Opportunities for Rural Primary Care to Improve Continuity and Person Centeredness
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This observational descriptive study focuses on the communication patterns that occur between members of a healthcare team. The goal was to identify where the system breaks down are and recommended approaches to improve the care being provided to high-risk and high cost patients. The theory of relational coordination provides the theoretical framework necessary to support this project. Seven high-risk patient cases who were recently discharged from the emergency department (ED) and had a risk stratification score of greater than or equal to four were included in the study. A type of microanalysis referred to as coordination process diagramming (CPD) along with the development of a communication process content table (CPCT) was used to analyze the information gathered. From the analysis recommendations to prevent the breakdown of communication between health care providers and to improve the care of high risk patients were made. Results demonstrate that “delays in care” was the most common category for communication breakdowns. The informal emergency room (ER) follow-up process resulted in delays in outreach and follow-up office visits. Furthermore, many conversations between health care team members are not being documented in the electronic health record (EHR). Recommendations for this practice included considering the use of a transitional care manager, ensuring the documentation of all conversations and developing a more systematic ER follow-up process employing the use of admission, discharge and transfer messages (ADTs). Having efficient and effective communication between health care team members is one step in improving the care for high-risk and high-cost patients.