Coordination of Care by Primary Care Practices: Strategies, Lessons and Implications

HSC Research Brief No. 12

April 2009

Ann S. O'Malley, Ann Tynan, Genna R. Cohen, Nicole M. Kemper, Matthew M. Davis

Primary care practices occupy a pivotal position in the broader health care system, serving as the usual first point of contact for patients and shouldering much of the responsibility for managing their ongoing care. Yet coordinating that care -- across multiple providers, settings, and services -- remains one of the most persistent challenges in American medicine. A study by the Center for Studying Health System Change (HSC) examined how real-world primary care practices actually go about coordination, identifying concrete strategies as well as the structural and financial barriers that impede their efforts. Drawing on 62 interviews with physicians, office staff, and other health care professionals conducted between December 2007 and May 2008, the research reveals a diverse landscape of coordination approaches shaped by practice size, patient population, local market conditions, and available technology. While there is no universal formula, certain recurring themes emerge: personal continuity between doctor and patient matters enormously, systematic office processes provide essential scaffolding, and the prevailing payment system actively works against coordinated care.

Why Coordination Matters and Why It Remains Difficult

Care coordination encompasses the deliberate organization of patient care activities and the sharing of information among all participants involved in a patient's treatment. When done well, it ensures that each provider -- primary care physician, specialist, hospital, home health agency, or community service -- has the information needed to make sound clinical decisions, and that the patient receives appropriate follow-up at every transition. When coordination breaks down, the consequences range from duplicated tests and conflicting medications to missed diagnoses, preventable hospitalizations, and worse health outcomes.

Despite broad agreement on its importance, coordination has proven stubbornly hard to achieve. The HSC study identified several root causes. First, the dominant fee-for-service payment model rewards discrete clinical encounters -- office visits, procedures, imaging studies -- but provides little or no reimbursement for the phone calls, record reviews, care-plan updates, and follow-up communications that constitute the substance of coordination work. Practices that invest time in these activities absorb the cost themselves. Second, a deep-seated culture of professional autonomy among physicians fosters what some respondents described as a default posture of non-communication: specialists may not routinely send consultation notes back to referring physicians, and primary care doctors may not consistently relay relevant history to specialists. Third, the lack of interoperable health information technology means that even willing communicators often lack efficient mechanisms for exchanging clinical data across practice boundaries.

The researchers found that no single approach to coordination works for all practices. Instead, practices select and adapt strategies based on their particular circumstances -- including how many physicians they employ, which patient populations they serve, what resources they can access, and how their local health care market operates. The strategies identified fall into four broad domains: coordination within the primary care practice itself, coordination between primary care and specialty practices, coordination across the inpatient-outpatient boundary, and coordination with community services.

Within-Practice Coordination Strategies

The most foundational element of coordination, according to study participants, is interpersonal continuity of care -- the ongoing relationship between a patient and a specific clinician or small clinical team. When patients consistently see the same physician, that doctor accumulates a deep understanding of their medical history, social situation, preferences, and patterns. This accumulated knowledge makes it far easier to notice when something has changed, to interpret ambiguous symptoms, and to tailor treatment plans. Several respondents emphasized that continuity also strengthens trust, making patients more likely to follow through on referrals, medication regimens, and self-management plans.

To reinforce continuity, some practices have adopted organizational structures that assign patients to small care teams, sometimes called pods. In these arrangements, a physician works alongside a consistent set of nurses, medical assistants, and clerical staff who collectively manage a defined panel of patients. Because the same team handles a patient's calls, test results, referral paperwork, and appointment scheduling, fewer things slip through the cracks. When the physician is unavailable, other pod members can step in with full awareness of the patient's situation.

Several practices reported deliberately limiting panel sizes -- the number of patients assigned to each physician -- in order to protect the time needed for coordination activities. Larger panels generate more revenue per physician but leave less time per patient for the work that falls outside the exam room. Restricting panel sizes is especially common among practices serving patients with complex chronic conditions, where the coordination burden is heaviest.

Dedicated care coordinators represent another strategy. These staff members -- typically nurses or social workers -- take responsibility for tracking referrals, following up on test results, arranging services, and serving as a point of contact for patients navigating the system. In some practices, care coordinators focus primarily on high-risk patients with multiple chronic diseases, mental health conditions, or significant social barriers to care. In others, the role is broader, encompassing duties such as managing transitions after hospital discharge or connecting patients with community resources.

Phone triage systems also emerged as an important coordination tool. By channeling incoming patient calls through trained nurses who can assess urgency, provide guidance, and route problems to the right staff member, practices reduce unnecessary visits and ensure that pressing issues reach a physician quickly. Some practices have extended this concept to include proactive outreach -- calling patients after hospitalizations, after specialist visits, or when overdue for preventive care.

Patient engagement was frequently cited as a dimension of within-practice coordination that deserves more attention. Respondents noted that patients who understand their own conditions, know what medications they take and why, and actively participate in care planning are better equipped to relay information between providers and flag potential problems. Some practices provide written care plans, use teach-back techniques to confirm understanding, or employ patient portals that give individuals electronic access to their own records.

Underlying many of these within-practice strategies is the use of standardized office processes. Practices that establish clear protocols for handling referrals, tracking lab results, managing prescription refills, and documenting phone encounters reported fewer coordination lapses than those that relied on informal, ad hoc communication. Electronic health records can facilitate standardization, but respondents emphasized that the technology alone is insufficient -- practices must also invest in redesigning workflows and training staff to use systems consistently.

Between-Practice Coordination: Managing Referrals and Specialist Relationships

Coordination between primary care physicians and specialists is one of the most commonly cited trouble spots in American health care. The HSC study found that many practices address this challenge by limiting the number of specialists to whom they refer. Rather than sending patients to whichever specialist has the next available appointment, these practices cultivate relationships with a smaller set of consultants whose communication habits and clinical approach they know and trust. Over time, the referring physician learns which specialists reliably send back timely, informative consultation notes and which do not. Some practices formalize these relationships through service agreements that specify mutual expectations around turnaround times for reports, circumstances warranting direct phone communication, and protocols for co-managing patients with ongoing conditions.

Electronic referral systems, or e-referrals, offer another mechanism for tightening the referral loop. When a referral is generated electronically, the system can automatically attach relevant clinical data -- recent lab values, imaging reports, medication lists, the specific clinical question prompting the referral -- so that the specialist has the context needed to provide a useful consultation. Some e-referral platforms also allow the primary care practice to track whether the appointment was scheduled, whether the patient actually attended, and whether the consultation report has been returned. This tracking capability addresses a widespread problem identified in the study: referrals that disappear into a void, with no one certain whether the patient was seen or what the specialist recommended.

Co-location -- housing primary care and specialty services in the same physical space -- represents a more structural approach. When a cardiologist or endocrinologist practices in the same building or suite as the primary care team, the barriers to informal consultation drop dramatically. A primary care physician can walk down the hall to discuss a case, and patient records are more readily shared. Co-location also reduces the logistical burden on patients, who can see multiple providers in a single trip. However, co-location is feasible primarily for larger practices or integrated health systems, and it obviously cannot cover the full spectrum of specialties a primary care practice might need.

Referral tracking systems, whether electronic or paper-based, serve as a safeguard against patients falling through the cracks. Several practices described implementing registries or tickler files that flag referrals requiring follow-up. Staff members are assigned to check whether consultation reports have arrived within an expected time frame and to contact the specialist office or the patient directly when they have not. Without such systems, respondents acknowledged, it is easy for a referral to be forgotten until the patient surfaces months later with a worsened condition.

Bridging the Inpatient-Outpatient Divide

The transition from hospital to home -- or from hospital to a skilled nursing facility or rehabilitation center -- is widely recognized as a particularly vulnerable period for patients. Medication changes made during hospitalization may conflict with outpatient regimens; discharge instructions may be unclear; follow-up appointments may not be scheduled; and the outpatient physician may not learn of the hospitalization until well after the patient has been discharged. All of these gaps create risk for adverse events, including preventable readmissions.

One strategy the HSC study documented involves primary care physicians continuing to provide care to their patients during hospitalization. In some communities, particularly smaller ones, primary care doctors still make hospital rounds and manage their own patients' inpatient care. This continuity ensures that the physician who knows the patient best is directing treatment decisions and can personally orchestrate the transition back to outpatient care. However, the growth of hospitalist medicine -- in which physicians who specialize in inpatient care manage hospitalized patients -- has reduced this practice in many areas, creating new seams in the care continuum that must be bridged through communication and handoff protocols.

Advanced practice nurses, including nurse practitioners, have emerged as important players in managing transitions. Some practices employ nurse practitioners specifically to follow patients through the discharge process, reconcile medications, ensure that outpatient follow-up appointments are scheduled before the patient leaves the hospital, and conduct post-discharge phone calls or home visits. These transitional care roles have been shown in research to reduce readmission rates and improve patient satisfaction.

The study also highlighted formal programs designed to improve care transitions. The Care Transitions Program, developed by Eric Coleman at the University of Colorado, provides patients with tools and coaching to manage their own transitions -- including a personal health record that the patient carries between settings and a structured follow-up protocol. Several practices participating in the HSC study had adopted elements of this approach, or similar transition programs, as a way to close the information gaps that typically accompany hospital discharge.

Coordination with community services -- including home health agencies, social services, mental health providers, and public health programs -- was also identified as an area where primary care practices can strengthen the web of support around patients with complex needs. Some practices maintain directories of local resources and assign staff members to connect patients with appropriate services. Others participate in community health networks or collaborate with area agencies on aging and other social service organizations to ensure continuity across the medical and social dimensions of care.

Policy Implications: Payment Reform and the Medical Home

The study's findings carry direct implications for health policy. Perhaps the most fundamental is the need for payment reform. As long as coordination activities go unreimbursed, practices that invest in them operate at a financial disadvantage relative to those that do not. Respondents described the paradox bluntly: the health system talks about wanting coordination but declines to pay for it. Proposed remedies include per-member-per-month care management fees, shared savings arrangements that reward practices for reducing avoidable utilization, and bundled payment models that give providers a financial stake in the full episode of care rather than just their own piece of it.

The patient-centered medical home (PCMH) model, which was gaining significant policy attention at the time of the study, aims to address many of these issues. The medical home envisions a primary care practice that takes comprehensive responsibility for each patient's care, coordinates across all providers and settings, ensures access through expanded hours and communication channels, and uses evidence-based clinical processes supported by health information technology. Several large demonstration projects were underway to test whether the model could improve quality and reduce costs.

However, the HSC researchers cautioned that measurement and recognition of medical homes should be flexible enough to accommodate the wide variety of practice structures and strategies documented in the study. Small practices may achieve effective coordination through strong personal relationships and simple tracking systems, while large multispecialty groups may rely more heavily on electronic systems and dedicated staff roles. A one-size-fits-all set of structural requirements risks penalizing practices that coordinate well through different means or rewarding practices that meet structural criteria without actually delivering better-coordinated care.

Technical assistance and infrastructure support represent another policy lever. Smaller practices, which make up a large share of the primary care landscape, often lack the resources to invest in electronic health records, hire care coordinators, or redesign workflows on their own. Public and private initiatives that provide training, shared technology platforms, and quality improvement support can help these practices adopt coordination strategies that would otherwise be out of reach. The study found that practices of all sizes can coordinate well, but smaller ones need proportionally more external support to do so.

Health information technology interoperability emerged as a recurring theme throughout the interviews. Even practices with sophisticated electronic health records found themselves unable to exchange data seamlessly with hospitals, specialists, laboratories, and pharmacies that used different systems. Without interoperability, clinicians resort to fax machines, phone calls, and patient self-report -- methods that are slow, unreliable, and labor-intensive. Policy efforts to promote adoption of interoperable health IT standards were seen as essential to enabling coordination at scale.

Finally, the study noted that effective coordination requires a shift in professional culture. Physicians trained in an era of individual clinical autonomy may not instinctively see communication with other providers as part of their core responsibility. Medical education, residency training, and continuing professional development programs can all play a role in fostering the collaborative mindset that coordination demands. Similarly, patients need to be empowered as active participants rather than passive recipients -- equipped with the information, tools, and confidence to help bridge the gaps between the various providers and settings that contribute to their care.

Data Source and Methodology

This research drew on 62 semi-structured interviews conducted between December 2007 and May 2008 with physicians, practice administrators, nurses, and other staff in primary care practices of varying size, structure, and setting. Practices ranged from solo and small-group offices to large multispecialty organizations and included both independent practices and those affiliated with larger health systems. The interviews explored how practices organize and carry out coordination activities, what resources they use, what barriers they face, and what strategies they have found most effective. Interview data were coded and analyzed qualitatively to identify themes and patterns across practice types.

This research was funded by the Robert Wood Johnson Foundation.

Sources and Further Reading

Agency for Healthcare Research and Quality (AHRQ) -- Care Coordination: https://www.ahrq.gov/ncepcr/care/coordination.html

Robert Wood Johnson Foundation: https://www.rwjf.org/

National Committee for Quality Assurance (NCQA) -- Patient-Centered Medical Home: https://www.ncqa.org/programs/health-care-providers-practices/patient-centered-medical-home-pcmh/

Centers for Medicare & Medicaid Services (CMS) -- Quality Initiatives: https://www.cms.gov/medicare/quality

American College of Physicians: https://www.acponline.org/