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    Coordinated care lessons in dermatology

    The idea is this: By organizing patient care and sharing information with providers involved in the care of patient, patients, providers and payors may benefit with safer, more effective care, according to the Agency for Healthcare Research and Quality in Rockville, Md.

    The concept, called coordinated care or care coordination, is designed to benefit patients with chronic conditions, such as psoriasis. While primary care providers are often at the center of this care, dermatologists and other providers might also be at the model’s pulse.

    Lindsay C. Strowd, M.D., assistant professor of dermatology at Wake Forest Baptist Health, Winston-Salem, N.C., tells Dermatology Times that dermatologists are integral in the management of many conditions that might benefit from the coordinated approach.

    “Dermatologists are certainly aware of the fact that the skin is a highly visible part of our overall health, and that it often can serve as a clinical window into conditions that may be going on inside the body,” she said. “Dermatologists can be helpful to a person’s overall medical health and can be very helpful with primary care physicians at identifying potential cutaneous signs of internal diseases.”

    The concept of coordinated care comes in when the dermatologist looks for and notices something else about the patient — a concerning blood pressure reading, for example — which leads to a referral, Dr. Strowd says.

    The concept is gaining ground in medicine because it helps defragment a fragmented system. Today’s healthcare system is disjointed and patients often are unclear about why they’re being referred when primary care and other doctors refer them to specialists. Add to that, specialists might not have clear or adequate information about why a patient is being referred and what has been done to address the condition for which the patient is being referred, according Agency for Healthcare Research and Quality.

    The result can be suboptimal, inefficient, more costly care and a frustrating care experience, according to Dr. Strowd.

    The model makes sense in the care of diseases with known associated comorbidities. For example, advances in psoriasis treatment and improved coordinated care will allow better overall care of these patients, researchers concluded in a paper published January 2017.

    “Dermatologists and primary care providers share roles in screening for associated comorbidities (including cardiovascular disorders, chronic kidney disease, Crohn disease, dyslipidemia, diabetes mellitus/insulin resistance, depression, metabolic syndrome, obesity, and psoriatic arthritis), managing patients' treatments, and reevaluating treatment needs as new therapies are approved,” the authors wrote.


    Dr. Strowd says dermatologists and other providers might avoid care coordination because it takes time to communicate with other providers. But electronic medical records (EMRs) have made the process easier, because many are set up to facilitate email communication among physicians, she says.

    Dermatologists who engage in coordinated care might even find a financial boost in Medicaid and Medicare reimbursement, according to Dr. Strowd.

    “Dermatologists actually get incentivized to do electronic communication, or to what [the government calls] close the referral loop. If a patient is sent to you that is referred from a physician, and you respond back to that physician with your findings and recommendations, documenting that you have actually done that, it can work toward your getting higher levels of reimbursement for your services,” Dr. Strowd says.

    Dr. Strowd says dermatologists and other specialists who engage in coordinated care benefit by getting information they need, including about medication use, tests and studies performed and more.

    “From a clinical standpoint, I also get a lot of academic satisfaction from working with colleagues in other areas of medicine,” she says.


    New York Times' reporter Paula Span wrote about "The Tangle of Coordinated Healthcare," April 13, 2015, suggesting the model can be overwhelming for patients and caregivers if too many well-meaning care coordinators follow up.

    But this isn't generally the case, dermatologists say.

    The success of the model depends on whether it's based on quality control indicators, versus on financial and regulatory goals, according to Iltefat Hamzavi, M.D., a dermatologist who specializes in treating hidradenitis suppurativa (HS) patients using a coordinated care model.

    Dr. Hamzavi, senior staff physician in the Multicultural Dermatology Center at Henry Ford Hospital, in Detroit, Mich., says Henry Ford Hospital's HS coordinated care model offers care from dermatologists and infectious disease specialists, to surgeons and mental health professionals. It's coordinated by dermatologists, driven by input from the patients, and based on HS Foundation best practices, he says.

    "Often, what we'll do is bring those specialties to meet the patient support group. This provides input from patients and the clinic develop a feedback system based upon live patient interactions with the whole team of specialists" Dr. Hamzavi says.


    It takes more time to coordinate care among different specialties and definitely takes a certain degree of effort from the provider’s standpoint to reach out to other physicians, Dr. Strowd says.

    “I’m sure there are various levels of effectiveness to working together. But I think it’s important to recognize that, if it’s in the patient’s best interest, it’s a worthy endeavor,” she says.

    Dermatologists should make the process as efficient as possible. For example, sending an email to a colleague in another specialty via a healthcare system EMR is much faster than picking up the phone, she says.

    “I think the best way to get started is to reach out to a primary care colleagues because that’s one of the main places where we get referrals from our patients. Reach out to some of the physicians that consistently refer patients to you and make sure they’re satisfied with the communication that they’re receiving from your end. Sometimes, even offering to do a short talk on something that may be of interest to them, like skin cancer or treatment guidelines or psoriasis management, is helpful in coordinated care,” Dr. Strowd says.

    The idea of care coordination is very sensible, says Steven R. Feldman, M.D., Ph.D., professor of dermatology at Wake Forest School of Medicine.

    “The health system is so complex, having a coordinator, ambassador or concierge to rely on for help makes a lot of sense if that coordinator person (or perhaps, someday, computer) has the tools to address patients' needs for information, access to medication and appointments, and, perhaps most of all, motivation to take medication well,” Dr. Feldman wrote in an email interview with Dermatology Times.

    “There seems to be only upside here. Care coordination done well could make life better for patients and their families and could improve patients’ treatment outcomes, potentially while reducing costs. Care coordination done poorly seems to me to be less beneficial but unlikely to make things worse than not having a care coordinator at all,” he said.



    Jaclyn Smith, BS; Abigail Cline, PhD; Steven R. Feldman, MD, PhD. "Advancs in Psoriasis," Southern Medical Journal. Jan. 1, 2017. DOI: 10.14423/SMJ.0000000000000596


    Lisette Hilton
    Lisette Hilton is president of Words Come Alive, based in Boca Raton, Florida.


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