The Importance of Care Management Communication: Keisha’s Story

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care-management-communicationKeisha remembers periodically feeling a racing heart for most of her adult life, but it wasn’t until her early fifties that a diagnosis of atrial fibrillation (an irregular heart rhythm) was finally confirmed. Medical treatment helped slow her heart rate, but did not reverse her to a normal heart rhythm. In order to prevent the formation of blood clots in her heart that could result in a stroke, her primary care physician (PCP) placed her on anticoagulants (blood thinning medication). In an effort to lose weight, Keisha started a daily routine of exercise. As she increased her exercise, she began to feel pressure in her chest. When the chest discomfort progressed, she went to see her PCP. Her EKG was normal, but because of a family history of heart attacks, her PCP referred her to a cardiologist for a cardiac catheterization. On arriving at the cardiac unit, it was discovered that Keisha’s anticoagulation level was far too high to allow her to safely undergo the catheterization without serious risk of post-procedural bleeding. The cardiologist decided to postpone the catheterization and send her home. Two nights later, Keisha came to the local emergency department with extreme chest pain and was diagnosed with a severe heart attack (This is a true patient story, but not her actual name.)

Problems Facing Care Management and Communication

In 2011, the National Academy of Medicine (NAM, formerly the Institute of Medicine) identified patients and providers as the groups who must be engaged to improve the quality, safety, and cost of care. The NAM emphasized that informed and engaged patients coupled with effective physician-to-patient and physician-to-physician communication were essential to achieving the Triple Aim (improving the health of populations, improving the experience of care, and reducing per capita costs of health care).

Effective communication between clinicians responsible for the care of the same patient has long been recognized as essential to good care. However, the literature is replete with evidence that this communication is often less than ideal. A study published in JAMA Internal Medicine (formerly the Archives of Internal Medicine) in 2011 entitled Referral and consultation communication between primary care and specialist physicians: finding common ground concluded that there are major differences in the perceptions of communication among primary care physicians and consultant physicians. Although 69.3 percent of PCPs reported that they informed specialists regarding the patient’s history and reason for consultation “always” or “most of the time,” only 34.8 percent of specialists said they received this information “always” or “most of the time.” Consultation results were sent to the referring PCP “always” or “most of the time” according to 80.6 percent of specialists, but only 62.2 percent of PCPs reported receiving these results “always” or “most of the time.”

According to the Joint Commission, ineffective hand-off communication is a critical patient safety problem in health care. The Joint Commission estimated 80 percent of serious medical errors involve miscommunication between caregivers during the transfer of patients. In addition to causing patient harm, defective hand-offs can lead to delays in treatment, inappropriate treatment, and increased length-of-stay in the hospital.

A study of malpractice claims between 2009 and 2013 by CRICO indicated that communication problems were a contributing factor in 30 percent of medical malpractice cases. This percentage included 1,744 deaths and $1.7 billion in hospital costs. In addition, 37 percent of all high-severity injury cases or deaths involved communication failures. The researchers further concluded that the problem is likely much larger as there are probably numerous communication-related patient harm events and costs that do not result in malpractice claims.

The Importance of Communication Among the Care Management Team

As expanded interdisciplinary care teams fall into place to deal with the complexities of modern healthcare and to manage population health, effective communication is becoming even more important. For teams to effectively coordinate care and improve health outcomes, good communication is critically important. One cannot occur without the other.

Many clinicians and healthcare administrators do not receive training in communicating with their colleagues or patients. To overcome this problem, regulatory agencies are developing strategies and tools to improve communication. For example, the Agency for Healthcare Research and Quality and the Department of Defense have jointly developed the TeamSTEPPS program to improve communication and foster more effective teamwork in pursuit of higher-quality, safer, and more cost-effective care. This includes information exchange strategies and tools such as SBAR, check-backs, call-outs, and handoff protocols. While many aspects of this program are inpatient focused, they are largely applicable to care across the continuum.

Furthermore, standard, evidence-based clinical guidelines are increasingly becoming an important part of clinical practice. As defined by NAM, clinical guidelines are “systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.” Guidelines are important for many reasons including to serve as a tool for making care more consistent and efficient and for closing the gap between what clinicians do and what scientific evidence supports. They are also important for improving communication among care providers and assuring every patient receives the best possible care.

Good Care Management Communication Matters to Patients

With respect to Keisha, how might communication improvement strategies and tools have improved her care and avoided an unnecessary heart attack? While Keisha had been assigned a nurse care manager to help manage her heart arrhythmia and anticoagulation as a part of an at-risk insurance contract, the care manager was not informed of the patient’s chest pain and cardiology referral. The PCP informed the cardiologist of Keisha’s chest pain, but failed to mention the patient’s history of atrial fibrillation and long history of anticoagulation. As a result, neither the cardiologist or the nurse care manager were aware of the need to implement the standard, evidence-based pre-catheterization protocol that had been created specifically for patients on blood thinners. If the cardiologist or the nurse care manager had been adequately informed of Keisha’s complete clinical situation, either could have implemented the protocol that would have allowed the catheterization to occur. If the catheterization had occurred, Keisha’s extensive coronary vessel disease would have been recognized and appropriately treated with placement of cardiac stents, thereby avoiding unnecessary harm and higher costs.

As healthcare organizations attempt to improve their population health management capabilities, effective care management is becoming increasingly important. Highly effective communication is critically important in providing top-quality patient care. When communication breakdowns occur, it is often the result of poor verbal communication between members of the care team, ambiguity about roles and responsibilities, information gaps during decision making, and/or inadequate tools in place to support effective communication. Any breakdowns in communication among members of an interdisciplinary care team—including the patient—can lead to clinical complications, deaths, and unnecessary costs.

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