In an effort to improve communication about specific patients between doctors, subspecialists and hospitals, the American College of Physicians has created a new "toolkit" to help coordinate care.

ACP unveiled the High Value Care Coordination Toolkit in April, urging primary care and specialty doctors to use its components to improve their back-and-forth communication regarding patients.

The toolkit is intended to make sure that subspecialists get accurate and appropriate information about patients referred to them and that they pass back to primary care physicians the information they need to monitor the care of their patients.

"This is not a trivial issue," said Dr. Bruce Leff, who chairs ACP's Council of Subspecialty Societies. "It really has an important effect on patient care and patient outcomes, as well as the way physicians organize themselves to provide best quality care."

The toolkit includes five components:

• A checklist of information to include in a primary care referral to a subspecialty practice
• A checklist of information to include in a subspecialist's response to a referral request
• Lists of additional pertinent data that should be included with referrals for 33 specific medical conditions, developed by participating subspecialty societies
• Templates of model care coordination agreements between primary care and subspecialty practices, and between a primary care practice and a hospital care team
• Recommendations to physicians on how to prepare a patient for a referral

Lack of communication between primary care physicians and subspecialists is a common problem that can result in very frustrating situations, said Leff, a Johns Hopkins geriatrician who provides primary care and, thus, wears both hats.

"It's quite frustrating to have a patient sent to you and you have no idea why a physician has sent the patient to you," Leff said. "Specialists want to know why they're seeing the patient, as opposed to a patient dropping into their office not knowing why their doctor has sent them."

Referrals also are made without including relevant test results, which can lead to much waste and repeated effort, said Dr. Carol Greenlee, a Colorado endocrinologist and vice-chair of the Council of Subspecialty Societies.

She gave the example of a doctor referring a patient to a specialist following an abnormal liver test, but then failing to include the results of that test in the referral.

"We realized that people were practicing in silos, with very poor communication," Greenlee said. "People thought they were communicating, but when you checked on the other side, you found the right information wasn't getting through."

"This toolkit is intended to make sure the patient gets there in a prepared state to the right specialist at the right time with the right information," she said.

Improving communication between doctors also could help save money. ACP says that up to 30 percent, or $765 billion, of health care costs have been identified as potentially avoidable, with many of those costs attributed to unnecessary services.

"Communication is really critical to efforts to improve quality and control cost," Leff said. "As the incentives to improve care and have more cost-conscious care move forward, there will be even more incentives to move in this direction."

The need for better coordination came up as doctors began to contemplate the role of "neighbors" to a Patient-Centered Medical Home, Greenlee said. "We recognized that the Patient-Centered Medical Home couldn't function without good integration with specialists," she said.

The Council on Subspecialty Societies initiated the drive to build a communications toolkit at a leadership summit in April 2013. Greenlee said the council appointed a task force composed of primary care groups, subspecialty/specialty groups and patient advocates to build the toolkit.

The toolkit's components not only serve to improve communication, Leff said, but also can be used to clarify the roles between primary care doctors and subspecialists.

For instance, Leff said, as a primary care doctor he sometimes wants to entirely hand over patient care to the subspecialist, such as in cases of cancer. "Oncology just isn't in my wheelhouse," he said.

In other cases, the primary care doctor might want to retain patient care but get good advice on that care from a subspecialist.

Leff gave the example of a referral to a gastroenterologist for a digestion issue. "I want to know whether the therapy should be x or y," he said. "I'm not handing over care, I just want a little guidance and then I will handle whatever care the specialist recommends."

More Information

The High Value Care Coordination Toolkit is available on the ACP website.