The Physician-Hospital Compact

A Primary Care ViewpointA Primary Care Viewpoint

R. Scott Hammond, M.D., FAAFPR. Scott Hammond, M.D., FAAFPAssociate Clinical Professor, University of Associate Clinical Professor, University of

Colorado School of MedicineColorado School of Medicine

shammond@evcohs.comshammond@evcohs.com

Problems with care coordinationProblems with care coordination

Coordination Research Source

PCP and ED Medical history and lab results absent in 33% of charts

Gandhi. J Gen Int Med. 2000

30% of adults report their regular physician not informed of ED care

Gandhi. Ann Int Med. 2005

PCP and hospital 3% of PCPs involved in discharge plans.<20% received discharge summary at 1 week38% of discharge summary had no lab results.21% had no discharge meds.

Kripalani. JAMA. 2007

Hospital and patient 33% of adults prescribed new medication received information on whether to take pre- hospital meds.

Schoen. Health Aff. 2005

Hospital transitionsHospital transitions

•• 23% of patients >65 are transferred to another 23% of patients >65 are transferred to another institution and 11.6% with HHC. institution and 11.6% with HHC. AHRQ 2002AHRQ 2002

•• 39% of Medicare patients had 2 or more 39% of Medicare patients had 2 or more transitions within 30transitions within 30--day period (4% had 4 or day period (4% had 4 or more). more). Coleman, E Health Services Research. 2004Coleman, E Health Services Research. 2004

Hospital ReadmissionsHospital Readmissions

•• 19.6 % of Medicare patients readmitted within 19.6 % of Medicare patients readmitted within 30 30 days days of discharge.of discharge.

•• 34% were readmitted within 34% were readmitted within 90 days 90 days of discharge.of discharge.

•• $17.4 billion cost to Medicare for unplanned hospital $17.4 billion cost to Medicare for unplanned hospital readmissions in 2004.readmissions in 2004.

Source: National Transitions of Care Coalition: Source: National Transitions of Care Coalition: Improving Transitions of Improving Transitions of CareCare, Sept.2010, Sept.2010

Hospital readmissionsHospital readmissions

30-day readmission rate

Reference

Medicare Of those readmitted, only 50% seen by a

physician

NEJM 2009;360(14):1418- 1428

Tertiary care hospital 10x risk of readmission, if not seen by a

physician

J Hosp Med.2010; DOI 10.1002/jhm.666

Kaiser Southern California

3x risk of readmission for patients > 65, if not

seen by a physician

California HealthCare Foundation. October 2010

Communication in post- hospital visit

Reduced readmissions when hospital discharge

summary available

J Gen Int Med 2002;170(11):955-960

Capitol District Physicians’ Health Plan

Reduced from 14% to 6% with incentives for

California HealthCare Foundation. October 2010

CO PCMH PilotCO PCMH Pilot Hospital SubHospital Sub--Group SummaryGroup Summary

Barriers SolutionsIdentification•Patients

Do not know their provider•Hospitals

PAs/NPs not listed as providers

• Wallet ID Card• Instruct patient to present cards to ED/Hospital• Educate hospital staff to ask for card

Notification•PCP

Fax notification pile-upED/Hospitals do not always send notification

•HospitalTime constraints/too busy to callAfter-hour push back from PCP

• Practices dedicate personnel to handle faxes• Practices develop team care and care

coordinator to address notifications and bi- directional information

• Practices agree to accept calls from ED/hospitals

• Hospitals set up procedures to notify PCP of admission

Communication•Patient

• Does not bring paperwork to ED or discharge summary to PCP

•PCP• Lack of standardize information/access to

info through EMRs•Hospital

• Some ED/hospitals lack care coordinators• Care fragmented by silos (secondary

referrals)

• Practices set policy to send information to ED prior to arrival

• Practices instruct patients to bring information to ED

• Create a transitional care template of core elements

• Build a Medical Neighborhood• ED/hospitals identify staff to function as care

coordinator• Notify PCPs of referrals• Work with CORHIO

Working TogetherWorking Together What CAN a PCMH do?What CAN a PCMH do?

•• Care coordinator job description and protocol Care coordinator job description and protocol consistent with available resources.consistent with available resources.•• Patient Navigator/Disease Management/Health CoachPatient Navigator/Disease Management/Health Coach

•• External care coordinationExternal care coordination•• Hospital and skilled nursing facilitiesHospital and skilled nursing facilities•• SpecialistsSpecialists

•• Internal care coordinationInternal care coordination•• HighHigh--acuity patientsacuity patients

•• PostPost--hospitalhospital•• MultiMulti--morbid diseasesmorbid diseases•• Frequent Frequent EDED utilizationutilization

working togetherworking together ‘‘What can we doWhat can we do’’

PCP PCP -- Where are the patients? Where are the patients? Hospital Hospital -- Who are the Who are the providers?providers?

How do we communicate?How do we communicate?

••Mode of communication (phone, fax, pager, email)Mode of communication (phone, fax, pager, email)

••Timing of communication related to admission and discharge Timing of communication related to admission and discharge

••Process and accountability for scheduling postProcess and accountability for scheduling post--hospital visitshospital visits

What do we need to know?What do we need to know?

••Core elements of medical history sent before/after hospital Core elements of medical history sent before/after hospital admission admission

••Core elements of hospital discharge or ED summaryCore elements of hospital discharge or ED summary•• Final reason for hospitalizationFinal reason for hospitalization•• Recommended F/U appointment intervalsRecommended F/U appointment intervals

P di l b k F/U iP di l b k F/U i

Building a NeighborhoodBuilding a Neighborhood

Implementation - Hospital, Hospitalists

Right peopleEstablish common ground (common pain)Provide practice/provider informationBuild communication lines

Where to send info, how, whenPortal accessDetermine record content

Hospital transition record

PhysicianPhysician--Hospital CompactHospital Compact

•• PurposePurpose

•• PrinciplesPrinciples

•• DefinitionsDefinitions

•• Components of Care TransitionsComponents of Care Transitions

•• Mutual Agreement for Care ManagementMutual Agreement for Care Management

•• The 4 DomainsThe 4 Domains

•• Transition of Care RecordTransition of Care Record

PostPost--hospital Prehospital Pre--visitvisit

•• Phone call within 48 hours of dischargePhone call within 48 hours of discharge•• Reconcile medicationsReconcile medications

•• Reminder to bring list or all medications to F/U visitReminder to bring list or all medications to F/U visit•• Make appointments and coordinate careMake appointments and coordinate care•• Obtain reportsObtain reports•• Assess patient needs and supportAssess patient needs and support

PostPost--hospital F/U visithospital F/U visit•• ““TeachTeach--backback””

•• Medication reconciliation and educationMedication reconciliation and education

•• AssessmentAssessment•• Adjust or modify medicationsAdjust or modify medications•• Review test results and reportsReview test results and reports•• Further monitoring and testingFurther monitoring and testing•• Discuss new treatment planDiscuss new treatment plan•• Discuss advance directivesDiscuss advance directives

•• SelfSelf--managementmanagement

•• ““Red FlagsRed Flags”” and how to respondand how to respond

•• Written care planWritten care plan•• Medications, treatment, goalsMedications, treatment, goals•• AfterAfter--hours care hours care -- instructions and contactsinstructions and contacts

•• F/U appointments scheduled/coordinatedF/U appointments scheduled/coordinated

Transition Coach RoleTransition Coach Role

•• 4 coaches located in 4 hospitals (PHO 4 coaches located in 4 hospitals (PHO –– 900 physicians)900 physicians)•• Patients identified during hospitalization for transition Patients identified during hospitalization for transition

supportsupport•• Coach ensures PCP followCoach ensures PCP follow--up visit, med reconciliationup visit, med reconciliation

Transforming Primary Care, Advisory Board Company 2010

A vision without a task is but a dream;

a task without a vision is drudgery;

a vision and a task is the hope of the world.

Inscription on a church Sussex, England

R. Scott Hammond, M.D., FAAFPAssociate Clinical Professor, University of Colorado School of Medicineshammond@evcohs.com