Table 3 Example analytic matrix for the care coordination component

A

(+) Medical director describes the benefit of the nurse’s calling patients upon hospital discharge and talking with them about their medications before they come in for a visit. Prior to the Comprehensive Primary Care initiative, he would spend the whole patient visit trying to figure out the medications of a recently discharged patient, “instead of actually taking care of them.”

(+/−) Nurse reports that the specialists in the community are generally good about sending patient information to the practice after a visit. The practice does have to track down some information, which she notes is one of the harder things to do, but at the same time, the practice is getting better at referral tracking. “Because it’s out of your control. You’re dependent on somebody else. You know, to get that. But as we get better and better at our referral tracking, that will flow a little bit easier, too.”

B

(+) Nurse reports that having staff to follow up with high-risk patients after a hospitalization improves the care that the practice can provide for these patients going forward.

(−) Practice manager reports that not having an electronic interface with other care settings to exchange patient information means that the practice had to develop a process for collecting this information manually, scanning the records into the electronic health record, and then making sure that key information is manually entered into discrete fields in the electronic health record for appropriate tracking.