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Real-Time ReferralProgram Overview
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Primary Care – Specialty Care
Primary Care
Specialty Care
• An ideal system will provide timely specialty input, when needed.
• No more and no less
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Stakeholders: Purchasers / Payers
• Our care is too expensive for population-based and value-based payments
• Credible threats to exclude AMCs from network coverage
• The referral rate doubled between 1999 and 2009
• 1 in 3 patients is referred to a specialist each year (1 in 2 for the elderly)
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Stakeholders: The Patient
• “I have a problem today.”
• Care burden:
• Time from work
• Copayment
• Transportation
• Parking
• Child care
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Stakeholders: The PCP
• Timely access to specialty guidance
• Some questions have:
• A narrow scope
• Available data in the shared EHR
• Without the need for an exam
• Relational continuity with the patient
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Stakeholders: The Specialist
• Address lower-complexity questions efficiently
• High complexity cases improve teaching
• Reimbursement for non face-to-face work
• Improve access
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RTR Program
eReferral + eConsult = RTR Program
• eReferral: Improves quality and clinical content of referrals, optimizing utilization
• eConsult: timely input from specialists for lower complexity, data-driven questions
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Impact at 1-Year- UCSF Experience
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RTR Program
• 72 hour eConsult response expectation
• Specialist can convert to a scheduled visit for case
complexity
• 0.5 wRVU payment to Specialist
• 0.5 wRVU credit for PCP (toward productivity)
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I am referring @name@, a @age@ y/o @sex@, to Gastroenterology for direct scheduling for colonoscopy
Indication: (choose one)
My assessment that this patient is safe for an endoscopic procedure with sedation.
This patient, (please select any that apply)____ has had a recent MI or STROKE____ requires HOME OXYGEN____ is on ANTICOAGULATION therapy____ has a clinically significant CARDIAC ARRHYTHMIA ____ has a history of CHRONIC OPIATE or SUBSTANCE ABUSE____ has a history of a PSYCHIATRIC disorder to consider when planning sedation.____ has severe OSA ____ Other co-morbidity that should be considered in consultation prior to sedation
If the patient has one of the above risks, @he@ will be scheduled in the GI clinic for an evaluation prior to the procedure.
eReferral
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eConsult
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Clarify Expectations for Follow-Up
Pending specialist evaluation, I anticipate:
-CONSULTATION ONLY: Recommendations and Return to Primary Care
-CO-MANAGEMENT—PCP IS FIRST CALL: PCP maintains responsibility for day-to-day management -CO-MANAGEMENT—SPECIALIST IS FIRST CALL: Specialist assumes responsibility for management of thIs
problem.
-E-CONSULT
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Improved Access for Primary Care PopulationReferrals and eConsults per 100 Primary Care Visits
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Improved Access for Primary Care PopulationReferrals and eConsults per 100 Primary Care Visits
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Increased External Referrals
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UC- Wide Expansion
• RTR Implementation at UCSD, UCLA, UCD and UCI
– Synergistic efforts to improve access to specialty care
– Improve the total value of care for their PC populations
– Share EPIC platform
– Buy-in
• 14 specialties will be introduced over 12 months
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ROI
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Primary Population of 50,000
• Improved access to specialty care has important implications not reflected in the model.
• Strengthening referral relationships• Greater access to higher complexity, external referrals to our
specialty practices• The reduction in ED use and hospitalization within 120 days of
referral (seen at UCSF)
Year 1 (ramp up)
Year 2
Averted visits 275 1378eConsults 186 931
Gross Savings $70,695 $353,476eConsult Fee
(Medical Center / Medical Plan)
$19,893 $99,468
Net Saving $50,802 $254,008ROI 3.55:1 3.55:1
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Conclusion • Significant impact on:
• Referral rates
• Specialty care utilization
• Costs
• eConsult does not appear to induce demand
• High acceptability among PCPs and specialists
• Referral templates fundamentally improved referral
communication
• High quality, patient centered care – This is not merely
reducing cost > quality
• Timely access to specialists
• PCP relationship continuity
• Decreased complexity of care management
• Save patient out-of-pocket costs
• Train tomorrow’s physicians to deliver more flexible care
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RTRRTR