That's the Disease Management Care Blog's main take-away after reading the Care Continuum Alliance's "Population Health Management in Physician Practice: A Call to Action."
The CCA commissioned a survey that asked 105 primary care physician leaders about the implementation of population health-based care coordination in their clinics. The clinics were from all regions of the U.S. and ranged in size from 5 to 95 physicians (a total of 1,916 physicians with a mean of 18). To be included in the survey, they had to be planning or had already implemented patient-centered care initiatives, many of which were modeled after the medical home. 93% already had an electronic record and10% reported being part of an Accountable Care Organization (ACO).
First the good news.
Over and beyond hiring non-physician providers (96% had at least one nurse practitioner and 70% had a physician assistant), 91% reported that they had hired a "care coordinator." What's more, 85% said that population health was conceptually important in their practices and the majority 55% rated this as either a "4" or "5" on 1 to 5 scale.
But the bad news is that less than half were familiar enough with the concept to fully implement it in clinical practice. The number one challenge in this area was the difficulty in making sure that roles and responsibilities of the care coordinators were appropriately defined.
It should be noted that the practices surveyed in this report were not typical of primary care, where experience with care coordination is even lower. This was a elite group of innovators on the cutting edge of primary care who had committed precious resources and already were hiring care coordinators. Yet even these select clinics risk being operationally stymied by not knowing how to effectively implement it in their practice settings.
The CCA report appropriately concludes with a call for education, tools and support to help physicians fully implement this in their clinics. The DMCB wholeheartedly agrees. Based on this report, hiring care coordinators is certainly necessary but isn't sufficient to attain high quality population health.
We still have our work cut out for us.