Exploring Ideas for Improving Exploring Ideas for Improving Care CoordinationCare Coordination

Eric A. Coleman, MD, MPH

Associate Professor

Divisions of Geriatric Medicine and

Health Care Policy and Research

University of Colorado Health Sciences Center

4 Key Areas for Change4 Key Areas for Change

1) Develop systems to notify patients of test results2) Develop processes for better communication

between primary and specialty care3) Medication reconciliation4) Coordination outside of office hours

Lab Result ManagementLab Result Management

““Where no news is not Where no news is not necessarily good news…”necessarily good news…”

Burden of Test Result Management Burden of Test Result Management

Per week, full-time PCP needs to review:

– 360 chemistry results (SMA7 = 7)– 460 hematology results– 12 pathology reports– 40 radiology reports

Physician PerspectivePhysician Perspective

43% of physicians surveyed report being satisfied with the way they manage test results

83% report experiencing a delay in reviewing lab results with potential to adversely affect care

Implications for:– Efficiency– Safety– Risk management

The Black Hole??The Black Hole??

25% of physicians routinely inform patients of normal lab results

67% of physicians routinely inform patients of abnormal lab results

24% had a reliable system for identifying patients overdue for f/u labs

What Can We Learn What Can We Learn from the Literature?from the Literature?

33% of abnormal TSH values do not receive timely follow-up

36% of abnormal pap smear are ‘lost’ to follow-up

25% malpractice claims due to failures in follow-up

Lab Management—3 Main StepsLab Management—3 Main Steps

Retrieve and review resultsCommunicate and interpret results to

patientsIncorporate findings into care plan

Break It Down—Test ResultsBreak It Down—Test Results

Protocol for normal results, no action required Protocol for normal results, action required Protocol for abnormal results no action required Protocol for abnormal results action required Protocol for abnormal results urgent action

required Protocol for detecting when test not obtained

Communication StrategiesCommunication Strategies

Pre-formatted letters for sharing results with patients on paper

Portal to EMR to allow patients to view once MD as released

Phone calls for abnormal resultsE-Visits for abnormal results (with appropriate

time compensation)

Lab Tracking ToolsLab Tracking Tools

Paper Forms EHRS/EMRPatient Portal/web access (after MD releases)MS AccessMS Outlook

Using MS Outlook to Track LabsUsing MS Outlook to Track Labs

Most clinics already have the software – Low cost approach; – free self-guided tutorial– However, all tracking systems require up front time

Track a test from the time it was ordered to the time that the results are given to the patient using built-in features

Will provide reminders or warnings when a task is overdue or a test has not returned

Can also generate mailing labels to mail results to patients

Improving the Referral ProcessImproving the Referral Process

Communication BreakdownCommunication Breakdown

Lack of clarity over reason for referralDisruption in continuity of careDelayed diagnosisUnnecessary/duplicative testingDissatisfaction by all parties

Generalist/Specialist Generalist/Specialist CommunicationCommunication

Specialists report receiving information 32% of the time

Generalist report getting referral letter 55-80% of the time

Patients are a “silent partner” who may self-refer

Two to TangoTwo to Tango

63% of PCPs dissatisfied35% of Specialists dissatisfiedRoom for improvement on both ends

Improving the Referral ExperienceImproving the Referral Experience

Redesign flow of informationReferral agreements between IPA and Practice

for how communication will occurClearly stated referral questions and answersFriendlier consultant letter formatState preferred method of communication

Referral AgreementsReferral Agreements

Service requested:– Evaluation– Evaluation and initial

management– Evaluation and

ongoing management– Procedure– Second opinion– Other

Reason for referral Preferred

communication– Fax– Email– Voicemail– Mail– Other

Care Coordination Out of the Care Coordination Out of the OfficeOffice

Develop a Flow Chart or Develop a Flow Chart or ‘How To Guide” for Clinic‘How To Guide” for Clinic

How do I get an appointment?How do I get my labs?How do get I care from specialists?How do I get care after hours?

After HoursAfter Hours

Flow diagram—care seeking after hoursAnswering machine that says “go to ED” not

acceptableDon’t have too solve problem 100%--call back in a

few hours to see how they are doingInitiate first steps of therapy (UTI, hyperglycemia)Malpractice concerns—need documentation

Out of Hours—Telephone ChartingOut of Hours—Telephone Charting

Move to Action!Move to Action!What is the status quo in your clinic?What advice would your patients give us?What have you tried?

– What went well?– What did you learn?

What will be your next PDSA?What tools or resources will you need?

Medication ReconciliationMedication Reconciliation

Medication ReconciliationMedication ReconciliationWhat Are We Looking For?What Are We Looking For?

Create a single listIdentify discrepancies (incompatible regimens)Drug/Disease=pertinent positives and

negativesDrug/Drug=most common, most serious

Engaging the PatientEngaging the Patient

Encourage patient to bring all medications or list to every encounter

Provide with a dedicated tote bag Key=> must positively reinforce behaviorInitial MA or RN review

Scripting Patient CareScripting Patient Care

Coach or give permission to speak up:– Every time a prescriber takes out a prescription pad,

ask “would you like to see my medicine list” or “will this new medication interfere with my current meds?”

My Medications are:

Medication Dose

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Allergies: _____________________

Reason Side Effects

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Personal Health RecordPersonal Health Record

Remember

to take this Record with you

to all of your doctor visits