GE Healthcare Camden Group Insights Blog

Coordinating Care Across the Continuum

Posted by Matthew Smith on Aug 19, 2014 12:19:00 PM

By William K. Faber, MD, MHCM
Chief Medical Officer
Health Directions

Continuum of CareQuality and value in health care are driven not just by excellence in discreet locations of care, but in the coordination of care between sites and practitioners. Quality health care is the result of a team effort rather than the talents of individuals. Many of the failures of health care occur during the transitions between the doctor’s office and the hospital, or between the hospital and home, or between doctors’ offices. Value in health care is driven in large part by two major factors: selecting the appropriate site of care and the quality of the communication between the sites of care.

The Continuum

The “continuum of care” is a current buzz phrase in health care. It acknowledges that people need different kinds of health care services throughout their lives and that not all of this care needs to be delivered at the hospital, which is the most expensive place to receive care. We can think of health care as a spectrum of services that start with primary prevention (e.g. immunizations) and progresses to secondary prevention (e.g. medicines to lower cholesterol), diagnostic services, outpatient treatment, inpatient (hospital) treatment, rehabilitation services, skilled nursing services, home health, palliative care and hospice. To control the cost of care, we should ask “what is the lowest cost setting in which we can deliver the needed care with excellence?”

Examples of care delivered in unnecessarily expensive sites include: giving IV antibiotics in the hospital when they could be given at home or in a skilled nursing facility, certain surgeries being done in a hospital when they can now be done well in ambulatory surgery centers, utilization of urgent care centers when the same care could be delivered in a regular doctor’s office, and palliative care at the end of life in an intensive care unit instead of a hospice. Over the past 20 years, many services have migrated out of the hospital to the benefit of the consumer. Hospitals have to pass their high overhead on to patients in the form of charges. Hospitals should be reserved for care that can be competently delivered nowhere else.

It is incumbent on systems that would provide high quality, low cost care to actively select and direct patients to the best place of care for their need. Guiding patients to the best site of care is rightfully the role of primary care providers and care managers.


Even if we are successful in differentiating care into cost effective locations, and are additionally successful in guiding patients to the most cost effect sites, we are left with the challenge of seamlessly handing off patients (and all pertinent information about them) between those facilities and practitioners. Imagine transporting sand from one bucket to another using your hands alone. Some of the sand falls between your fingers in transition. Think of the sand as bits of medical information as a patient is transported from one site of care to another. 

Examples of waste and risk that result in from poor transitions include: repeating an expensive test, such as an MRI, because the second facility does not know that the first facility already did one; patients getting home without knowing the change in the dose of the medications they see on their kitchen counter; and the results of a test done in the hospital which come back after the patient has left which never get reported to the patient. Countless tests get reordered for want of solid transition management. Thousands of patients get unnecessarily readmitted to the hospital each year because they are confused as to what they should do after leaving the hospital.

The Solution: Care Coordination

Healthcare is complex and disjointed. Traditional payment systems reward the efforts of individuals. Emerging forms of payment challenge us to invest in new, patient centered services that provide the “glue” between individual services. Care coordination can be enhanced by the use of care managers, information system integration, handoff protocols, and discharge instructions.

Care Management: Care management takes many forms: disease managers, hospital discharge planners, social workers, office based care managers, insurance company care managers, individual doctors and nurses, and family members. Ironically, care management often stops at the boundaries of the entity that is paying for the care.

The gold standard in patient-centered medical care would be for one, primary care manager to be linked to a patient and his or her family to assist in navigation regardless of the hospital system, form of insurance or phase of care. This one person would be well known and trusted by the patient, take global responsibility for the well-being of the patient and would be on “speed dial” for the patient and his or her closest family members.

The greater the breadth of the care manager’s involvement, the more effective they will be in reducing waste and risk. Care managers should be concerned with the very practical issues of transportation and financial resources for the patient.

Referrals to specialists or outpatient tests are useless if the patient does not have a ride. Prescriptions are useless if the patient cannot afford them or take them.

Information Systems: Even though most systems and providers have now converted to electronic health records, the dream of digitized information has not yet been realized, because systems do not automatically “talk to” one another. Some providers use their EHR as a dictation service and do not create structured notes with searchable fields of information. Provider concerns for privacy puts a block on the free exchange of information between parties who would benefit from the free flow of information. Hospitals and physician offices are often on different EHR platforms. Some of this can be overcome by campaigns to get patients to sign releases to share information. Some can be overcome through the use of Health Information Exchanges (HIEs), and some of this can be overcome through “push” messaging or protocols that prompt providers to send notes to important recipients on the team in a timely manner.

For instance, a system could adopt and support policies that patients being discharged from the hospital should have a follow up appointment in their PCP’s office within three days of discharge before they even leave the hospital with a complete discharge summary in the hands of that PCP before the patient arrives. A complete discharge summary would list all new medicines, changes in medication dosages, all new diagnoses, all significant procedures and test results and all pending test results and recommended post-hospitalization testing and specialty appointments.

Similarly, Primary Care Providers should communicate with the Emergency Department and or hospitalist team whenever they are aware of one of their patients who is heading to the hospital, to fill that doctor in on what medications the patient is taking, what tests have already been done, and the psychosocial context of the trip to the hospital. Is this the seventh time the patient has gone to the ER for chest pain in the past three months, despite repeated negative workups for cardiac disease? The best information systems allow inpatient providers to and outpatient providers to directly access the same unified electronic record.

About the Author

William K. Faber, MD Health DirectionsDr. William K. Faber, Chief Medical Officer for Health Directions, is a physician executive with progressive senior leadership experience. He most recently served as Senior Vice President of the Rochester General Health System in New York, where he guided the development of the system’s Clinical Integration program and assisted more than 150 providers at 44 sites through the conversion process from paper records to an Electronic Health Records system (Epic). Dr. Faber formerly participated in the governance of the Advocate Physician Partners (APP) Clinical Integration program and directed APP’s Quality Improvement Collaborative.


Clinical Integration, Health Directions, Clinically Integrated Network

Topics: Continuum of Care, Care Management, William K. Faber MD; Primary Care Provider

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