Real-Time Referral Program Overview

2 Primary Care – Specialty Care Primary Care Specialty Care An ideal system will provide specialty input, at the right time, In the right form.

3 Stakeholders: Purchasers / Payers Our care is too expensive for population-based and value-based payments Credible threats to exclude UC Health Systems from network coverage The referral rate doubled between 1999 and in 3 patients is referred to a specialist each year (1 in 2 for the elderly)

4 Stakeholders: The Patient “I have a problem today.” Care burden: Time from work Copayment Transportation Parking Child care

5 Stakeholders: The PCP Timely access to specialty guidance Some questions have: A narrow scope Available data in the shared EHR Without the need for an exam Relational continuity with the patient

6 Stakeholders: The Specialist Address lower-complexity questions efficiently See the patients in clinic who need our expertise See the patients in clinic for our fellows’ experience Reimbursement for non face-to-face work Improve access

7 Program Overview

7 RTR Program Structured Referral + eConsult = RTR Program Structured Referral: Improves quality and clinical content of referrals, optimizing utilization eConsult: timely input from specialists for lower complexity, data-driven questions

Specialist Office Visit Baseline Referral Process PCP Referral Scheduling

Specialist Office Visit Structured Referral Platform - Decision support - Pre-referral evaluation expectations - Consultative question - Relevant Data - Co-management expectation PCP Structured Referral Scheduling

PCP Structured Referral Specialist Office Visit eConsult Option eConsult Scheduling

PCP Structured Referral Specialist Office Visit eConsult Option eConsult If too complex, specialist converts to a standard referral Scheduling

Specialist Office Visit eConsult Option eConsult 3-business-day response Specialist: 0.5 RVU payment PCP: 0.5 RVU credit PCP Structured Referral Scheduling

Appropriateness Minimum Data Set Consultative Question Recent Assessment Referral Type Auto-populated Data a ______

10 I am referring a y/o to Gastroenterology for direct scheduling for colonoscopy Indication: (choose one) 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. Structured Referral Template

11 eConsult

17 Program Impact at UCSF

Referral Rate for standard office-visit Referrals to Medicine Subspecialties per 100 Primary Care Visits BaselineStructured ReferralFull Intervention

Mean: 12.19/100 PC visits Mean: 9.85/100 PC visits 16% Decrease (p=0.0001) BaselineFull Intervention Structured Referral Referrals to Medicine Subspecialties per 100 Primary Care Visits

Standard office-visit Standard office-visit + eConsult BaselineStructured ReferralFull Intervention Referrals to Medicine Subspecialties per 100 Primary Care Visits eConsults were used for 8% of total referrals

Referrals to medicine subspecialties BaselineFull Intervention Referrals to non-medicine specialties 3.5% Increase Structured Referral Referrals to Medicine vs Non-Medicine Specialties per 100 Primary Care Visits

Results: Access Specialty care in ≤ 14 days

Results: Utilization and Cost  ED visits decreased 12% (9.8% 8.6%)  Pro fee costs decreased 17% (p = 0.016)  Admissions decreased 10.8% (6.6% 5.9%)  Pro fee costs decreased 9.5% (NS) 120 Days Following all Referrals & eConsults (n = 13,738)

Specialist Survey Responses

PCP Survey Responses

15 Increased External Referrals

16 UC- Wide Expansion RTR Implementation at UCSD, UCLA, UCD and UCI –Synergistic efforts to improve access to specialty care –Improve the total value of care for their PC populations 14 specialties will be introduced over 12 months

Return on Investment model 17 Primary Care Population of 50,000 Improved access to specialty care has important implications not reflected in the model. Greater access to higher complexity, external referrals to our specialty practices The reduction in ED use and hospitalization within 120 days of referral (seen at UCSF) Strengthening referral relationships Year 1 (ramp up)Year 2 Averted visits eConsults Gross Savings$70,695$353,476 eConsult Fee$19,893$99,468 Net Saving $50,802 $254,008 ROI 3.55:1

18 Conclusion Significant impact on: Referral rates Specialty care utilization Costs eConsult does not appear to induce demand High acceptability among PCPs and specialists Referral templates fundamentally improved referral communication High quality, patient centered care – This is not merely reducing cost > quality Timely access to specialists PCP relationship continuity Decreased complexity of care management Save patient out-of-pocket costs Train tomorrow’s physicians to deliver more flexible care

19 RTR