The Challenge of Care Coordination

As an endocrinologist, care coordination is something I struggle with in my clinic. There being only 200 or so endocrinologists in the Philippines, I often see patients from places where there are no endocrinologists. They travel great distances to see me. As you can imagine, persons with diabetes will need care from others such as an ophthalmologist, cardiologist, nutritionist, dentist etc. These healthcare professionals may or may not be available where the patients live. If they are not available where they are, I have to choose who to refer to in the faculty medical arts building (attached to a medical school and a university hospital) where I hold clinic and ask my secretary to schedule an appointment for them. While all medical specialties are housed under one roof, scheduling can be hit or miss. Sometimes, the patient can be seen that same day before they travel back home and sometimes not. Tracking whether the patient has indeed been seen is another problem. I can find out months later when the patient comes to her appointment with me that she was not seen for example by an ophthalmologist despite my referral.

If the healthcare professional I need to refer my patient to can be found in their home province, I write a referral letter – often to a doctor I don’t know or never met. Sometimes I get a reply back but most often I don’t. I have to ask my patient when he follows up about the progress of his care with the other doctor. Frustratingly, some doctors change my patient’s medications without coordinating with me, undoing the progress made in controlling blood sugar. This often happens when the patient is on insulin. A doctor who is uncomfortable in managing a patient on insulin may attempt to shift the patient to oral medication.

It is not only healthcare professionals I need to coordinate with but also funding agencies where patients can seek support for their treatment. I am asked to write clinical abstracts and fill up forms. One particular frustration I have had with one government office (I will not name) was when my patient was denied support because his diabetes was controlled. The diabetes was controlled because he was on medication he was struggling to pay for. Without telling me, my patient stopped taking his medicines for a week, had his blood sugar checked (which was of course elevated at this time) and re-submitted his application for support. His application was finally approved. Thankfully, this is a rare occurrence.

What is care coordination? The Agency for Healthcare Research & Quality describes it this way –

Care coordination involves deliberately organizing patient care activities and sharing information among all of the participants concerned with a patient’s care to achieve safer and more effective care. This means that the patient’s needs and preferences are known ahead of time and communicated at the right time to the right people, and that this information is used to provide safe, appropriate, and effective care to the patient.

On August 20 9 pm Manila time, join the #HealthXPH tweet chat where we will discuss care coordination.

T1 Why is care coordination difficult?

The short answer – because care is fragmented.

Reducing Care Fragmentation: A Toolkit for Coordinating Care. (Prepared by Group Health’s MacColl Institute for Healthcare Innovation, supported by The Commonwealth Fund), April 2011. This helpful reference can be downloaded here.

T2 How can we improve the referral process?

How can we track what happened to the referral? How can information be transferred efficiently from the referring doctor to where it is needed? How can any change in management be communicated among the team members taking care of the patient?

T3 How can we support patients and families during care transitions?

Do you have a referral network? I work with a cardiologist who refers his patients with uncontrolled diabetes to me. He expects that after I have adjusted the patient’s medications and the diabetes is controlled that I will refer the patient back to his clinic. I do so happily, knowing that this reduces my waiting list. I also feel confident that he will know when it is time to refer back again.