The percentage of long-term services and supports (LTSS) organization members with a care plan that was transmitted to their primary care practitioner (PCP) or other documented medical care practitioner identified by the member within 30 days of its development.
Why It Matters
A care plan improves care only if the people delivering care can see it. LTSS care managers and direct care workers are often in the member’s home and observe changes in function, home safety, nutrition and medication use that no other member of the care team sees. When that information does not reach the member’s primary care practitioner (PCP), the PCP manages the member’s health without the most current picture of the member’s needs, risks and supports.
The 2016 Medicaid and CHIP Managed Care Final Rule requires managed LTSS (MLTSS) programs to ensure that each provider furnishing services to enrollees maintains and shares, as appropriate, an enrollee health record in accordance with professional standards.[1] The 2024 Ensuring Access to Medicaid Services final rule strengthens oversight of person-centered service planning in home and community-based services, including annual reassessment of functional need and annual review of the person-centered service plan.[2] A plan developed and reviewed under that oversight informs care only if it reaches the practitioners who deliver it.
Communication breakdowns between primary care and other providers are common and consequential.[3,4] In one study, 28 percent of PCPs were dissatisfied with the content of information received from specialists and half were dissatisfied with its timeliness;[5] in another, PCPs who did not consistently receive such communication were more likely to report that their ability to deliver high-quality care was jeopardized.[6] Electronic health records have not been widely adopted by LTSS providers and often do not capture the information these providers need, so exchange still depends heavily on the care coordinator.[7] LTSS-SCP makes that coordination visible and measurable.
Historical Results – National Averages
Performance results for this measure are currently unavailable.
References
- Centers for Medicare & Medicaid Services. 2016. “Medicaid and Children’s Health Insurance Program (CHIP) Programs; Medicaid Managed Care, CHIP Delivered in Managed Care, and Revisions Related to Third Party Liability.” Federal Register 81, no. 88: 27497–901. https://www.federalregister.gov/d/2016-09581.
- Centers for Medicare & Medicaid Services. 2024. “Medicaid Program; Ensuring Access to Medicaid Services.” Federal Register 89, no. 92: 40542–874. https://www.federalregister.gov/d/2024-08363.
- Savoy, A., S. Khazvand, A. Mathew, A.M. Gilmore, E. Cottingham, A. Sangani, M. Weiner, and T.M. Damush. 2023. “Consultants’ and Referrers’ Perceived Barriers to Closing the Cross-Institutional Referral Loop, and Perceived Impact on Clinical Care.” International Journal of Medical Informatics 180: 105265.
- Fattahi, H., F. Ghasemi Seproo, A. Fattahi, V. Rostami, and A. Shokri. 2025. “General Practitioners’ Perspectives on Barriers to Communication With Specialists in the Referral System: A Systematic Review and Meta-Synthesis.” Health Science Reports 8, no. 5: e70785. doi: 10.1002/hsr2.70785.
- Gandhi, T.K., D.F. Sittig, M. Franklin, A.J. Sussman, D.G. Fairchild, and D.W. Bates. 2000. “Communication Breakdown in the Outpatient Referral Process.” Journal of General Internal Medicine 15, no. 9: 626–31.
- O’Malley, A.S., and J.D. Reschovsky. 2011. “Referral and Consultation Communication Between Primary Care and Specialist Physicians: Finding Common Ground.” Archives of Internal Medicine 171, no. 1: 56–65.
- McGinn-Shapiro, M., S. Mitchell, E.G. Walsh, M. Ignaczak, and L. Bercaw. 2015. “Information Exchange in Integrated Care Models: Final Report.” Office of the Assistant Secretary for Planning and Evaluation. https://aspe.hhs.gov/basic-report/information-exchange-integrated-care-models-final-report.
