’s hospitals: the Joint
Commission’s annual report on quality and
safety, 2007 (http://www.jointcommission
.org/assets/1/6/2007_Annual_Report.pdf).
2. Hinds PJ, Bailey DE. Out of sight, out of
sync: understanding conflict in distributed
teams. Organization Sci 2003;14:615-32.
3. Press MJ, Michelow MD, MacPhail LH.
Care coordination in accountable care organizations: moving beyond structure and incentives. Am J Manag Care 2012;18:778-80.
4. Bodenheimer T. Coordinating care — a
perilous journey through the health care system. N Engl J Med 2008;358:1064-71.
5. Stavert RR, Lott JP. The bystander effect in
medical care. N Engl J Med 2013;368:8-9.
DOI: 10.1056/NEJMp1406033
Copyright © 2014 Massachusetts Medical Society.
Toward Increased Adoption of Complex Care Management
Clemens S. Hong, M.D., M.P.H., Melinda K. Abrams, M.S., and Timothy G. Ferris, M.D., M.P.H.
M
any observers of U.S. health
care are now convinced
that improved management of the
care of patients with complex,
high-cost conditions is an essential part of the solution to our
health care cost problem. Increasing evidence supports the use of
specially trained, primary care–
integrated, complex care management (CCM) teams to improve
outcomes and reduce costs by
addressing the needs of the
small proportion of patients who
account for a majority of health
care expenditures.1 For example,
for successive cohorts of highrisk patients from 2006 through
2012, Massachusetts General Hospital achieved savings of 4%, 8%,
and 19% by pursuing a CCM approach.2 CCM is a nearly universal element of the strategies used
by providers accepting financial
risk under Medicare’s account-
able care organization contracts.3
Even as the momentum builds,
however, substantial financial
and nonfinancial barriers to more
widespread adoption remain.
The fee-for-service payment system is the most significant barrier to CCM adoption. CCM services are not easily separated into
discrete, reimbursable units. Even
when these services are disaggregated, most are not currently reimbursed. Providers, therefore,
have little incentive to adopt CCM.
In fact, when these programs are
affiliated with hospitals, the fact
that effective CCM reduces the
rate of hospitalization creates a
financial disincentive. Although
it might be possible to pay for
CCM on a fee-for-service basis,
global-payment or shared-savings
approaches that reward reductions in avoidable health care
utilization are clearly preferable.
Providers that are reimbursed
through contracts that hold them
accountable for costs of care (either total medical expenses or
changes in total medical expenses) have an incentive to implement
CCM. Many providers, however,
remain unable to commit to such
contracts. Fortunately, incremental payments used in conjunction
with traditional fee-for-service
systems can feasibly support CCM.
In such a hybrid model, payers
provide a care management fee
(typically a per-member-per-month
payment) to cover the costs of
the CCM, and the provider is at
risk only for the management fee.
This approach provides an incentive to reduce avoidable use of
services without requiring the
provider to take on risk for the
total costs of care for its patient
population. Contracts under which
providers take on risk for care
n engl j med 371;6 nejm.org august 7, 2014
The New England Journal of Medicine
Downloaded from nejm.org on November 20, 2016. For personal use only. No other uses without permission.
Copyright © 2014 Massachusetts Medical Society. All rights reserved.
491