The Role of Primary Care Staff in Coordinating Care for Patients with Complex Medical Conditions

According to the Centers for Disease Control and Prevention, 6 in 10 American adults have one chronic disease, such as heart, lung, or kidney disease; cancer; Alzheimer's disease; and diabetes, and 4 in 10 have two or more. These patients see more physicians across care settings, experience more transitions of care, and suffer more adverse events than those without chronic conditions.  

Care transitions and coordination can be a vulnerable time for patients, and many find themselves relying on patient navigators or advocates to help them manage their care.  

According to a 2020 survey published in the Journal of General Internal Medicine, nearly 40% of respondents reported at least one gap in care coordination and nearly 10% reported at least one preventable outcome such as repeat tests, medication interactions, and emergency department visits.​​  

In response to this concerning trend, ECRI addressed the consequences of poor care coordination for patients with complex medical conditions in its Top 10 Patient Safety Concerns for 2023. 

Give​n that more than 883 million office-based physician visits occur annually in the United States, compared with about 36.5 million hospitalizations, care coordination challenges in the ambulatory care environment may surpass those encountered in acute care. Therefore, in addition to ensuring accurate medication reconciliation, primary care leaders and providers can implement the following strategies to help alleviate some of these challenges. 

Leaders can prioritize care coordination improvement initiatives by: 

• Establishing multidisciplinary care coordination teams consisting of physicians, nurses, pharmacists, social workers, patient navigators, and community health workers across the healthcare continuum in their local community. 
• Fostering collaborative strategies to build mutual trust among primary care, specialists, hospital, and postacute care staff (e.g., regular meetings among staff at various healthcare sites, routine discussions of handoff and transfer challenges). 
• Providing education and training on effective handoff communication techniques (e.g., SBAR [situation, background, assessment, recommendations]) and teamwork skills (e.g., TeamSTEPPS) for staff.  
• Ensuring that the organization has a system for tracking diagnostic tests, emergency department visits, hospitalizations, and referrals. 
• Standardizing processes related to scheduling appointments and following up on missed visits and referrals. 
• Working with the information technology department to ensure the interoperability of electronic health record systems so that information can easily be transferred between points of care. 
• Analyzing feedback from patients and their families regarding the care experiences. 
  

Primary care providers and staff can prioritize care coordination improvement initiatives by: 

• Conducting warm handoffs between patients and providers at other care facilities.  
• Engaging patients and their families in shared decision-making and advance care planning. 
• Promoting equitable, person-centered care, especially for patients at higher risk of poor outcomes related to gaps in care coordination.  
• Ensuring patients understand how to access patient portals to review medications and visit notes
  

Want to learn more about this issue and other top concerns? View ECRI's Top 10 Patient Safety Concerns for 2023 or reach out to an ECRI expert for further assistance.