Implementation of a Referral Enhancement Platform “Why not just offer eConsults?”

Program Aims Innovations in the referral process: 1)Reduce delays in access to specially care 2)Improve care coordination between PCPs and specialists 3)Improve the total value of care at UC Health

Why address standard referrals & care-coordination broadly? “Why not just do eConsults”

Ask Specialists “Many new patients leave the first visit very unhappy. When a patient has waited 3 months to see me, and I say that I can’t make an assessment without x and y pieces of data — that they will need to wait further and return before we can really get started…”

Ask Specialists “Some patients referred to [Nephrology] should have gone to Urology” “We need to be alerted via pager if a patient has rising creatinine with hematuria or proteinuria”

Ask Specialists Specialists differ in their expectation of PCP collaboration. “You don’t titrate the meds aggressively enough“ “I could not believe the PCP titrated my medication” The Structured Referral Template addresses care-coordination expectations

Because referrals typically include little clinical information, specialists often doubt the the feasibility of eConsult. “The number of questions we could address via eConsult is going to be very small.” Improvement in quality of standard referrals changes the relationship. Ask Specialists

“Sometimes people will go to cardiology twice a year and it doesn’t add a lot more than what I would have been doing if I had been seeing the patient.” “Perennial follow-up” Ask PCPs

“It’s impossible for most patients to envision the realities of care coordination… More specialty care might not be better.” “The worst is when we’re working at odds,” Ask PCPs

The process is the intervention Bringing PCPs and specialists together to develop an eConsult program will unearth crucial deficiencies and needs. The Structured Referral provides a point of reference to implement problem-specific solutions

(If the patient has a rapid rise in creatinine, hematuria and new or worsening proteinuria, please page Nephrology at along with submitting this referral.) UCSF Experience

My assessment that this patient is safe for an endoscopic procedure with sedation. This patient, (please select any that apply) ____ has had a recent MI or STROKE ____ requires HOME OXYGEN ____ is on ANTICOAGULATION therapy ____ has a clinically significant CARDIAC ARRHYTHMIA ____ has a history of CHRONIC OPIATE or SUBSTANCE ABUSE ____ has a history of a PSYCHIATRIC disorder to consider when planning sedation. ____ has severe OSA ____ Other co-morbidity that should be considered in consultation prior to sedation If the patient has one of the above risks, will be scheduled in the GI clinic for an evaluation prior to the procedure. My assessment that this patient is safe for an endoscopic procedure with sedation. This patient, (please select any that apply) ____ has had a recent MI or STROKE ____ requires HOME OXYGEN ____ is on ANTICOAGULATION therapy ____ has a clinically significant CARDIAC ARRHYTHMIA ____ has a history of CHRONIC OPIATE or SUBSTANCE ABUSE ____ has a history of a PSYCHIATRIC disorder to consider when planning sedation. ____ has severe OSA ____ Other co-morbidity that should be considered in consultation prior to sedation If the patient has one of the above risks, will be scheduled in the GI clinic for an evaluation prior to the procedure.

____CONSULTATION ONLY: Recommendations and Return to Primary Care ____CO-MANAGEMENT—PCP IS FIRST CALL ____CO-MANAGEMENT—SPECIALIST IS FIRST CALL UCSF Experience

Engage PCPs Gather PCP concerns Tell the humanizing stories from the specialist perspective Relationships: Co-management conferences Adapt the intervention. Maximize value for PCP

Engage PCPs Share Data – The referral rate among PCPs varies widely (see next slide) – The structured referrals should offer decision support to advance PCP evaluation and conservative management

Referrals / 100 Primary Care Visit By Individual PCP Each bar represents an individual PCP