learning & action networks session - healthinsight · improving outcomes with care coordination...
TRANSCRIPT
Learning & Action Networks Session
Care Coordination
Do You Know Where Your
Patients Are?
Improving Outcomes with
Care Coordination
Janet Tennison, PhD, MSW
Project Coordinator, HealthInsight
This material was prepared by HealthInsight, the Medicare Quality Improvement Organization for Nevada and Utah, under contract with the Centers for Medicare & Medicaid
Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 10SOW-UT-2013-PO-78
Breakout Objectives
• Understand Care Coordination and its
importance
• Identify current challenges in referral
processes
• Gather ideas to improve referral
management
What is Care Coordination?
Care Coordination is a proactive; high-performance approach that fills in care gaps by ensuring patients’ care is planned, organized,
and continuously monitored.
US Department of Health & Human Services. Report to Congress: national strategy for quality improvement
in health care;2011. Retrieved From HHS Website http://www.healthcare.gov/center/reports/quality032120.
Care Coordination is HOT
• Meaningful Use
• Patient-Centered Medical Home
• National Quality
Forum Strategy
• National agencies
• Improved patient
experience,
provider satisfaction
• Improved care
quality, population
health
• Decreased costs
Change Concepts for Practice Transformation 'i'"J' .. ;-.. J··~ . .. ..·
'I .. ~ •Reducing - ... ~ ...... .:.
Barriers to Care
Changing Care Delivery
Continuous endTum-a..d Helling Relltionshlpe Building
Relationships
laying the Foundation
Engaged Leadership
W gner EH. Col~m n K Reid RJ. Phi ps K. Abrams MK Sugorm nJR The Ch nges Involved an P~t,ent·Centered
~ ed~tal Home Transformabon Plirnary Care Cl mcs mOffiCe Pracbce. 2012: 39·241·259. SNM..
Care Coordination – The Need
• Patients expect PCP to be involved in, aware
of their health-related activities
• Care being provided by more providers
besides PCP—making the care team much
bigger
• Care is often provided in
silos, without effective
communication or
collaboration
What Did the Doctor Say?
Other Specialists
“I don’t know anything about this patient”
• Other conditions
• Allergies
• Preferences
• Special needs
Primary Care Providers “I don’t know what the specialist did”
• New Diagnoses
• New Treatment/s
• New Medications
• Follow-up needs
What Did the Doctor Say?
Care Coordination Components
Collaborative
Relationships
Transitions of
Care
Referral
Management
Medication
Management
Patient & Family
Engagement
Referral Management
Do you know where
your referrals are?
• Did your patient go
see that specialist?
• Do you know what
happened?
Referral Rates Have Doubled
(1999-2009)
• Typical PCP coordinates with 229 other
providers in 117 practices1
• Average Medicare beneficiary sees 7
different providers from 4 practices, fills
upwards of 20 RX’s per year2
• Specialist visits account for more than half of
all outpatient provider visits3
1. Pham et al. Primary care physicians’ links to other physicians through Medicare patients:
The scope of Care Coordination. Annals of Internal Medicine;2009;150:236-242.
2. Chronic Conditions: Making the Case for Ongoing Care Partnership for Solutions,
Partnership for Solutions, Johns Hopkins Univ. 2002.
3. Expenses for office-based physician visits by specialty, 2004, Machlin and Carper,
AHRQ, 2007
Referral Worse Case Scenario
PCP writes for referral in EHR
Reception tells patient to expect
a call from specialist
MA faxes referral to specialist
Wrong number— fax goes to lady
in Texas
Patient seen by PCP one year
later with worsening symptoms
MA faxes referral #2 to correct
number
Specialist calls patient for
appointment
Patient no-shows
Patient seen by PCP in one year….
The Difficulty of Effective
Referral Management
1. Accountability is shared - creates ambiguity –don’t
know who is responsible to make it work
2. PCPs lack time to create personal relationships with
other providers decreasing communication
3. Added time/effort to achieve effective referrals
not reimbursed
4. Most PCPs lack dedicated personnel or
information infrastructure to coordinate care
effectively
Reducing care fragmentation. A toolkit for coordinating
care. California Health Foundation, Oakland: CA.
Table Discussion
1. How does my clinic currently manage
referrals?
2. Do we manage effectively? What are gaps?
3. Do we know our “Medical Neighbors” (who we refer to now)?
EHRs and Care Coordination
Study of EHR use and care coordination
1. Timely access to complete information
(improved)
2. Agreement on treatment goals and plans among a patient’s clinicians (improved)
3. Agreement on roles and responsibilities
among clinicians (not improved)
Graetz I, et. al. Care coordination and electronic health records: Connecting
clinicians. AMIA Annual Symposium Proceedings;2009;208–212
Clinic Best Practice:
Premier Family Medicine
Elements of Effective Referral
Management
1. Accountability
- Make a commitment to improve it
- Develop a formal referral tracking system
- Consider dedicated MA
2. Patient Support
- Develop team support for patients
- Assess health literacy
3. Relationships and agreements
- Identify your key neighbors
- Establish referral agreements
Reducing care fragmentation. A toolkit for coordinating
care. California Health Foundation, Oakland: CA.
Accountability: Why Provide Formal
Referral Tracking
• Internal analysis of referral patterns
can provide critical insights for PCPs
• Closing the loop—knowing patient was seen
• Analysis of referral patterns can pro-actively
identify “outlier” patterns
• Provides data for negotiating future managed
care contracts
Manual Referral Tracking
Week ______________ to Week _________________
Dr. Smith Cardio Endocri Gastro Hematol Mental
Health
Nephrol
Mrs.
Jones
Sent 10/12
Received
10/25
Mr.
Brown
Ms.
Green
Referral Summary Log
Dr. ___________________ Week ___/___/___ to ___/___/___
TOTALS: Allergy/Immunology _____
Cardiology _____
Endocrinology _____
Gastroenterology _____
Hematology _____
Infectious Diseases _____
Nephrology _____
Oncology _____
Pulmonology _____
Rheumatology _____
Dedicated Medical Assistant as
Flow Manager
Expanded Pre-Visit Work for
Dedicated MA
" TAKE wrrn MEALS ? uo PRO&eM t I EAT AL.L. THE 11ME ! "
Patient Support: Health Literacy
Referrals and Health Literacy
Study of colonoscopy understanding
(n = 764), mean age 63
CONCLUSIONS: Comprehension of colonoscopy preparation
leaflet generally low; significantly lower among people with low
health literacy.
• Poor comprehension affects patient safety
• Negative economic impact.
We must improve comprehension of complex medical
information by reducing literacy-related barriers.
Smith et al. The influence of health literacy on comprehension of a colonoscopy preparation
information leaflet. Diseases of the Colon and Rectum;2012;55(10);1074-1080.
Table Discussion: Patient
Understanding
Name one thing your clinic can do to ensure patients understand referral instructions
Relationships:
The Medical Neighborhood
Clinic Activity: Who’s In Your ‘Hood?
• Identify the top 5 – 10 medical neighbors you
communicate with
• Rate them – are they good neighbors?
- Are they timely, consistent, meet your
• Rank and prioritize
and your patients’ expectations
Medical Neighborhood Survey
Identify your neighbors and prioritize those who will agree to work with you in care coordination referral management.
Facility Facility type Contact Address Phone/email Rate 1-5 (5 is best)
Cooperative
Provide correct
information
Are timely
Agreement
in place?
Coop. Info Timely
Ortho Clinic A Outpatient
ortho
Lisa Bone 222 Surgery St. (801) 222-0000 5 2 3
Agreements
PCP Responsibilities to Provide Other Specialty Responsibilities to
Provide Mutually agreed upon demographic and
clinical information
Referral reason and diagnosis code/s
Current care plan
Special needs (translation, cultural/ethnic,
transportation)
Summary of care including allergies, current
medications
Patient education regarding referral
need/procedure details
Follow-up for patients who no-show
Mutually agreed upon communication
(telephone, email)
Mutually agreed upon time for pre-referral
work-up
Notification of no-shows within 24 hours
Notification of cancellation without
rescheduling
Recommendations for additional
procedures/tests
Timely access to appointments
Discussion of specialty visit results with
patient and addition to care plan, as indicated
Mutually agreed upon communication
processes
Communication with specialty regarding
referral or admission
Notification of hospital referral/admission or
urgent care referral within 24 hours
Next Steps to Get the Gold
• Develop system/documented processes for
tracking
• Assign referral management accountability
• Consider use of Dedicated MA
• Determine patients’ referral support needs
• Go meet your neighbors
- Set up agreements
• Monitor & measure outcomes
Common Metrics
• Timeliness of communication with
hospitals/specialists
• % of time that consults are tracked to
completion
• % of organizations with which you have care
coordination agreements
• % of patients seen within X hours of
discharge from hospital
Don’t Forget to Celebrate
Share successes, send
neighbors thank-you letters,
treat them and your team to lunch
Breakout Objectives
• Understand Care Coordination and its
importance
• Identify current challenges in referral
processes
• Gather ideas to improve referral
management
• Develop Action Plan to Get the
the Gold!
Please Contact Me
Janet Tennison, PhD, MSW
(801) 892-6604