Continuity and coordination of care
IMPROVEMENTS IMPLEMENTED: Communication and coordination of patient care
Sanford Health Plan members are encouraged to pick a primary care provider (PCP) from our participating provider listing but are not required to have a PCP. The Plan’s Customer Service Department is available to assist members in selecting a provider by providing information on the location of the provider’s offices and their specialties.
The Plan strongly believes in the concept of the primary care provider functioning as the coordinator of all health care provided to a member. The primary care provider’s responsibilities for Plan members includes: evaluating the member’s needs, recommending and arranging for services required by the member, and facilitating communication and information exchange among the different practitioners and providers treating the member.
As you know, communication between primary care physicians and specialists, including behavioral health specialists, is crucial to the overall care of patients. Sanford Health Plan’s goal is to ensure that our members receive seamless, continuous and appropriate care regarding diagnosis, medication and treatment plans whether in an inpatient or outpatient setting. Coordination of care is essential to promote safe, proper and unduplicated health care.
Sanford Health Plan’s policy: Continuity and Coordination of Care
- PCPs should assume responsibility for the coordination of medically approved services required by members and should oversee all general medical care for their patients.
- Members are informed by the Plan of the importance of contacting their PCP whenever the member believes that medical services are needed. The only exception to this will be emergency services, which are medically necessary. In these situations, members are instructed to contact their PCP as soon as possible after receiving the emergency services to arrange for follow-up care.
- Members are reminded on all authorization letters to request that all of their health care providers send their medical records, such as office notes, laboratory results, x-ray results and/or medication lists to their PCP to ensure seamless medical care and treatment and to ensure that they have all of their health information in one location.
- Members have the right to select a Primary Care Practitioner (PCP) of their choice. If a member is dissatisfied for any reason with the PCP initially chosen, he/she has the right to choose another available PCP.
- All providers (PCPs, specialist, behavioral health practitioners, etc.) should systematically send relevant clinical information in a timely manner to the practitioner the patient is being referred to or has been referred from. Depending on the circumstances, relevant clinical information can include any of the following:
- Consultation/visit notes
- Medication lists
- Therapy notes
- Lab and imaging reports
- History and physical
- Rehabilitation evaluations
- Operative and pathology reports
- Hospital records/discharge summaries
- Treatment plans
- Progress notes
- Providers should review clinical information received from another practitioner in a timely manner and determine if further contact is needed to initiate additional care/visits.
- When a member is referred to a specialist provider, the specialist will be expected to send a report to the PCP regarding the care, treatment and progress of the patient and inform the member of the recommended treatment plan. However, if the member does not wish his/her PCP to receive medical information from the specialist, that is the right of the member.
- In the event a member requires hospitalization, participating practitioners will be expected to follow the member during the course of the hospitalization. If the admitting practitioner is other than the PCP, the practitioner should continually update and provide progress reports to the PCP. The practitioners should also coordinate follow-up care with the patient and/or family.
- For patients transitioning to another level of care, providers should develop a transition plan with the patient and/or family.
- Members have the right to fully participate in all treatment decisions related to their health care. Members who are unable to participate in treatment decisions have the right to be represented by parents, guardians, family members or other representatives.
- Providers should educate members regarding their unique health care needs; share the findings of history and physical examinations; discuss potential treatment options (without regard to plan coverage), side effects of treatments and management of symptoms; and, in general, recognize that the member has the right to choose the final course of action among clinically acceptable choices. A choice of treatment must not be made without prior consultation with the member as member acceptance and understanding of the treatment plan facilitates successful care outcomes.
- Providers are responsible for informing members of the specific health care needs that require follow-up and for ensuring that members receive, as appropriate, training in self-care, medication management, use of medical equipment, potential complications and when these should be reported to the practitioner, scheduling of follow-up services and patient education as part of discharge planning.
- Providers are responsible for counseling and facilitating service availability for members who are unable to, or are failing to; cooperate with their own treatment plan. These services should identify social, financial, or other barriers that are preventing members from cooperating with treatment plan and refer them to the appropriate social service entities.
Sanford Health Plan has resources to help you with the challenges of coordinating patient care. Our Utilization Management and Customer Service staff are available to work with all parties and ensure appropriate care.