Coordinating Care across Diseases, Settings, and Clinicians: A Key Role for the Generalist in Practice

The goal of coordination of medical care is to support patients and their families in their efforts to receive effective health care from an increasingly complex health care system. Coordination involves the regulation of diverse elements into an integrated and harmonious operation (1). Starfield (2) describes the essence of health care coordination as the availability of information about prior problems and services and the recognition of that information as it bears on needs for current care. This information includes knowledge about patients and families, and their experiences with and responses to health care. Ideally, information is made available through easily accessible medical records; written and verbal communication among clinicians, patients, families, and community resources; and clinicians' knowledge gained from past experiences with patients. Medical advances have created the need for coordination of care by contributing to greater longevity, and because chronic illnesses become more prevalent with aging, more patients experience more health conditions. As the knowledge base required to practice medicine has increased, it has become impossible for any one physician to possess all the information needed to care for a patient, resulting in the need for medical specialization and coordination of care among multiple specialists (3). Furthermore, medical care is being provided in a greater variety of settings, including nonphysician provider offices, nursing facilities, and patients' homes. Coordination of activities across care settings is therefore needed. Coordination of medical care, a core function of primary care (2), is embraced by generalist physicians as a defining principle of their work (4-6). Generalists are well positioned to care for the many patients whose conditions do not fall neatly into a single disease category (4, 7, 8). The structure of generalist practice does not easily lend itself to coordination of care, although relatively small changes could help this greatly. The scenarios in the Appendix, which are adapted from a report by the Institute of Medicine (9), provide dramatic examples of coordinated care on clinical outcomes. Scenario 1 demonstrates a team approach to care coordination, in which clinicians and staff play differing roles depending on their expertise. In contrast, scenario 2 depicts elements of fragmented care that are commonly seen. We review the literature on coordination of care and its effectiveness and make recommendations for generalist research, education, and practice. Methods In 2003, the Robert Wood Johnson Foundation Generalist Physician Faculty Scholars program asked current and past grantees and National Advisory Committee members to consider several topics, including coordination of care, and their implications for the future of generalist research, education, and practice. A volunteer group of 5 physicians (3 from general internal medicine and 1 each from family medicine and pediatrics) was formed, on the basis of interest in the topic and representation from each generalist discipline, to review the literature on coordination of care and make recommendations. A series of 5 telephone conference calls and more frequent electronic mail correspondence took place over 6 months. The group chose to study the following questions from the point of view of the generalist physician's practice: What evidence exists that care coordination improves health care? What role should the generalist practice play in care coordination? What improvements, if any, should be made in collaboration among generalist and subspecialty physicians? How should teams be structured to provide optimally coordinated care? What is the role of patients and families in care coordination? How can medical informatics contribute to care coordination? After reviewing the current literature, the working group formulated 6 key recommendations and pointed out gaps where more research is needed before recommendations could be made. Findings from the published literature were incorporated whenever possible. At the 2003 national grantees' meeting, these recommendations were discussed by a group of more than 100 scholars, mentors, and nationally acknowledged experts on generalist physician practice. The literature review and recommendations were subsequently refined and incorporated into this article. The Robert Wood Johnson Foundation Generalist Faculty Scholars Program and the National Center for Research Resources provided funding for investigators' time to conduct and report on this study. The funding agencies played no role in the design, conduct, or reporting of the study. Results Consensus Recommendations 1. More evidence is needed to substantiate the value of care coordination in improving health outcomes and to identify the most useful components to be included in models of care coordination. Recommending optimal approaches to coordinated care is difficult because of several factors: no agreement about what constitutes coordinated care; the need for a core set of outcomes of coordination that are measurable and sensitive to change, but also relevant to patient care; few published studies on the complex populations that may benefit most from improved coordination; and few studies aimed at determining which coordination activities might be most useful. Although the terms are often used interchangeably, many interventions that have been described as coordinated care (10, 11-13) actually concern collaborative care. Collaboration is simply the act of working together (1), whereas coordination involves regulation of participants to produce higher-order functioning. It requires developing and guiding a therapeutic plan and integrating the inputs of multiple clinicians, patients, and families (and, at times, community agencies, employers, or schools) toward a common goal. Table 1 summarizes studies on coordinated care. This table is not an exhaustive list; rather, it represents the best interventions in the outpatient setting for a variety of age groups and conditions. Some studies (12, 14, 15) involved personnel dedicated to coordinating care, whereas others examined only collaboration between primary care and specialty physicians. Table 1. Examples of Collaborative Care and Coordinated Care Most studies that reported positive results evaluated the effect of interventions on health care outcomes (10, 11, 14, 15), such as appropriate utilization of care. In contrast, studies that examined health outcomes tended to report mixed results (12, 13, 16-18). Although the obvious goal of improving health services is to improve health, the immediate target of interventions to improve coordination is not a disease process but rather the health care system. Immediate improvements might include better access to care, more timely care, more accurate plans, fewer medical errors, and increased patient participation. These factors are difficult to measure, although resultant improvements in utilization can be measured and quantified. Improvements in health resulting from changes in the system of health care are mediated through improvements in health care delivery, and evaluation that focuses only on health outcomes may not recognize beneficial changes to the health care system that are necessary but not sufficient to improve health outcomes. Most studies investigating the impact of coordination of care were limited to patients with a single disease, which decreases their ability to show changes in outcomes resulting from improved coordination of care for patients with complex needs. Demonstration projects focusing on groups of patients with 1 or more comorbid conditions, which account for the majority of visits by patients with chronic conditions (19), might prove more useful in measuring the value of care coordination. Defining which elements of care coordination are critical for improving health outcomes and operationalizing them for implementation and study have yet to be achieved. Some argue that better quality measures are needed to measure outcomes associated with generalist care functions (20). The need for improved measures is illustrated by an effort to coordinate care for children with chronic conditions in primary care settings. Investigators found that families had many unmet needs that were unsuspected by their pediatrician (21). In this case, increased reporting of unmet needs might be a positive outcome because unmet but newly recognized needs can be targeted with future interventions. Intermediate outcomes, such as the family's sense that their needs have been heard, are also very important. Coordinated care remains a core value of primary care and generalist practice, but more evidence linking these intuitively valuable results, improvements in health care outcomes, and health outcomes is needed to demonstrate its value to policymakers and payors as a necessary component of the health care system. 2. The generalist physician's practice is an appropriate hub for the medical aspects of care coordination for most patients. Health care is increasingly being provided by teams, whose members have differing expertise in the many tasks needed to provide high-quality care. As a team grows in size, communication becomes much more complex. The maximum number of lines of communication is nonlinear, as described by the equation (n 2 n)/2, where n is the number of team members (22). Thus, on a team with 5 members, 10 lines of communication are possible. It is easy to assemble a team of at least this size: For instance, a team that cares for a patient with a simple, chronic orthopedic condition might include at a minimum the patient, a family member, generalist and orthopedic physicians, and a physical therapist. To help simplify and streamline communication, care coordination models put 1 clinician at the center of the network, so that other team members are generally required to communicate only with the