Transcript Slide 1

Reducing Care Fragmentation:
PRESENTATION ON COORDINATING CARE
MacColl Institute for Healthcare Innovation
Group Health Research Institute
Raise your hand if the following are
not rare events in your practice:
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You don’t know the people to whom you are referring
patients.
Specialists complain about the information you send with a
referral.
You don’t hear back from a specialist after a consultation.
Your patient complains that the specialist didn’t seem to
know why s/he was there.
A referral doesn’t answer your question.
Your patient doesn’t come back to see you after a
consultation.
A specialist duplicates tests you have already performed.
You are unaware that your patient was seen in the ER.
You were unaware that your patient was hospitalized.
The Good Old Days
Current Fragmentation of Care
• Patients experience and
clinicians operate in
“silos” of care.
• Referral networks are
large1 and often
depersonalized.
1
Pham HH, O'Malley AS, Bach PB, Saiontz-Martinez C, Schrag D. Primary care physicians' links to other physicians through
Medicare patients: the scope of care coordination. Ann Intern Med. Feb 17 2009;150(4):236-242.
Patients Report Experiencing Poor Coordination
Percent U.S. adults reported in past two years:
Your specialist did not receive basic medical
information from your primary care doctor
13
Your primary care doctor did not receive a
report back from a specialist
15
Test results/medical records were not
available at the time of appointment
19
Doctors failed to provide important
medical information to other doctors or
nurses you think should have it
21
No one contacted you about test results, or
you had to call repeatedly to get results
25
Any of the above
47
0
20
Source: Commonwealth Fund Survey of Public Views of the U.S. Health Care System, 2008.
40
60
Commonwealth Survey of PCPs
Percent reporting that they receive information back for “almost all” referrals
(80% or more) to Other Doctors/Specialists:
100
82
76
75
62
68
75
61
50
37
25
0
AUS
CAN
GER
NETH
NZ
UK
Source: 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
US
Clinicians Also Report Fragmented Care
• 63% of primary care providers and 35% of
specialists are dissatisfied with their current
referral process
– 25% of the time, primary care providers report
receiving no information from specialists after
their patient’s visit
– 68% of the time, specialists report receiving no
information from primary care before referral
visits
Source: Gandhi TK, Sittig DF, Franklin M, Sussman AJ, Fairchild DG, Bates DW. Communication breakdown in the outpatient referral
process. J Gen Intern Med. Sep 2000;15(9):626-631. .
How often do you get the
information you need after referral?
What do you think your patients
would say about their experience?
Why work on Care Coordination?
Patient experience
Safety & quality
Resources
Practice environment
The Patient-centered Medical Home
Key Features:
1. Engaged leadership
2. Quality improvement strategy
3. Empanelment
4. Patient-centered interactions
5. Organized, evidence-based care
6. Care coordination
7. Enhanced access
8. Continuous, team-based health
relationships
Defining Care Coordination
The deliberate organization of patient care
activities between two or more participants
involved in a patient’s care to facilitate the
appropriate delivery of health care services.
(McDonald, 2007)
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What constitutes a high quality referral or transition?
Institute of Medicine’s (IOM) report Crossing the Quality Chasm:
A New Health System, for the 21st Century:
Safe
Planned and managed to prevent harm to patients from medical or
administrative errors.
Effective
Based on scientific knowledge, and executed well to maximize their
benefit.
Timely
Patients receive needed transitions and consultative services
without unnecessary delays.
Patientcentered
Responsive to patient and family needs and preferences.
Efficient
Limited to necessary referrals, and avoids duplication of services.
Equitable
The availability and quality of transitions and referrals should not
vary by the personal characteristics of patients.
The Care Coordination Model
Key Changes
Assume accountability
Provide patient support
Build relationships & agreements
Develop connectivity
#1 Assume Accountability
• Decide as a primary
care clinic to improve
care coordination.
• Develop a
referral/transition
tracking system.
#2 Provide Patient Support
• Organize the practice team to
support patients and families
during referrals and
transitions.
• Referral coordinator:
– Tracks all referrals and
transitions
– Provides patient (and family)
with information about referral
– Addresses barriers to referrals
– Follows up on missed
appointments
Patient Support ≠ Case Management
% of panel
<5%
Clinical Care Management
Clinical Monitoring Medication Mgmt
Logistical Self-mgmt Support
10%
Clinical Follow-up Care
Logistical Clinical Monitoring
20%
Care Coordination
Logistical
©MacColl Institute for Healthcare Innovation, Group Health Research Institute 2011
#3 Build Relationships & Agreements
• Identify, develop and maintain
relationships with key specialist
groups, hospitals and community
agencies.
• Develop agreements with these
key groups and agencies.
• Lessons learned:
– Talk through the process for a
“typical” patient case
– Focus on the system and not the
people
Where might you start?
Community Agencies?
Tracking & following up on lab/imagining results;
Identification & tracking of linkages to community resources.
Medical Specialists?
Guidelines for referral, prior tests, and information;
Expectations about future care and specialist-to-specialist referral;
Expectations for information back to PCMH.
EDs/ Hospitals?
Notification of visit/admission and discharge;
Medication reconciliation after transition;
Involvement of PCMH in post-discharge care.
#4 Develop Connectivity
• Develop and implement an
information transfer system.
• Key elements of system:
– Integrates information needs and
expectations (per agreements)
– Assures that information
transmits to correct destination
– Key milestones in the referral
process can be tracked
– Referring clinicians and
consultants can communicate
with each other
Electronic Referral (e-referral) Systems
• Web-based, and may or not be connected to EMR.
• Effectiveness depends on consultants or hospitals
participating.
• Can embed referral guidelines and other elements of
agreements.
• Can monitor completion of referrals and return of
information to the PCMH.
• Users of e-referral systems often gravitate to
experimenting with e-consultations.
Why make care coordination a priority?
• Patients and families are frustrated by fragmented
“silos” in health care.
• Poor hand-offs lead to delays and
miscommunications in care that may be dangerous
to health.
• There is enormous waste associated with
unnecessary referrals, duplicate testing, unwanted
and unnecessary specialist to specialist referral.
• Primary care practice will be more rewarding.
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