Colorado Medical Society Colorado HMO Association RECOMMENDATIONS FOR TRANSITION OF CARE FOR PATIENTS WITH SPECIAL NEEDS AND CIRCUMSTANCES

PREAMBLE

In the process of transitioning of care from one health plan to another, at times it becomes necessary for a patient to leave an ongoing doctor-patient relationship during treatment of a chronic or protracted medical condition and establish a relationship with a new physician. There is great value to the care of the patient in developing a process to facilitate such transfer with minimal disruption to all involved parties.

The recommendations presented herein are designed to recognize the special needs of certain patients with chronic or protracted illnesses who are under the care of either a primary care or specialty care physician at the time of transition. They provide a preferred method by which the patient interacts with the two physicians at both ends of the transition and the new health plan. They provide a framework which is simple and flexible, compensates the transferring physician for the time and effort expended, gives highest priority to concern for patient satisfaction, and promotes an effective vehicle for health plans to transition potentially high cost patients into their plan.

Developed through discussions between the Colorado Medical Society and the Colorado HMO Association, these recommendations are presented to health plans and physicians for their voluntary adoption.

RECOMMENDED ELEMENTS OF TRANSITION

1) EARLY NOTIFICATION. Typically a patient who will be changing plans involuntarily will have a time delay between the notice of change and the effective date. The patient should advise the current physician practice as soon as possible.

 

A. Health plans should make available: (1) A written description of the process used to facilitate transition of care, (customer service, new member nurses, etc.) (2) a written description of its review process of requests to continue services with an existing, non-affiliated provider.

 

2) IDENTIFICATION OF PATIENTS WITH SPECIAL NEEDS AND CIRCUMSTANCES. Current physicians are expected to identify patients with unique needs and initiate a process to facilitate their transition to a new provider.

A. Health plans should make available to those patients so requesting, available participating providers (primary care and specialty practices) and how to contact them to ease referral and selection.

B. If requested by the patient, it is appropriate for the current physician to suggest a physician to the patient, and then begin communication with that physician.

 

3) TRANSITION PLANNING VISIT. The current physician and patient should schedule a visit in the period before effective date of new plan to plan a smooth transition to the accepting physician's practice.

 

4) TRANSFER OF PATIENT INFORMATION. The current treating physician should: (A) Collect and prepare for transfer of adequate medical records to inform accepting physician of patient's past medical history, treatment modes, medication history, pertinent diagnostic measures, current treatment plan, etc. and, (B) create a letter of referral summarizing pertinent historical and biographical data to facilitate accepting physician's development of rapport with the patient and family.

 

5) INTRODUCTORY VISIT TO ACCEPTING PHYSICIAN. Should be arranged as soon as practical after effective date of new plan. The current treating physician should make a recommendation to the patient regarding the timeliness of scheduling the first appointment. The purpose is to begin development of relationship, ensure pertinent records are available, prescriptions are transferred if necessary and consideration of ancillary needs (durable medical equipment, etc.).

 

6) PHYSICIAN TO PHYSICIAN CONSULTATION. It may be appropriate for former and accepting physicians to formally consult regarding patient's unique needs.

 

7) COMPENSATION. Fair and appropriate compensation should be paid promptly for each of these services by the plan in effect at the time of service.

These recommendations should also apply when a physician is separating from a health plan. When: (A) The physician is voluntarily leaving the plan, the physician should initiate the transition process. (B) The plan initiated disaffiliation, the health plan should initiate the transition process.

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