Care coordination between specialty care and primary care: a focus group study of provider perspectives on strong practices and improvement opportunities

Figures & data

Figure 1 Agency for Healthcare Research and Quality (AHRQ)’s 2007 report on care coordination⁹ consolidates four relevant frameworks into one operational summary framework, which categorizes concepts into three areas – (I) baseline assessment, (II) coordinating mechanisms, and (III) outcomes; our work demonstrates the use of focus groups and thematic analysis to examine I and II.

Table 1 Top five themes by number of times mentioned

Theme	Number of responses	Topic	Nature of response	Primary associated concept in operational framework for care coordination^Citation9
Building relationships improves the work	120	Communication	Strong Practice	II.a (relational coordination)
Lack of care coordination	91	Patients	Improvement Opportunity	I.a (need for coordination)
Ineffective/incorrect/missing templates for consult request by PCP	90	Tasks structure	Improvement Opportunity	I.c (enabling resources)
Lack of feedback	80	Communication	Improvement Opportunity	I.e (information requirements)
Difficulty contacting SCP team	77	Communication	Improvement Opportunity	II.c (coordination processes)
Top 5 of 86 themes	19% of 2,413 responses

Abbreviations: PCP, primary care provider; SCP, specialty care provider.

Table 2 Top ten themes by number of facilities at which they were mentioned

Theme	Number of facilities	Topic	Nature of response	Primary associated concept in operational framework for care coordination^Citation9
Building relationships improves the work	22	Communication	Strong Practice	II.a (relational coordination)
Lack of care coordination	22	Patients	Improvement Opportunity	I.a (need for coordination)
Informal consults are appreciated	22	Communication	Strong Practice	II.c (coordination processes)
Ineffective/incorrect/missing templates for consult request by PCP	21	Tasks structure	Improvement Opportunity	I.c (enabling resources)
Gaps in communication with patient	21	Patients	Improvement Opportunity	I.e (information requirements)
Lack of feedback	20	Communication	Improvement Opportunity	I.e (information requirements)
Emphasis on communicating with patients	20	Patients	Strong Practice	I.d (structures of care)
Noneffective service/coordination agreements	20	Roles clarity	Improvement Opportunity	I.a (need for coordination)
Interdisciplinary meetings help	20	Communication	Strong Practice	II.a (relational coordination)
Difficulty contacting SCP team	19	Communication	Improvement Opportunity	II.c (coordination processes)

Abbreviations: PCP, primary care provider; SCP, specialty care provider.

Figure 2 Nature and topic of responses mentioned at intended PCP groups and at intended SCP groups.

Abbreviations: PCP, primary care provider; SCP, specialty care provider.

Table S1 Communication themes

	Number of responses
Strong Practice theme
Building relationships improves the work	120
Informal consults are appreciated	59
Interdisciplinary meetings help	42
Easy to contact SCP	41
Feedback is important	26
Easy to contact PCP	23
PCP learns from each consult	18
Outlook communication is helpful	8
Total	337
Improvement Opportunity theme
Lack of feedback	80
Difficulty contacting SCP team	77
Structured PCP training recommended	58
Lacking relationships	47
Difficulty contacting PC team	40
Lack of PCP knowledge	16
Disagreements occur over patient care plan	14
Specialty-to-specialty teamwork recommended	14
Outlook communication problematic	11
Unofficial communication too time-consuming	5
Delayed results/feedback	3
Total	365

Abbreviations: SCP, specialty care provider; PCP, primary care provider; PC, primary care.

Table S2 Tasks structure themes

	Number of responses
Strong Practice theme
Effective/correct templates for consult request by PCP	36
Cosigning PCP on notes is helpful	35
Total	71
Improvement Opportunity theme
Ineffective/incorrect/missing templates for consult request by PCP	90
Incorrect/insufficient administrative practice	55
PCP needs clear plan, guidelines for f/up	49
Consult prework too difficult/time-consuming	39
Incorrect/insufficient medical information provided to SCP	35
Too much documentation work	28
Priority classification improvements needed	24
Insufficient/improper medical examination/practice by PCP	23
Unnecessary consults	22
E-consult availability needed	22
Reminder-induced consults create unwanted visits	5
Unnecessary f2f consult	2
Total	394

Abbreviations: SCP, specialty care provider; PCP, primary care provider; f/up, follow-up; f2f, face-to-face.

Table S3 Patient perception themes

	Number of responses
Strong Practice theme
Emphasis on communicating with patients	57
Perception of good care	33
Total	90
Improvement Opportunity theme
Lack of care coordination	91
Gaps in communication with patient	67
Patients don’t understand process or roles	38
Dual care complicates	25
Problems related to no shows	12
Patient concern for PCP knowledge of SCP work	6
Copay problems	4
Noncompliant patients	3
Total	246

Abbreviations: SCP, specialty care provider; PCP, primary care provider.

Table S4 Organizational role themes

	Number of responses
Strong Practice theme
Effective service/coordination agreements	34
PC RN care manager role importance	21
Work together to see reluctant patients	3
Total	58
Improvement Opportunity theme
Noneffective service/coordination agreements	53
Fee basis complexities or under-use	31
Complexity related to facility-to-facility differences	29
Central or direct scheduling recommended	23
Unknown contact in PC or SC	19
Too much handed back to PCP from referral	19
Varied methods of graduation	17
Shared reminder responsibility and clarity needed	16
SCP clinician limitations	16
Veteran travel scheduling gaps	9
Untracked consults	6
PCP should always refer	5
Unutilized cancellations	3
SC should refer if urgent	2
SC recommends plan not referred for by PC	1
Total	249

Abbreviations: SCP, specialty care provider; PCP, primary care provider; PC primary care; SC, specialty care; RN, Registered nurse.

Table S5 Geographical distance themes

	Number of responses
Strong Practice theme
Information systems facilitate care	40
Nearby SCP facilitates effective care	13
Total	53
Improvement Opportunity theme
CPRS limitations	71
Distance technology solutions desirable	34
Distant SCP creates challenges	30
Clinical space limitations exist	20
Lack of visibility	13
Slow computing	6
No secure messaging	3
Total	177

Abbreviations: SCP, specialty care provider; CPRS, computerized patient record system.

Table S6 Supply/staffing and workload balance themes

	Number of responses
Improvement Opportunity theme
More support staff needed	56
Not enough specialists	44
Student continuity issues	43
Turnover (PCP/SCP/staff)	18
PCP workload too high	18
Split time/part time complexities	17
Recommend NP staffing	13
Burnout	3
Total	212

Abbreviations: SCP, specialty care provider; PCP, primary care provider; NP, nurse practitioner.

Table S7 Access themes

	Number of responses
Strong Practice theme
Timeliness of consults to appt is good	24
SCP at CBOC improves access	5
Total	29
Improvement Opportunity theme
Poor SCP access for patients	52
Poor PCP access for patients	25
Insufficient timeliness of consults/appts	24
Poor phone systems	20
SCP not where need is (eg, CBOC)	9
Short appts	2
Total	132

Abbreviations: appt, appointment; SCP, specialty care provider; PCP, primary care provider; CBOC, community-based outpatient clinic.

McDonaldKMSundaramVBravataDMClosing the Quality Gap: A Critical Analysis of Quality Improvement Strategies. Technical Review 9. Volume 7 – Care CoordinationRockville, MDAgency for Healthcare Research and Quality2007

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