| Facilitators of Care Coordination |
Representative Verbatim Comments from Key Informants |
| Involve Entire Care Team |
I think that one—one thing that I know that they’re trying to do here is to make certain that every breast cancer is discussed in a multi-disciplinary forum. The other thing that started, probably around three years ago now, is the breast tumor board, which has been just outstanding and really has driven up the level of care. Maybe it’s a little bit more than three years, but that has been instrumental, having an interdisciplinary-focused approach, where everybody’s presented the cases. We do meet weekly, that’s also helpful. So we do discuss cases each week.
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| Strong Follow-up Policy |
Well, I mean, we’ve decreased our no-show rate tremendously because we put into a certain amount—we put into place certain policies. So one of the policies is that as long as the patient is in Allscripts [EHR], there is an automated message, reminding them of the appointment two days prior. In addition to that, we have a person who—a team of medical assistants, who, part of their job assignment at the end of each day, is to go through that same list the day before, and to make sure that, you know what, you got the automated message, now here’s the personal message from the breast center asking you to come in. And then—the other part of their job though is the system will also do a no-show call, saying, “Hey, you missed your appointment,” but then we also have the medical assistants call them as well right there. If the patients have missed their appointment, they make a phone call. If they can’t get in touch with the patient, they send a certified letter. So the PCA who does the vitals and does whatever needs to be done before the patients are seen has a list of all the appointments for each clinic, and for those patients who don’t show up they get a letter automatically, and a phone call at the end of each clinic. So every day, every breast clinic section, the clerk prints out a list of people who were scheduled and did not show. She goes through that list, and sees if they rescheduled their appointment; sometimes patients on their own reschedule it. And it’s when they miss those appointments, we have a system in place where somebody actually gives the nurse practitioner a list, “Ok, these were the patients who were supposed to show up, and these are the people that didn’t show up.” And if they don’t show up, then I have to go through the list to make sure and call and see to see why they didn’t show up. Every clinic has a no-show policy; it’s just, for whatever reason, like that Mary and Michelle, the nurse practitioners, or whoever was before them, or whatever, just- we’ve really taken it a bit more personally. It is a policy that the patient gets a phone call that day.
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| Co-location of Services |
Actually, that’s the number one benefit of being here. We’re on one floor, one unit, literally just tap them on the shoulder, they’re all terrific. I mean, I have to say, they’re really—we have a nice, nice team here. Well, I mean, I think the idea of having it all in one place – one place and everybody working together and it’s so easy to do multidisciplinary care. I think that is really the thing. So, basically, you know, we’re a multidisciplinary clinic and that makes a whole big difference. The fact that they don’t have to go anywhere else is like one stop shopping. You know, the beauty is that the format that we have here, their offices are right here. Sometimes, I think the patients get free visits, because as a doctor walks by, and that’s their doctor, they engage in a conversation. So, it’s – sometimes it’s just even a curbside consult…. Usually, we get them to see them as part of the day – not necessarily scheduled, but you can just walk them down there because we’re all here.
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| Barriers to Care Coordination |
Representative Verbatim Comments from Key Informants |
| Short on Staff |
We just don’t have an appropriate staff for the level of patients that we see on a daily basis. We don’t have enough patient navigators. Okay, we have a lot of patients, but not enough navigators to manage them. So, there is no patient navigator here that does that…. Well, you know, if I don’t have enough nurses, then they send me help. You know, they will, but you have to beg. They will send you help, and they will- but the thing is, if you are not really from this clinic, it’s kind of different. I think everybody’s being stretched as much as possible, as long as it works. That kind of thing. Until it becomes critical, then they will do something. … [They] will not hire, so we’re going to be stretched.
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| Resource Constraints |
We used to have a navigator, and the navigator had to leave; there was no funding for the navigator- we lost funding for the navigator. If I said, ‘Ok, fine. I think the best way to do this is to hire one extra person, you know, whose sole job would be to do this, like the coordination.’ You know, then I would say, ‘Ok, I need an extra salary line for that.’ And then the next response would come down, ‘Oh, there’s no salary line.’ So, now, I’m here again with the no psychologist, or psychiatrist to see these patients, so that’s very bad, you know? Because a lot of these people are in distress. So we’ll say we won’t compete but the truth is we compete. [for resources] I think that they are very dedicated, and they understand that there’s quality of care that needs to be provided, and they absolutely want to do it, but—but the resource’s limit—limited to what you can do. No, things are not being cut- but it’s not abundant, either.
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| Challenging Patient Population |
But we still have a tremendous community issue, I think, of either not trust, or not wanting to go follow up A large majority of them are also undocumented; they do not like to be tracked, they do not like to be interviewed, and they don’t actually share their official phone number on the chart. I think it’s more financial issues, because—or even—you know, coming, getting off of work, logistics of how to get here, not getting paid for the day, I think that’ll contribute to them coming to clinic. They just don’t want to take the time off. So those are people that fall through the cracks because there’s no way to get information from them and they’re not responsive. There’s only so much you can do. You can’t physically go to people’s house and bring them.
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