Primary Care Is on Life Support, But Case Management Could Be Antidote
January 1, 2023 6 minutes read
By Melinda Young
EXECUTIVE SUMMARY
Primary care is facing decline due to financial factors and clinician burnout. One solution is to assign case managers or care coordinators to primary care offices to improve communication between primary care providers, hospitals, and other healthcare entities.
- Primary care coordinators can ensure patients’ family practitioners are aware of hospitalizations, changes in medication, and other issues arising from a medical crisis.
- These case managers should be knowledgeable about primary care and care coordination.
- Health systems with primary care practices could fund this position, but more funding is needed from payors and government entities to support this role.
Primary care clinicians are becoming an endangered species in the United States, partly due to underfinancing and a perception of too much work for too little reward.1-3
According to a recent report, the 2021 National Academies of Sciences, Engineering, and Medicine noted primary care is slowly dying. Primary care receives only about 5% of the healthcare spending dollar — a much lower proportion than what is spent in many other comparable nations.1-3
Care coordination and case management have left out primary care providers, with more focus paid to other post-acute care settings. Timely and comprehensive communication between hospitals and providers is lacking, and primary care providers (PCPs) spend up to five hours a day on electronic medical record documentation.1,2
It was not supposed to be this way. Primary care has been integral to the chronic care model and addressing care gaps and teamwork. They were the providers patients trusted and knew best. But decades of financial neglect and unmanageable caseloads has led to patient access issues and provider burnout. Fewer new doctors are moving into the field.
These problems are affecting patient transitions through the care continuum as well. PCPs sometimes receive too little information about their patients’ hospitalizations and ED visits. Communication between hospitals and primary care is lacking, says Thomas Bodenheimer, MD, professor emeritus in the department of family and community medicine at the University of California, San Francisco.
Before the advent of hospitalists, PCPs worked in the ambulatory and hospital settings, following their patients. They knew the patient’s issues and crises and could easily coordinate patients’ care from hospital to home.
But that has changed in the era of the hospitalist model. With hospitalists, acute care patients always can access a physician in the hospital. But efficient care coordination and communication between acute care and primary care are missing.
“Ambulatory care providers — particularly primary care — wouldn’t get paid to see their patients in the hospital, so most primary care providers stopped going to the hospital to see their patients,” Bodenheimer explains. “That meant there had to be coordination between what was going on in the hospital and primary care physicians that really knew the patients.”
PCPs need input on what happens to their hospitalized patients, yet coordination has been poor. “Now, a primary care provider, who has known the patient for 10 years, is completely shut out of any communication regarding the patient,” Bodenheimer says. “The PCP could come into the hospital and see the patient without getting paid, and some have us have done that. But that’s not what is done most of the time, and that’s why care coordination has become such an issue.”
Coordination between acute and ambulatory care could improve if primary care practices employed their own case managers or care coordinators to work with hospital case managers. “We need someone who has skills in coordinating care between ambulatory and acute care,” Bodenheimer says. “Generally, hospitals have a discharge coordinator who deals with the discharge part, but what about during the hospitalization?”
Coordination may improve in health systems that include primary care practices — at least through electronic medical records (EMRs) between care settings. Some managed care or bundled care for specific populations, such as Medicaid or Medicare, may employ their own care coordinators to facilitate communication between providers. Research shows care coordination can lead to better patient outcomes and cost savings.4
“Coordination between care management and primary care and other clinicians is paramount,” says Christine Vogeli, PhD, an assistant professor at Harvard Medical School and Massachusetts General Hospital.
The results of a recent study showed significant cost savings when patients received intensive care management that included effective coordination and communication with primary care providers.2 (For more information, see the story in this issue on intensive care management.)
From a managed care perspective, a selective narrow network involving primary care and specialists supported by comprehensive patient navigation can lower costs and improve patients’ access and satisfaction.5
The care continuum can be confusing to patients, making it difficult to know which specialists and healthcare facilities to access. Care coordination that helps patients make appointments with physicians can improve this.
Researchers found that even if patients are offered fewer choices, they are more satisfied with their ambulatory care if someone helps them connect with the right physician through a warm handoff. Their satisfaction is mainly due to phone-delivered care coordination from nurses, pharmacists, and other professionals.5
“People were a lot happier with a narrower network and with navigation,” says Timothy T. Brown, PhD, an associate professor in the School of Public Health at the University of California, Berkeley. (For more information, see story about patient navigation in this issue.)
Who Is Responsible?
One problem with improving coordination between acute care and ambulatory care is the question of who is responsible for the patient. It is not ideal for hospital case managers to handle all ambulatory care transitions because the nurses and social workers in this role often do not know the patient well, or how primary care practice works. “The care coordination model is really good, but I’d put that person in the primary care practice, rather than in the hospital,” Bodenheimer says. “There are a number of programs set up to improve coordination between ambulatory care primary care physicians and specialists, and so it’s done much better in some places. But it’s still a problem finding who’s responsible for wherever the patient is in the health system.”
Gaps in communication during transitions can occur in health systems where all coordination is left to the hospital case manager or care coordinator. For example, primary care can be left out of transitions from the hospital to a skilled nursing facility.
“If the care coordinator in the hospital is doing an excellent job, she could solve all those problems,” Bodenheimer says. “But it means being in contact with primary care, and primary care physicians say all the time that no one in the hospital ever calls them — that they only call when the patient is being discharged, and sometimes not even then.”
Ideally, care coordination could be the role of the primary care provider. But this is not happening in today’s healthcare environment. “Primary care should be responsible wherever a patient is — whether in the MRI suite, nursing home. [PCPs] should be responsible for making sure everything is OK,” Bodenheimer notes.
PCPs could keep track of their patients more consistently if case managers or care coordinators are on staff. But cost is the biggest barrier. “The problem is primary care is seriously underfunded and really struggling to survive,” Bodenheimer explains. “To hire an RN to be a care coordinator and work with the hospital care managers — most primary care providers can’t do that.”
Improve Documentation
Large health systems that own primary care practices might have enough resources to dedicate a care coordinator to the ambulatory side, and they could make transitions work more smoothly. But it is less practical to expect solo primary care providers to make this investment.
Hospital systems could consider staffing a care coordinator to work with PCPs, but it will require training and commitment. Or they could find creative ways to free PCPs’ time. For instance, they could help physicians clear documentation time that could be used in care coordination instead. One way to do this is to give them volunteer help with EMR documentation, Bodenheimer suggests. For example, a health system or PCP could recruit pre-med students to volunteer as scribes.
“Pre-med students want to do community service to get into medical school,” Bodenheimer explains. “They can work two years during their pre-med time, which is a wonderful idea.” PCPs also could seek nursing student volunteers or interns to help with patient follow-up and care coordination.
REFERENCES
- Bodenheimer T. Revitalizing primary care, part 1: Root causes for primary care’s problems. Ann Fam Med 2022;20:464-468.
- Bodenheimer T. Revitalizing primary care, part 2: Hopes for the future. Ann Fam Med 2022;20:469-478.
- McCauley L, Phillips Jr RL, Meisnere M, Robinson SK. Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care. National Academies Press. 2021.
- Rowe JS, Gulla J, Vienneau M, et al. Intensive care management of a complex Medicaid population: A randomized evaluation. Am J Manag Care 2022;28:430-435.
- Brown TT, Hague E, Neumann A, et al. Impact of a selective narrow network with comprehensive patient navigation on access, utilization, expenditures, and enrollee experience. Health Serv Res 2022; Sep 16. doi: 10.1111/1475-6773.14066. [Online ahead of print].
Primary care is facing decline due to financial factors and clinician burnout. One solution is to assign case managers or care coordinators to primary care offices to improve communication between primary care providers, hospitals, and other healthcare entities.
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