Don’t let your patients fall through the cracks
Each year, BCBSNM analyzes data for ways to improve coordination of patient care. Any clinician working in health care today has seen the suffering and cost created when patients “fall through the cracks” of coordinated care.

This year, we surveyed 1,500 professionals in our network to determine where the greatest opportunities lie. The findings were reviewed quantitatively and qualitatively by the physicians and other clinicians on the Quality Improvement Professional Review Committee. Three issues rose to the top:

• Communication to the community-based primary care physician when patients are admitted to hospital systems that use the hospitalist model
• Communication back to the community-based primary care physician from ophthalmologists and optometrists performing diabetic retinal exams
• Appropriate feedback from behavioral health providers when physicians have referred patients for behavioral health issues

How you can help prevent your patients from falling through the cracks depends to an extent on your role: community-based primary care or specialist/hospitalist.

Primary care

• Remind your patients if they ever need emergency care, admission to a hospital, or are seen by a specialist, that it is important to tell the new caregiver that you are their physician. We hear from hospitals that patients say they don’t know who their primary care doctor is. And patients who are in an altered mental state may be unable to convey that information.
• Consider asking your patients to keep one of your business cards in their wallet in case they become acutely ill and cannot speak for themselves.
• Consider having a “cheat sheet” for your patients that explains what you expect of them. One item might be that if they see a specialist, you want them to ask the specialist to send you results of any studies or findings. Empower your patients to be your advocates for information exchange.
• If your patients are admitted through a hospitalist service, consider faxing your contact information to the hospital for inclusion in the chart with a reminder that you want to receive the discharge summary.
• If you refer a patient to a behavioral health provider, explain to the patient that you will want the behavioral health provider to inform you of changes to medications that may occur.
• If your patient is a BlueSalud member with special health care needs, you can refer the patient to a BlueSalud Care Coordinator who can help him or her navigate the health care system and get needed services (call 1-877-232-5518, option 3).

• Remember that your primary care colleagues depend on you to know how you have treated the patient or have altered therapy. This is especially important with inpatient stays, where key studies and alterations in medications may have occurred. In our survey data, your primary care colleagues express that it is particularly useful to know about medications at the time of discharge. While “medication reconciliation” is a focus for most hospitals, closing the loop with the community-based clinician is also important.
• For diabetic eye exams, remember that the New Mexico Academy of Ophthalmology (NMAO) maintains an easy-to-use form (designed in conjunction with the New Mexico Medical Review Association) that can be sent with the patient or sent to the referring physician (if one is identified). You can download the form here.

Issue 12, 2009 • Blue Review • www.bcbsnm.com