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The American College of Physicians (ACP) convened a panel today to release a new paper that issues recommendations for more effective collaboration between primary care and specialty physicians to improve patient care. Beyond the Referral: Principals of Effective, Ongoing Primary and Specialty Care Collaboration, lays out how a lack of care coordination when care is provided by more than one clinician can cause fragmented care, increase risks for errors, and cause patient and clinician frustration; and the paper outlines how the process should be improved. The panel took place during a press briefing at Internal Medicine Meeting 2022, ACP’s annual scientific meeting.

“The ways in which our health care system coordinates care between primary and specialty care physicians is broken,” said George M. Abraham, MD, MACP, FIDSA, president, ACP. “Our patients can find the experience frustrating; physicians can often find information they need about their patients difficult to obtain, and we know that together we could be doing better.”

Carol Greenlee, MD, MACP, prior chair, ACP Council of Subspecialty Societies and an author of the paper, and Shari Erickson, chief advocacy officer and senior vice president of governmental affairs and public policy, ACP, joined Dr. Abraham on the panel.

The paper outlines four guiding principles that should underpin primary care and specialty care collaborations:

• Patient and Family Partnering:  Clinical care teams should work collaboratively with patients, families, and caregivers to empower them to be active partners in all aspects of their care. Their needs, preferences, and limitations should be actively predicted, solicited, and considered in all care encounters and decisions.
• Defined Clinical Roles and Responsibilities:  The roles, responsibilities, and mutual expectations of primary care and specialty care team members should be clear and acceptable to all parties, including the patient and family.
• Timely, Productive Communication:  All parties should engage in timely, informative, and focused communication with one another that highlights critical issues and/or items needing action.
• Effective Data Sharing:  Patient data should be shared in a timely, thorough, actionable, and well-organized manner.

“A better functioning system of collaboration between primary care and specialty care physicians has the potential to improve clinician satisfaction, use health care resources more efficiently, and improve patient access to specialty care,” said Greenlee. “Our recommendations can reduce the chance of poor outcomes for our patients.”

Included with the paper, ACP also published a playbook that defines what is needed for each specific role or working relationship when more than one clinician is involved in the care of a patient.  The playbook outlines what are the critical elements of both a referral request and response.

Erickson discussed how ACP has applied these types of principles to advocacy work on models of care.

“The need to improve collaboration between primary and specialty care is at the heart of the Medical Neighborhood Model of care that ACP submitted, alongside the National Committee for Quality Assurance, to the Physician-Focused Payment Model Technical Advisory Committee,” said Erickson.  “We hear from both general internal medicine physicians and internal medicine subspecialist physicians about the deficiencies in our care delivery system.  The Medical Home Neighborhood, following the principles we laid out in our paper, would ensure that when a patient is seeing multiple clinicians care coordination actually happens and is meaningful.”