Primary Care-Specialist Physician Collaborative Guidelines for Patient Engagement
These guidelines were developed to help you our patient understand the roles played by your primary care physician and specialist in the care delivery process.
• To provide optimal health care for our patients.
• To provide a framework for better communication and safe transition of care
between primary care and specialty care providers.
• Safe, effective and timely patient care is our central goal.
• Effective communication between primary care and specialty care is key to providing
optimal patient care and to eliminate the waste and excess costs of health care.
• Mutual respect is essential to building and sustaining a professional relationship and
• A high functioning medical system of care provides patients with access to the ‘right
care at the right time in the right place’.
• Primary Care Physician (PCP) – a generalist whose broad medical knowledge
provides first contact, comprehensive and continuous medical care to patients.
• Specialist – a physician with advanced, focused knowledge and skills who provides care for patients with complex problems in a specific organ system, class of diseases or type of patient.
• Prepared Patient – an informed and activated patient who has an adequate understanding of their present health condition in order to participate in medical decision--making and self--management.
• Transition of Care – an event that occurs when the medical care of a patient is
assumed by another medical provider or facility such as a consultation or hospitalization.
• Technical Procedure – transfer of care to obtain a clinical procedure for diagnostic,
therapeutic, or palliative purposes.
• Patient-Centered Medical Home –a community-based and culturally sensitive model
of primary care that ensures every patient has a personal physician who guides a team of health professionals to provide the patient with accessible, coordinated, comprehensive and continuous health care across all stages of life.
• Patient Goals – health goals determined by the patient after thorough discussion of the diagnosis, prognosis, treatment options, and expectations taking into consideration the patient’s psychosocial and personal needs.
• Medical Neighborhood – a system of care that integrates the PCMH with the medical community through enhanced, bidirectional communication and collaboration on behalf of the patient.
Types of Transitions of Care
• Pre-consultation exchange – communication between the generalist and specialist to:
.......1. Answer a clinical question and/or determine the necessity of a formal consultation.
.......2. Facilitate timely access and determine the urgency of referral to specialty care.
.......3. Facilitate the diagnostic evaluation of the patient prior to a specialty assessment.
• Formal Consultation (Advice) – a request for an opinion and/or advice on a discrete question regarding a patient’s diagnosis, diagnostic results, procedure, treatment or prognosis with the intention that the care of the patient will be transferred back to the PCP after one or a few visits. The specialty practice would provide a detailed report on the diagnosis and care recommendations and not manage the condition. This report may include an opinion on the appropriateness of co--management.
• Complete transfer of care to specialist for entirety of care (Specialty Medical Home Network) – due to the complex nature of the disorder or consuming illness that affects multiple aspects of the patient’s health and social function, the specialist assumes the total care of the patient and provides first contact, ready access, continuous care, comprehensive and coordinated medical services with links to community resources as outlined by the “Joint Principles” and meeting the requirements of NCQA PPC--PCMH recognition.
• Co-management – where both primary care and specialty care providers actively contribute to the patient care for a medical condition and define their responsibilities including first contact for the patient, drug therapy, referral management, diagnostic testing, patient education, care teams, patient follow--up, monitoring, as well as, management of other medical disorders.
• Co--management with Shared management for the disease - the specialist shares long--term management with the primary care physician for a patient’s referred condition and provides expert advice, guidance and periodic follow--up for one specific condition. Both the PCMH and specialty practice are responsible to define and agree on mutual responsibilities regarding the care of the patient. In general, the specialist will provide expert advice, but will not manage the condition day to day.
• Co-management with Principal Care for the Disease (Referral) – the specialist assumes responsibility for the long--term, comprehensive management of a patient’s referred medical/surgical condition. The PCMH continues to receive consultation reports and provides input on secondary referrals and quality of life/treatment decision issues. The generalist continues to care for all other aspects of patient care and new or other unrelated health problems and remains the first contact for the patient.
• Co--management with Principal Care for the Patient (Consuming illness) – this is a subset of referral when for a limited time due to the nature and impact of the disease, the specialist practice becomes first contact for care until the crisis or treatment has stabilized or completed. The PCMH remains active in bi--directional information, providing input on secondary referrals and other defined areas of care.
• Emergency care – medical or surgical care obtained on an urgent or emergent basis.