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

jtennison@healthinsight.org

(801) 892-6604