AmeriHealth annually monitors the continuity and coordination of care that members receive to promote the appropriate diagnosis, treatment, and follow-up for medical care. Today, patients' health care needs are rarely met by a single professional. More often, it occurs through coordination and sharing of information by different providers.¹ Continuity and coordination of medical care services is the facilitation – across transitions and settings of care – of patients receiving the care or services they need and their health care providers getting the appropriate information needed to provide their care.

AmeriHealth utilizes the following data sources to evaluate continuity and coordination of care:

• Practitioner Site Assessments (medical record review):
  • – General Medical Records Review (GMRR)
  • – Clinical Appropriateness Review (CAR)
  • – Continuity of Care Review (COCR)
• Physician Assessment Post-Acute Care Admission for members with asthma and chronic obstructive pulmonary disease (COPD)
• Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey:
  • – members who received care from a physician or another health care provider besides their personal physician;
  • – members who stated that their personal physician seemed informed and up-to-date about care received from these physicians and other health care providers.
• Qualified Health Plan Enrollee Experience Survey (EES):
  • – members who saw a specialist;
  • – members who stated that their personal physician seemed informed and up-to-date about the care received by the specialist.

Methodology

Data is collected and analyzed per product in both Pennsylvania and New Jersey: HMO/POS, PPO/EPO, HMO Marketplace, POS Marketplace, and EPO Marketplace.

Practitioner Site Assessment: AmeriHealth utilized Healthcare Effectiveness Data Information Set (HEDIS^®) criteria and framework to select a random sample. The sample is large enough to estimate plan-wide percentages with 95 percent confidence and 10 percent oversampling.

Physician Assessment Post-Acute Care Admission: AmeriHealth utilized claims and encounter data.

Assessment data are analyzed to evaluate the exchange of information and transition in care settings and identify of potential barriers and opportunities for improved performance.

Results

Data review demonstrated inconsistency in collaboration in care among network physicians and other health care providers. Practitioner Site Assessments reported consistent documentation of communication between primary care physicians (PCP) and specialists; but communication from specialist to PCP was not as evident in the records. Data for physician assessment post-acute care admission reported fluctuations in care per member enrollment and diagnosis, with an average rate of follow-up care of 42.83 percent for asthma and 57.40 percent for COPD. Of note, there were no members enrolled in either HMO Marketplace or POS Marketplace with inpatient admissions for the diagnosis of COPD in 2016. Review of CAHPS data indicates that even though most members feel that their personal physicians are informed of care received by other health care providers in 2016, three-year trend analysis reports show inconsistent results with some plans showing improvement and some plans declining. EES data also reported decreased results for 2016.

AmeriHealth acknowledges certain barriers that influence coordination of care, including, but not limited to:

• facility discharge practices;
• access to electronic records utilized by different health care systems;
• members not keeping health care providers informed of changes in care (e.g., hospital admissions, emergency or urgent care);
• PCPs and specialists not informed of all providers involved in the member?s care (i.e., other specialists);
• for members with multiple complex conditions, lack of identification of a PCP.

Our goal is to assist providers in facilitating the coordination and collaboration of care to achieve optimal outcomes. AmeriHealth offers the following resources to network providers:

• Clinical Practice Guidelines
• NaviNet^® web portal
• HealthShare Exchange of Southeastern Pennsylvania
• Care Management Programs

Providers are also encouraged to utilize the Clinician Collaboration Form located on the Worksheets, Forms, and Guides web page for New Jersey and Pennsylvania.

¹Gulliford, M., Naitani, S., Morgan, M. ?What is ?continuity of care??? J Health Serv Res Policy. 2006 Oct;11(4):248-50. Available from: https://www.ncbi.nlm.nih.gov/pubmed/17018200.

HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA). Used with permission.

NaviNet is a registered trademark of NaviNet, Inc.