Newswise — PHILADELPHIA, April 24, 2015 – Primary-care physicians play a pivotal role in assuring that patients who require specialized care are transitioned properly from one clinical environment to another to help lower the risks for adverse events and repeat hospitalizations, according to a health quality management expert who spoke today at the National Quality Summit sponsored by the National Association for Healthcare Quality (NAHQ,

Transitions in care can be broadly defined as practices implemented across the continuum of care, such as within a healthcare delivery organization, across settings (e.g. acute to post-acute) and within a community or population. For its first-ever National Quality Summit, NAHQ assembled a prestigious roster of health quality authorities to discuss best practices for assuring favorable outcomes at every stage in the care transitions continuum.

In 2009, the Journal of Hospital Medicine reported that 1 in 5 patients discharged from a hospital to the home experienced an adverse event within three weeks, and the National Quality Forum found that preventable hospital readmissions that occur within 30 days of discharge cost Medicare $15 billion a year. Further, according to the Annals of Internal Medicine, the cost of poor discharge planning is estimated between $14 and $44 billion a year.

“Implementing strategies to lower hospital readmission rates is critical for improving quality and patient safety and reducing healthcare costs. Numerous studies have shown that quality transitions in care are one method to reduce readmission rates,” said NAHQ Summit Chairman Eric A. Coleman, MD, MPH, professor of medicine and director of the Care Transitions Program at University of Colorado Anschutz Medical Campus.

Summit speaker Neil Kirschner, Ph.D., senior associate, regulatory and insurer affairs, American College of Physicians, said Medicare and other health insurance providers expect primary-care practitioners and specialists to be responsible for managing care transitions. No small task, says Kirschner, considering a typical doctor deals with more than 100 different medical practices.

“Care-transitions management is not easy and has to be a team effort involving the primary-care provider and support staff, as well as appropriate specialists, health care facility administrators and patients and caregivers,” said Kirschner.

The Patient Centered Medical Home The American College of Physicians represents more than 141,000 internal medicine physicians and subspecialists and has developed, in collaboration with the American College of Physicians, American Academy of Family Practitioners, American Academy of Pediatrics and American Osteopathic Association, an integrated care delivery model, called Patient Centered Medical Home, through which patient treatment is coordinated through the primary care provider to ensure patients receive the necessary care when and where they need it.

“The objective of the Patient Centered Medical Home is to have a centralized setting that fosters partnerships between patients (and families and caregivers when appropriate) the primary care team of professionals and rest of the medical neighbors involved in the patient’s care,” Kirschner explained. “The PCMH team is responsible for taking care of all of the patient’s health care needs and assuring that, when necessary, appropriate care is arranged with other providers. This includes care for all stages of life – acute care, chronic care, preventative services and end-of-life care.”

Kirschner said, above all, the PCMH model is designed to optimize quality and patient safety and assure that care transitions are managed properly and cost-effectively. Core elements of the PCMH include:

• Patients have ongoing relationships with the PCMH team of clinical professionals, which provides first contact and continuous and comprehensive care• The PCMH team is responsible for providing all of the patient’s health care needs or for arranging care with other qualified professionals• Care is available across all elements of the healthcare system, and the PCMH team ensures their patients receive appropriate care when and where they need it• Quality and safety are optimized by having patients involved in decision making, using evidence-based medicine and clinical decision support tools, and expecting doctors to be accountable for continuous quality improvement• Enhanced access to care is provided through open-access scheduling, expanded hours and e-consults.

Kirschner said the ACP has developed a High Value Care Coordination Tool Kit to foster more effective and patient-centered communication between primary care and specialist doctors. The tool kit provides referral information checklists, recommendations on how to prepare a patient for a referral, specific information to include in referrals for various conditions, and a care coordination template agreement between primary care and specialist practices. Kirschner believes the tool kit helps facilitate seamless, coordinated, high-quality care by assuring clear communication between personal physicians and specialists.

“The effectiveness of the PCMH model for coordinating care by specialists requires the various providers to be aligned with the goals of the PCMH care model,” said Kirschner. “Primary care practices should develop relationships with neighbor specialty providers who will work with PCMH practices to coordinate care, improve consultations and co-management of patients, and create seamless transitions for patients as they move through different components of the health care system.”

Health insurance providers also have a stakeholder role in the PCMH model, according to Kirschner. “Payers are recognizing the added value provided to patients who belong to PCMC practices,” he said. He said the American College of Physicians advocates that the most effective way to re-align payment incentive to support the PCMH model would be to combine traditional fee-for-service for office visits with a structure that includes a monthly care coordination payment covering physician and non-physician work outside the office visit and performance-based fees linked to quality, efficiency and patient experience measures.

“There is substantial data showing that the PCMH model is associated with improved outcomes and lower overall costs of care,” said Kirschner. “It’s good medicine and good business.”

About NAHQFounded in 1976 and covering a full spectrum of healthcare specialties, the National Association for Healthcare Quality (NAHQ) is an essential and interactive resource for quality and patient safety professionals worldwide. NAHQ’s vision is to realize the promise of healthcare improvement through innovative practices in quality and patient safety.

NAHQ’s 12,000-plus members and certificants benefit from cutting edge education and NAHQ’s unique collective body of knowledge, as well as opportunities to learn from a diverse group of professionals. These resources help assure success for implementing improvements in quality outcomes and patient safety, navigating the changing healthcare landscape, and serving as the voice of quality. Visit to learn more.


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