Patient Experiences with Coordination of Care: The Benefit
of Continuity and Primary Care Physician as Referral Source
Ann S. O’Malley, MD, MPH and Peter J. Cunningham, PhD
Center for Studying Health System Change, Washington, DC, USA.
BACKGROUND: Coordination across a patient’s health
needs and providers is important to improving the
quality of care.
OBJECTIVES: (1) Describe the extent to which adults
report that their care is coordinated between their
primary care physician (PCP) and specialists and (2)
determine whether visit continuity with one’s PCP and
the PCP as the referral source for specialist visits are
associated with higher coordination ratings.
DESIGN: Cross-sectional study of the 2007 Health
Tracking Household Survey.
PARTICIPANTS: A total of 3,436 adults with a PCP and
one or more visits to a specialist in the past 12 months.
MEASUREMENTS: Coordination measures were patient
perceptions of (1) how informed and up to date the PCP
was about specialist care received, (2) whether the PCP
talked with the patient about what happened at the
recent specialist visit and (3) how well different doctors
caring for a patient’s chronic condition work together to
manage that care.
RESULTS: Less than half of respondents (46%)
reported that their PCP always seemed informed about
specialist care received. Visit continuity with the PCP
was associated with better coordination of specialist
care. For example, 62% of patients who usually see the
same PCP reported that their PCP discussed with them
what happened at their recent specialist visit vs. 48% of
those who do not usually see the same PCP (adjusted
percentages, p<0.0001). When a patient’s recent spe-
cialist visit was based on PCP referral (vs. self-referral or
some other source), 50% reported that the PCP was
informed and up to date about specialist care received
(vs. 35%, p<0.0001), and 66% reported that their PCP
discussed with them what happened at their recent
specialist visit (vs. 47%, p<0.0001).
CONCLUSIONS: Facilitating visit continuity between
the patient and PCP, and encouraging the use of the
PCP as the referral source would likely enhance care
KEY WORDS: coordination of care; primary health care; continuity of
care; quality of care; medical home; referral; patient-centered care.
J Gen Intern Med 24(2):170–7
© Society of General Internal Medicine 2008
This study assesses whether continuity of care and referral
source are associated with better coordination of care from the
patient perspective. Primary care and care coordination con-
suggest that these aspects of care are
important to coordination; however, data linking these primary
care processes with better coordination for adults are less
plentiful in the literature than one might expect.
Coordination of care is a defining component of primary
Common to most definitions of coordination is the degree
to which information from various sources is recognized and
incorporated into a patient’s current care.
communication between the primary care physician (PCP) and
the other specialists a patient sees, and between the PCP and the
patient, in order to integrate specialists’ recommendations in a
way that is clinically appropriate, understandable to the patient,
and consistent with the patient’s needs. Coordination between
referring physicians and specialists is highly valued by
and is associated with higher quality care, enhanced
referral completion, greater physician satisfaction with specialty
care, and use of recommended preventive services.
working with their staff as a team, are well positioned to lead
coordination of care for patients given their generalist training
and knowledge across different body systems and conditions,
expertise in managing comorbid conditions, and ongoing rela-
tionship with a patient over time.
Yet, referring clinicians and specialists exchange information
less frequently than necessary, and this has adverse conse-
quences for patients.
This aspect of coordination has been
examined within particular health systems
in samples of
primary care clinics and physicians
and in an international
study of health systems,
with less coordination being associat-
ed with poorer patient outcomes, duplication of services,
lower provider satisfaction, less efficiency, and lower patient
ratings of physicians.
Analyses of Medicare claims data also
suggest that care is highly fragmented across physicians, in
particular for patients with chronic conditions.
Since patients are the parties experiencing care first-hand
from multiple providers (e.g., only the patient was present in
both the specialist’s and PCP’s office), they are uniquely
positioned to assess particular aspects of coordination. Exam-
ples of such aspects of coordination include: (1) whether the
Received July 28, 2008
Revised November 4, 2008
Accepted November 18, 2008
Published online December 19, 2008