Independence annually monitors the continuity and coordination of care that members receive to promote the appropriate diagnosis, treatment, and follow-up for medical care. Today, patients' health care needs are rarely met by a single professional. More often, it occurs through coordination and sharing of information by different providers.¹ Continuity and coordination of medical care services is the facilitation – across transitions and settings of care – of patients receiving the care or services they need and their health care providers getting the appropriate information needed to provide their care.

Independence utilizes the following data sources to evaluate continuity and coordination of care:

• Practitioner Site Assessments (medical record review):
  • – General Medical Records Review (GMRR)
  • – Clinical Appropriateness Review (CAR)
  • – Continuity of Care Review (COCR)
• Physician Assessment Post-Acute Care Admission for members with asthma and chronic obstructive pulmonary disease (COPD)
• Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey:
  • – members who received care from a physician or another health care provider besides their personal physician;
  • – members who stated that their personal physician seemed informed and up-to-date about care received from these physicians and other health care providers.
• Qualified Health Plan Enrollee Experience Survey (EES):
  • – members who saw a specialist;
  • – members who stated that their personal physician seemed informed and up-to-date about the care received by the specialist.

Methodology

Data is collected and analyzed per product: Keystone Health Plan East, Personal Choice^®, Federal Employee Program, Keystone Health Plan East Marketplace, Personal Choice Marketplace, Keystone 65 HMO, and Personal Choice 65^SM PPO.

Practitioner Site Assessment: Independence utilized Healthcare Effectiveness Data Information Set (HEDIS^®) criteria and framework to select a random sample. The sample is large enough to estimate plan-wide percentages with 95 percent confidence and 10 percent oversampling.

Physician Assessment Post-Acute Care Admission: Independence utilized claims and encounter data.

Assessment data are analyzed to evaluate the exchange of information and transition in care settings and identify potential barriers and opportunities for improved performance.

Results

Data review demonstrated inconsistency in collaboration in care among network physicians and other health care providers. Practitioner Site Assessments reported a gap in communication between primary care physicians (PCP) and specialists. Data for physician assessment post-acute care admission reported fluctuations in care per member enrollment and diagnosis. Review of follow-up care shows a decrease of 2.35 percent from 2015 (37.72 percent) to 2016 (35.37 percent) for members with the admission diagnosis of asthma and an increase of 1.39 percent form 2015 (54.41 percent) to 2016 (55.80 percent) for members with the diagnosis of COPD. Review of CAHPS data indicates that even though most members feel that their personal physicians are informed of care received by other health care providers in 2016, three-year trend analysis reports show results to be either fluctuating or declining. EES data also reported mixed results for 2016.

Independence acknowledges certain barriers that influence coordination of care, including, but not limited to:

• facility discharge practices;
• access to electronic records utilized by different health care systems;
• members not keeping health care providers informed of changes in care (e.g., hospital admissions, emergency or urgent care);
• PCPs and specialists not informed of all providers involved in the member?s care (i.e., other specialists);
• for members with multiple complex conditions, lack of identification of a PCP.

Our goal is to assist providers in facilitating the coordination and collaboration of care to achieve optimal outcomes. Independence offers the following resources to network providers:

• Clinical Practice Guidelines
• NaviNet^® web portal
• HealthShare Exchange of Southeastern Pennsylvania
• Care Management Programs

Providers are also encouraged to utilize the Clinician Collaboration Form, located on the Independence Worksheets, Forms, and Guides web page.

¹Gulliford, M., Naitani, S., Morgan, M. ?What is ?continuity of care??? J Health Serv Res Policy. 2006 Oct;11(4):248-50. Available from: https://www.ncbi.nlm.nih.gov/pubmed/17018200.

HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA). Used with permission.

NaviNet is a registered trademark of NaviNet, Inc., an independent company.