PCPs at the Helm of Care

In less than three months, Mr. K went from seeing only his primary care physician (PCP) to seeing 11 clinicians in 11 different offices for five procedures. During that time, he learned he had both a kidney stone and cancer in his liver, necessitating quick action in a limited timeframe. Throughout the process, his PCP coordinated his care, communicating with the new providers 40 times combined, and with Mr. K and his spouse a total of 12 times.

It would have been easy and time-saving for Mr. K’s PCP to hand him off to the oncologist in light of a new cancer diagnosis. Instead, Mr. K’s doctor “quarterbacked” the entire episode of care, despite not seeing him once during the 80-day span of cancer care. The PCP was even able to avert further health complications after one of the new clinicians prescribed medication that caused a potentially-dangerous imbalance in electrolytes. 

The role of PCPs in care coordination among specialists is critical to patient safety and outcomes. Unfortunately, in today’s healthcare environment, it can often be difficult for PCPs to have their desired level of involvement. One issue is that the number of PCPs is shrinking. Since 1998, the number of general medicine residents choosing to practice primary care has steadily decreased from 54% to about 20%.

Compared to just a few decades ago, PCPs report needing to see twice as many patients for the same financial return. More patients and fewer doctors mean that each doctor has less time for each patient—on average, only 15 minutes per visit. These time and cost burdens have led doctors to rely on specialists, perhaps more than they should have to, and a referral is often the easiest and quickest option. Though Mr. K’s PCP was able to stay involved throughout his care, the reality is that most PCPs do not have the time to do so. And as we all know, collaboration, in healthcare, is better for patients than handoffs.

In cases of complex medical conditions, specialists are necessary to achieve the best outcomes. But, handing off patients to specialists does not always produce the best results. A study of older patients using a specialist as their primary care provider found that continuity of care was lacking. And while health outcomes are similar between providers and specialists, hospitalizations and spending are notably higher among specialist-only groups, according to a report in the Journal of the American Geriatrics Society. 

Care coordination issues between specialists and PCPs often stem from the two providers having very different sets of critical information. Specialists are focused on handling a particular issue, and PCPs have the patient context. PCPs will know the nuances of existing health issues, what tests have already been performed, the kind of support a patient has, or not, at home, or in Mr. K’s case, if a new medication will shift electrolyte imbalance.

Recognizing that PCPs and specialists need to communicate effectively in order to properly coordinate patient care, the Duke Institute for Health Innovation (DIHI) has coined the idea of a “medical neighborhood,” building off the patient-centered medical home model. This system promotes direct interaction between PCPs and specialists as the first choice when further information is needed on a patient by making it easier for PCPs to drive this collaboration. The DIHI model proves that in many cases, consultation directly between PCPs and specialists can get the answers needed, as opposed to a referral that may be costly or never even completed.

The DIHI model also demonstrates that with increasing pressures and shrinking numbers among PCPs, it’s up to healthcare executives, innovation centers, vendors, and partners to facilitate PCPs continued position at the helm of care. Keeping patients with complex, even life-threatening issues, healthy is a matter of marrying the particular skills of specialists with deep knowledge from PCPs. This kind of collaboration between physicians, specialists, and their support systems will continue to save lives, control costs, and push the value-based mission forward.

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