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Pediatric Care Coordination: A Case Study
Five strategies for improving care coordination and access to specialty care.
Russell W. Kohl, MD, FAAFP: Peter B. Moyer, MHCL, CCLS; Cecilia L. Saffold, PMP, CHTS-PW
Author Disclosures: The authors are employed by TransforMED, a wholly-owned not-for-profit subsidiary
of the American Academy of Family Physicians.
Keywords: patient handoff, care coordination, pediatrics, community health networks, access to health
care, referral and consultation
Abstract
This article describes a pediatric care coordination project aimed at improving access,
communications and satisfaction among physicians, staff and patients. The project involved a large
pediatrics organization and three referral specialty practices highly utilized by the pediatrics
organization. The interventions were focused on five components of care coordination: referral
guidelines used, records transferred, communication modalities used, referral management workflow,
and co-management protocols. This article highlights the intervention strategies, participants and
outcomes of the project.
Introduction
More and more, physicians are feeling the need to achieve the so-called triple aim—to improve health
and the experience of health care for patients while decreasing the cost of health care. That is a
daunting challenge in itself, but add to that the implied challenge of finding solutions that are
manageable and cost-effective for physicians, and it seems next to impossible. Nevertheless, that is
what physicians in one Michigan city set out to do for an important subset of their patients.

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The project began as a collaboration between Priority Health, a Michigan based health plan, and
Spectrum Health, a health system based in Grand Rapids, MI. The goal was simple, though not easy
to achieve: to improve care for the children of the community by improving care coordination between
primary care and specialty practices while at the same time improving patient and physician
satisfaction. Specifically, they set out to better coordinate the largest pediatric primary care
organization in the community, We Are For Children, and three highly utilized specialty practices in
the community—practices in neurology, orthopaedics and pulmonary medicine. While the partner
organizations enlisted the help of our firm (TransforMED) in their project, the approach they took and
the principles underlying it may serve as a model for other organizations undertaking similar projects
on their own. This article describes the strategies used in the project. Data were collected before and
after the intervention to help measure the effect of the project on access and satisfaction.
To make the project as efficient as possible, TransforMED identified five focus areas to work on:
• Referral guidelines
• Records transfer
• Communication modalities
• Referral management workflows
• Co-management protocols
These five components offer high potential for improvements in specialty care access as well as
patient, staff and physician satisfaction. Over the course of the next nine months, interventions targeting
each of the five components were launched. These interventions included eight collaborative
workgroup sessions to develop solutions within these focus areas and monthly conference calls to assist
with the implementation of improvements. TransforMED provided session- and practice-level support, as
well as project facilitation. Changes implemented in the five focus areas are highlighted below.
Referral Guidelines. Specialty care and primary care physicians identified the conditions that
occasioned most referrals in their community and developed guidelines for each of them. While
specialty care physicians drafted the initial guidelines, a collaborative group process involving both
specialty and primary care physicians was used to review, discuss and modify them. Once
participants had established agreed-upon clinical protocols and referral criteria, they were able to
define urgent, emergent or routine referral status in a way that was understood and valued by specialty
and primary care physicians alike. The finished guidelines are available online at
http://www.helendevoschildrens.org/guidelines. Some pediatric primary care physicians built the
referral guidelines into their electronic medical records (EMR) system as clinical decision guides. Now
primary care physicians can quickly reference the community-endorsed guidelines when they are
thinking about referring a patient with one of the identified conditions. With the guidelines in place,
everyone is on the same page, which has improved access, saved time and improved satisfaction.
Records transfer. Specialty and primary care physicians determined the “ideal” set of patient records
to be transferred for each covered condition at the time of referral. This is a key efficiency; too much or

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too little information can create bottlenecks, callbacks, extemporaneous faxes, and wasted time for all
participants involved in the referral loop. One advantage the physicians in this project had was a
robust health information exchange, Michigan Health Connect (MHC). Michigan Health Connect has
an automated e-referral system that can be set up to meet the needs of all physicians in the referral
loop. The specialty groups were able to add the standard lists of needed records on MHC, so a
referring physician’s referral coordinator could be sure that he or she was sending the right information
to the specialist. This process greatly reduced phone calls and faxes between offices during the referral
process, thus saving time and money.
Communication Modalities. Specialty and primary care physicians identified the ideal means of
communicating between practices and physicians. Most referrals are now communicated to specialty
care practices exclusively through MHC, with visit summaries from specialty care practices are made
available instantaneously, also on MHC. The MHC e-referral system is equipped with tracking
capabilities, so primary care offices can effectively track their referrals to the specialty physicians. The
practices are still working toward an electronic messaging system that will further enhance
communication. The workgroup sessions held regularly for the duration of this project will continue into
the future to ensure continuous improvement in communications and processes. A primary driver of
project success was the participants’ ability to communicate effectively with each other during the
intervention.
Specialty and primary care physicians also thought they needed to address patient and caregiver
concerns about referrals. Primary care physicians often felt pressured to provide a referral based on a
family’s perceived need for one. Given the prevalence of well-intentioned but misinformed patients and
caregivers, project participants set out to provide educational materials to reduce worry and deal with
misconceptions about referrals. The referral guidelines proved a helpful way to reassure parents that all
physicians were on the same page. Helen Devos Children’s Hospital, part of Spectrum Health System,
also developed “Need to Know” documents that gave families useful information specific to common
diagnoses. These strategies helped patients and families feel more comfortable with referral decisions
being made. They also gave primary care physicians referral boundaries and helped relieve pressure
from families requesting unnecessary referrals.
Referral Management Workflow. Specialty and primary care practices were able to use the
referral guidelines, ideal record sets and communication methodologies already determined to begin
documenting an optimized referral management workflow. By conducting a baseline assessment that
identified inefficiencies, redundancies and lapses in workflows, the practices developed a gap
analysis that workgroups used in town-hall style meetings to solve problems communally and share best
practices. Since practices were primarily using MHC’s referral system, most solutions involved MHC,
allowing a common language and a more-or-less common methodology for care coordinators,
practice managers and MHC staff.
Co-management Protocols. In order to manage the health of patients after a referral, the practices
set out to draft co-management protocols for the most commonly referred and most challenging
conditions on the list of referral guidelines. Although multiple co-management tools were considered—

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narratives, worksheets, decision aids, flow charts, etc.—the group ultimately decided to incorporate an
outlined and consistent narrative into each after-visit summary. A team was selected to draft and format
the narrative outlines and to integrate them into Epic, the electronic health records system used in the
specialty practices. Achieving consistency in when, how and by whom follow-up care should be
provided was an important step in improving access at the specialty level and empowering primary
care physicians to deliver comprehensive care.
Discussion
After one year, the project’s results were noteworthy. Referral-process and satisfaction metrics collected
during and after the initiative showed considerable improvement (Table 1). The effects of the project
are most clearly visible in decreased wait times for referral appointments as well as in the numbers of
denied and rejected referrals and the numbers of misdirected referrals that occasioned secondary
referrals from specialist to specialist. The increased access to specialty care is visible in patient
satisfaction scores, particularly where pulmonology referrals are concerned. While the effects on staff
and physician satisfaction are less pronounced, higher percentages of staff members and physicians
agreed or strongly agreed with positive statements, and further improvements are visible in shifts from
Agree to Strongly agree.
None of the approaches to improving care coordination highlighted here are novel, but the degree to
which the practices integrated primary care and specialty care into the development of a joint,
community-based solution makes this a great example of how the patient-centered medical
neighborhood model can work. According to the data collected in this process, it appears that the
intervention improved care coordination and access to care and left patients, physicians and staff
more satisfied. The sharp drops in wait time for referral appointments apparently resulted at least in
part from the increased confidence the guidelines gave primary care pediatricians in their ability to
manage their patients’ problems themselves.
This was a quality improvement project, not a research project. The data collection methodology and
analytic tools used are correspondingly less sophisticated. We make no claims to statistical
significance for our results, but we did see improvements in most measures of access, efficiency and
satisfaction. More than that, we have anecdotal evidence that workgroup participants felt the
improvement, as comments such as these suggest:
• This innovative collaboration between primary and specialty care providers enhances the care
delivered to our common patients.
• The project has brought together many of the pieces of our community health system to make
tangible changes to improve the experience of patients.
• This has been the most meaningful project that I have had the pleasure to work on with our
pediatric specialty colleagues.
• Thank you for everyone’s efforts to get organized, and having referrals flow easier. This is a
“win” for our families!!!!!!!!!

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A major lesson of this project is the key role that the integration of health care across a community
plays in reducing barriers to access in health care. Previous attempts to change the system at the
single-practice level had had obvious limitations; what was needed was the kind of unified solution
provided by this intervention. The development of mutually-agreed-upon referral guidelines gave
primary care physicians confidence that they were delivering appropriate care and gave specialists
confidence that requested referrals were truly necessary.
The effect of this on access is clearly recognizable in the substantial reductions in time from referral
request to referral appointment. Another clear lesson is the value of a well-functioning health
information exchange to community-wide projects. Without MHC, the implementation of improvements
developed in the course of the project would have been much harder, and the effect of the project
would have been considerably reduced.

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Table 1:
Selected Statistics From Before and After the Coordination-of-Care Intervention
October 2012 October 2013 Change (%)
Business days from referral to appointment scheduling (monthly averages)
Neurology 41 18 -56.10
Orthopaedics 9 6 -33.33
Pulmonology 22 7 -68.18
Business days from referral to appointment (monthly averages)
Neurology 85 34 -60.00
Orthopaedics 39 23 -41.03
Pulmonology 54 23 -57.41
Denied and rejected referrals
Neurology 122* 61 -50.00
Orthopaedics 3 0 -100.00%
Pulmonology 4 1 -75.00
Secondary referrals made from specialist to specialist
Neurology 78 27 -65.38
Orthopaedics 13 3 -76.92
Pulmonology 2 0 -100.00
Patient satisfaction scores: “How often do you get an appointment as soon as
needed?” (Usually and Always responses)
Neurology 18/21 (85.71%) 35/40 (87.50%) 2.08
Orthopaedics 20/21 (95.24%) 52/53 (98.11%) 3.02
Pulmonology 37/42 (88.10%) 52/53 (98.11%) 11.37
Staff satisfaction scores: “I have the tools and resources needed to perform my job.”
(Agree and Strongly Agree responses)
Agree 46.7% 43.2% -7.5
Strongly Agree 48.3% 52.3% 8.3
Totals 95.0% 95.5% .5
Staff satisfaction scores: “I have the tools and resources needed to perform my job.”
(Agree and Strongly Agree responses)
Agree 32.5% 25.0% -23.1
Strongly Agree 49.2% 63.6% 29.3
Totals 81.7% 88.6% 8.4
Physician satisfaction scores: “I have the tools and resources needed to perform my
job.” (Agree and Strongly Agree responses)
Agree 41.2% 42.9% 4.1
Strongly Agree 47.1% 50.0% 6.2
Totals 88.3% 92.9% 5.2
Physician satisfaction scores: “I have adequate clinical and clerical support while
performing my job functions and taking care of patients.” (Agree and Strongly Agree
responses)
Agree 44.1% 42.9% -2.7
Strongly Agree 32.4% 42.9% 32.4
Totals 76.5% 85.8% 12.2
*In October 2012, the neurology practice was not accepting referrals for headache; the addition of a physician enabled them to start accepting such
referrals before October 2013, however, bringing down the number of rejected referrals.