9: Comprehensiveness and Care Coordination
This refers to the capacity of a practice to provide most of what patients need. Another pillar – care coordination – is the responsibility of primary care to arrange for services that primary care is unable to provide.
When a patients needs go beyond primary care practice’s level of comprehensiveness, care coordination is required with the other members of the medical neighbourhood, such as hospitals, pharmacies, and specialists. In high performing systems, clinicians automatically learn when their patients have been discharged from the hospital, and specialist’s referrals are used to their greatest capacity because diagnostic studies are secured in advance by the primary care clinician.
Improving care coordination requires teams because busy clinicians lack the time required to coordinate care for every patient with every health care institution. High-performing practices often include a care coordinator or referral coordinator whose sole responsibility is care coordination.