Care Coordination Agreements: Barriers, Facilitators, and Lessons Learned

Background:

With growing pressure to improve the quality and coordination of care, physicians feel a need to streamline their relationships with other practitioners around shared care for patients. Some physicians have developed written agreements that articulate the respective responsibilities of 2 or more parties for coordination of patient care, ie, care coordination agreements (CCAs).

Objectives:

To describe how CCAs are formed and explore facilitators and barriers to adoption of effective CCAs, the extent to which CCAs may be replicable in different market contexts, and the implications for policies and programs that aim to improve the coordination of care.

Study Design:

Qualitative study of primary care physicians participating in CCAs and representatives of their specialist, hospital, or communitybased partners.

Methods:

Semi-structured interviews with participating providers and national thought leaders in care coordination were reviewed to develop key themes.

Results:

Agreements that address referral and access processes were considered useful by all practices that had implemented them. Practices that implemented agreements including guidance on shared management of specific clinical conditions (comanagement) also found them useful. CCAs were most successful in settings where both parties to the agreement already had stable communication pathways (such as an electronic health record [EHR], designated staff) and strong working relationships.

Conclusions:

Policy changes (such as shifts in reimbursement to favor collaborative care or clarification of laws governing such collaborations) can help to support the development and implementation of CCAs, and can address factors that currently make some markets less supportive of coordination.

(Am J Manag Care. 2012;18(11):e398-e404)Primary care providers seeking to improve their patients’ access to and coordinate care with specialists, hospitals, and community-based organizations may struggle to build and maintain relationships with these entities. Care coordination agreements are written agreements that delineate the way primary care practices will share care responsibilities with these partners.

• Practices that have piloted this approach report improved access and quality of care, but note several pitfalls that can limit their utility.

• Changes in policy and care reimbursement can encourage further development of these agreements.

Physicians face significant challenges in coordinating care. Patients (particularly those with chronic illnesses) often see many providers; 1 study found that the typical fee-for-service Medicare beneficiary sees 7 different physicians in 4 different practices during 1 year.¹ Poor coordination may result in patients receiving conflicting advice from different providers (including conflicting medication prescriptions), and in lack of follow-up for new diagnoses, tests, or procedures posing risks to patients’ health.² The burden of care coordination may be particularly high for primary care providers (PCPs), who are charged with serving as the hub for communication and decision making between patients and all of their providers.³

While there is no single recipe for effective coordination, one promising strategy is the use of “service agreements” or “care coordination agreements.” Care coordination agreements (CCAs), written agreements that articulate the respective responsibility of 2 or more parties for ensuring coordination of patient care, can be helpful tools that allow PCPs to define the level of care expected from themselves and other providers, and to set out specific tasks for which each partner will be responsible. Similar care coordination efforts organized by insurers have been associated with decreased costs and, in some cases, increased quality of care.⁴ The American College of Physicians has endorsed further exploration of these agreements, particularly in the context of the patientcentered medical home,⁵ and has developed a set of model agreements.⁶ The National Committee for Quality Assurance’s 2011 standards and guidelines for the Patient-Centered Medical Home allow the development of service agreements between PCPs and specialists to count toward accreditation.⁷

CCAs have been adopted by a diverse group of primary care practices and in varied market contexts. A limited literature^8-10 suggests that CCAs can improve care coordination in certain tasks. There is also anecdotal evidence to suggest that CCAs are more common than they appear to be in the formal literature.¹¹ However, little research has been done to describe the circumstances under which CCAs are most likely to develop, to discuss common features, and to weigh the implications of having these agreements in place.

Design

Care coordination agreement cases are defined for the purpose of this study as dyads of a PCP and a partner (specialty practice, hospital, long-term care provider, urgent or emergent care provider, or community-based organization) that have agreed for at least 6 months to coordinate the care of shared patients. Further, CCAs must involve, if not focus on, delineating responsibilities of each party in the agreement so as to better coordinate patient care between a PCP and the other provider. The agreements should be in the form of a written document, or else have generated written supporting materials such as standardized referral forms, guidelines, protocols, or electronic medical record (EMR) support.

Participants and Methods

Under these criteria, practices were identified across the United States through iterative networking via contacts and e-mail listservs for Patient-Centered Medical Home initiatives as well as national primary care, specialty care, urgent care, and pharmacy societies. We purposively selected practices/organizations to include a range of characteristics in terms of size (small, medium, and large practices), ownership type, geography, and rural/urban and suburban settings. During a screening call, we identified practices/organizations that had a CCA supported by written agreements that the partners were willing to make available to the research team.

In all, 37 telephone interviews were conducted from July 2010 to April 2011 with 6 national experts who have published extensively in the peer-reviewed literature on care coordination and related issues or are leaders of national organizations at the forefront of policy related to care coordination, and 31 healthcare providers representing 15 partnerships. (One PCP was interviewed regarding 2 separate partnerships.) Respondents included independent practitioners, hospital-employed physicians, and physicians working in not-for-profit, academic, safety-net, and Veterans Affairs settings. Urban, suburban, and rural respondents were represented. No participants refused to be interviewed.

Notes were transcribed verbatim and jointly reviewed by both the lead interviewer and the research assistant for quality and validation purposes. The interview responses were coded and analyzed using Atlas.ti, a qualitative data management and analysis software tool.

Participants were required to submit a copy of each CCA or its supporting material to analyze its content and verify respondents’ assertions. A database of selected CCA agreements is available upon request to the authors.

RESULTS

We identified 15 CCAs. Five of the partnerships were with specialist practices, 6 were with hospitals, 5 involved community-based organizations such as behavioral health providers, and 1 involved an emergency care provider. (In some cases, agreements involved more than 2 participants.) Six agreements exclusively involved practices and organizations working with children; the remainder involved practices treating adults or all ages. Six were staffed by 5 or fewer physicians, and an additional 5 were staffed by 6 to 10 physicians; the remainder were larger practices. Through these CCAs, providers divide up the work of patient care, using some combination of broad strokes aimed at defining the relationship between 2 practices and specific details that help to standardize joint management of particular conditions. These agreements are generally developed at the practice or Independent Practice Association level rather than by individual physicians within practices. The following section describes attributes of CCAs in greater depth (see Table 1 for the frequencies with which various elements appear in CCAs).

Types of Care Coordination Agreements

Based on themes raised in respondents’ descriptions of their agreements, we identified 2 principal types of CCA. The first, which at times has been called a master service agreement, includes broad agreements as to how providers should generally conduct referrals and transitions of care. An example of one such agreement between primary care providers and specialists requires participants to “define responsibilities between PCP, specialist, and patient” and “maintain competency and skills within scope of work and standard of care.” The second type are comanagement agreements, which delineate specific understandings regarding division of tasks for comanagement of particular conditions (for example, a detailed algorithm outlining the process by which children with pediatric voiding dysfunction will be first evaluated by their pediatrician and then, if necessary, referred to a pediatric urologist). Many CCAs include elements of both types (for example, a master service agreement setting general expectations for interactions between participants as well as specific comanagement agreements for conditions of particular interest). (See Table 1, listing CCA characteristics among the practices evaluated for this study.)

Most Useful Features of Active CCAs

Coordination tasks most commonly addressed by existing CCAs include ensuring timely access for patients and standardizing the content in information transfer, as well as ensuring timeliness of information transfer and clear division of clinical comanagement responsibilities.

Referral and Access

Nearly every agreement addresses the mechanics of how referrals are requested and conducted. Respondents reported that limited access to referrals was often the strongest motivation to initiate the agreement in the first place. In general, the more standardized the referral process described in a CCA, the more consistently partners tended to apply the agreement and the more partner practices praised their utility.

Comanagement

Elements detailing the shared management of specific conditions were found in roughly half of the agreements we reviewed, and were described by all respondents who had developed them as a useful feature. For example, a comanagement agreement between a PCP and a pharmacist stipulates that for diabetic patients the pharmacist can order specific tests under the physician’s license and can adjust medications according to an agreed-upon protocol based on the test results.

Comanagement agreement elements include:

• Specifications for proper referral preparation for selected conditions, including transfer of records, workup, and education of the patient prior to specialist evaluation

• Evidence-based care protocols

• Continuing medical education for PCPs on comanagement of certain conditions

Providers generally developed generic comanagement plans for certain health problems in advance (for example, listing in advance the tests and therapies that a primary care provider would provide for a patient before arranging a consultation with a specialist), rather than customizing plans for each individual patient; in some cases, this meant that a patient could experience care that reflected a specialist’s input without ever leaving the PCP. A urologist who worked in a market with limited specialist availability reported his PCP colleagues would initiate a jointly developed process of evaluation and treatment, which frequently resolved patients’ symptoms before they were able to schedule a specialist visit. The CCA allowed him to spend more time operating and his practice to offer faster access to new patients.

Colocation

In some agreements, 1 partner had a representative provider who was embedded or co-located within the other partner’s practice; most frequently this was a behavioral health collaborator in a primary care practice. Participants reported that they benefited from what they described as the “osmosis” learning that takes place when providers share space and have the opportunity for frequent casual interactions.

Supporting Materials

Appendix

Practices often developed supporting documents to aid them in their tasks and improve consistency of care coordination (see Table 1 for frequencies of common supporting documents). Seefor details.

Barriers and Facilitators to CCA Establishment

Table 2

In the early planning phases of developing a CCA, many respondents reported having an outside stimulus to motivate providers (see). This might take the form of outside funding for time to develop the agreement, additional administrative support, or funding for additional patient care activities required as part of the agreement that might not otherwise be reimbursed, such as patient education or outreach.

Respondents also cited an organization’s intrinsic sense of mission, willingness to transform, and sense of identity as a leader in its local professional community as drivers of CCA development. Leaders of small independent practices described working with larger institutions as a longer, more cumbersome process. In some situations, champions within large organizations felt they were negotiating not just with their partner organization but also with their own leadership.

Nearly all respondents emphasized the role of strong preexisting relationships and trust. “In the end, it doesn’t matter what is on paper; it’s how you work together,” one respondent said. In fact, many adopters said that the act of discussing and negotiating the CCA was more fruitful than the actual terms of the agreement, which they described as “icing.”

Respondents also emphasized that CCAs had to offer what they called a “win-win”; that is, all partners had to benefit in concrete ways. For example, agreements that codify comanagement responsibilities between specialists and PCPs most often focus on conditions specialists are willing to give up (ie, they can backfill their time with more lucrative or more specialty-specific work) and PCPs are willing to handle (ie, they can be reimbursed appropriately for the costs of providing the care, sometimes at enhanced rates).

Barriers and Facilitators to Initial Implementation of CCAs

Respondents noted several elements that were helpful in initiating CCAs. In particular, staff members (from collaborating practices or a central organization) dedicated entirely or in part to monitoring the progress of the CCA, or facilitating communication between participants, were considered beneficial.

Master service agreements and comanagement agreements each faced unique implementation challenges. For more general master service agreements, parties sometimes found themselves struggling to maintain consensus on “appropriate” follow-up, availability, and cost of services to patients or insurers. Practices were sometimes surprised to learn the extent to which their values were truly shared—not just among their CCA collaborators, but within their own practices. In one case, a PCP champion who had negotiated a stringent agreement with specialist practices reported with chagrin that some of her own primary care colleagues proved to be a barrier during the implementation process: they were uninterested in sharing care and preferred to delegate certain responsibilities entirely to specialists.

Barriers and Facilitators to Long-Term Sustainability of CCAs

Compatible health information technology was the most commonly mentioned facilitator to the long-term sustainability of CCAs. A seemingly trivial barrier to rapid access to CCA details could prove significant over multiple patient encounters: one provider said that simply having agreements maintained on a separate website, rather than integrated directly into its EMR, had diminished compliance.

Except in the case of integrated delivery systems, patients whose care was governed by a CCA generally represented only a fraction of a partner organization’s business. Partners reported that CCAs were difficult to maintain when they did not have an easy, reliable way of knowing which of theirpatients fell under the agreement. A few PCPs wistfully expressed their hope that partner organizations would resolve this problem by simply adopting the principles of the CCA for all of their patients, but no partner organization we interviewed had elected to do so.

DISCUSSION

The CCAs discussed in this study represent emerging efforts at an innovative approach to care coordination among a diverse group of providers. This exploratory analysis describes these agreements and their effects on providers, with the caveat that these tools are still developing and further research will be necessary to fully characterize their impact once more data are available. Below are preliminary lessons learned from the early experiences of providers who have developed CCAs.

Specific Policy Changes Could Facilitate the Development of CCAs

Most providers interviewed stated that CCAs had increased their efficiency and improved the quality of care; this was true even for those respondents who were hard pressed to describe specific ways in which their day-to-day practice had changed. Rather, their perception of benefit often seemed to be rooted in their experience of developing the agreement, with its ongoing existence viewed as a testament to the strength of their relationship with their partners. Respondents with specific comanagement agreements were more likely to point to specific efficiencies or practice improvements. These perceptions of value may reflect greater provider satisfaction, an important potential benefit. Our qualitative analysis found that some communities’ characteristics (such as stable practices with longstanding relationships, the presence of shared information technology, and outside support for the initiation of agreements) were more amenable to CCAs than others. To date, most CCAs are relatively new and there are no published data on the impact of CCAs on healthcare utilization and costs.

While respondents could offer little concrete evidence of benefit from their early use of these agreements, their frequently voiced conviction that these agreements did improve the quality of their care suggests that further exploration of their potential to improve coordination would be helpful. Relatively low-cost policy changes could support providers in developing additional agreements and undertaking formal study of their effects.

Specialty societies can work together to develop joint guidelines for the comanagement of selected conditions, which were described by respondents as among the most useful elements of CCAs. This task may be politically difficult, however, as specialist supply is not uniform and specialists in some markets will be more willing to share patient care duties than others.

Clarifying existing federal laws that govern collaborations between independent practices, particularly with respect to concerns that their agreement could be construed as a kickback or a self-referral, can help to reassure providers. Again, we encountered no examples of providers experiencing legal trouble, but did see several cases where providers were reluctant to enter into agreements because of concerns that they would run afoul of these laws.

Policies affecting reimbursement could have a profound effect on CCAs. For example, policy changes that encourage a shift away from fee-for-service reimbursement and toward capitation, encouraging PCPs and specialty practices or other organizations to participate in ACOs, share accountability for the quality of patient care, and receive bundled payments, could, among many other effects, change the current dynamic that makes specialists in some markets less willing to give up reimbursement for treating conditions that might also be amenable to comanagement, or make providers more willing to communicate with one another about shared care for patients.

Policy makers who help set priorities for funding of research and pilot programs can support further (quantitative) research to determine whether certain types of CCAs are more effective than others in improving the quality, efficiency, and patient-centeredness of care. In particular, providers we interviewed had not yet measured patient satisfaction with overall coordination of care; this is an important part of understanding their use in patient-centered care.

Limitations

This study describes the experiences of a relatively diverse but self-selected group of providers about their experiences with care coordination agreements. As such, it may not provide a representative picture of all providers who have attempted such agreements. Qualitative projects such as this one have both strengths and limitations; while our methodology allowed us to capture respondents’ views both broadly and in depth, we were restricted to a small sample size, and cannot generate meaningfully precise estimates of, for example, the benefits of various CCA elements. In describing their experiences, most respondents did not provide utilization or financial data to verify their accounts, so we may not have accurately captured the effect care coordination agreements had on their practices. Finally, many of the agreements we evaluated were only a few years old, meaning that some of the benefits and challenges may not have been fully realized yet.

CONCLUSIONS

In general, providers who have developed CCAs say they have improved the coordination and quality of care their patients receive. The use of CCAs will likely continue to grow in selected markets and clinical settings, but without reimbursement or policy changes they may not be disseminated more broadly. As CCAs evolve, further study can clarify their effects on clinical practice.Author Affiliations: From Center for Studying Health System Change (EC, MKD), Washington, DC; Centers for Medicare & Medicaid Services (HHP), Baltimore, MD.

Funding Source: This study was funded by the Commonwealth Fund.

Author Disclosures: The authors (EC, MKD, HHP) report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article. This paper is based on work conducted before Dr Pham joined the Centers for Medicare & Medicaid Services, and does not reflect the policies or programs of CMS or of the Department of Health and Human Services.

Authorship Information: Concept and design (HHP); acquisition of data (EC, MKD, HHP); analysis and interpretation of data (EC, MKD, HHP); drafting of the manuscript (EC, MKD); critical revision of the manuscript for important intellectual content (EC, HHP); and obtaining funding (HHP).

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