1. TCPI Project Pathway: Session 6 of 8 Coordinated Care – Milestone # 8, 9, 10 (11, 12, 13, 14 for primary care)

2. About the TCPI Milestones
22 Milestones for specialty practices
27 Milestones for primary care
Scores on each milestone determine Phase completion
For example, to complete Phase 1, as score of 3 is necessary on milestone 13 (setting an aim).
Other phases require various scores for other milestones.

3. Milestone Classes Review Scoring and Strategies for Meeting Them (numbers in parentheses indicate milestone numbers for primary care)
Each Milestone-Group Class will be held live 3 times:
Quality Improvement Strategies and Action –milestones 14, 15, 16 (19, 20, and 21) (already held- recording available)
Improvement Goals – milestones 1, 2, 3, 13 (1, 2, 3, 18)
Staff Engagement: Teamwork and Joy – milestones 6 and 19 (6 and 24)
Identifying Patient Risk and Using Best Practices – milestones 7, 11 (8, 9, 10, 16)
Streamlining Clinical and Office Work – milestone 22 (27)
Coordinated Care – milestones 8, 9, 10 (11, 12, 13, 14)
Person and Family-Centered Care – milestones 4, 5, 12, 17 (4, 5, 7, 15, 17and 22 for primary care)
Business Strategies – milestones 18, 20, 21 (23, 25, 26)

4. Today’s Objectives
Review scoring for coordinated care-related milestones: 8, 9, 10 (11, 12, 13, 14 for primary care)
Outline strategies for meeting each of these milestones
Review relevance of milestones’ scores to phases
Open discussion

5. Coordinated Care Specialty milestones: 8, 9, 10
Primary care milestones: 11, 12, 13, and 14

6. Your Transformation Workplan – Practice Plan Tab

7. Related Specialty Milestones
Milestone 8: Practice facilitates referrals to appropriate community resources, including community organizations and agencies as well as direct care providers. (Primary care milestone 11 is identical to this one.)
Milestone 9: Practice works with the primary care practices in its medical neighborhood to develop criteria for referrals for episodic care, co- management, and transfer of care/ return to primary care, processes for care transition, including communication with patients and family.
Milestone 10: Practice identifies the primary care provider or care team of each patient seen and (where there is a primary care provider) communicates to the team about each visit/ encounter.

8. Milestone 8 (11 for primary care): Practice facilitates referrals to appropriate community resources, including community organizations and agencies as well as direct care providers. a score of 3 is needed to complete Phase 4

9. Strategies for Meeting Milestone 8 (#11 for primary care)
Change Package –
Vet all potential referral providers and agencies
Leverage personal relationships to cultivate referral opportunities
Maintain an inventory of community resources that may be available to patients
Work with community agencies to enhance services available to patients
Maintain formal (referral) links to community-based chronic disease self-management support programs, exercise programs and other wellness resources with the potential for bidirectional flow of information
Provide a guide to available community resources
Consider the types of community resources that are relevant to the patients you see: American Diabetic Association; Weight Watchers; Physical Therapy; sight centers for the blind; wellness centers; support programs.
Write a letter to each agency to introduce your practice and request information back about their agency and services.
Provide patients with contact information for those agencies relevant to the patient’s needs.

10. Strategies for Meeting Milestone 8 (#)
Change Package – continued
As a provider, employ the philosophy “You should only refer to a provider you would send your loved one to”
Create and maintain referral lists for medical residents in academic settings
Engage local health coalitions to identify resources in areas where resources are scarce
Find out how patients define quality of care and build those definitions into the practice model
Maintain a referral tracking system to assure “loop closure” (i.e. that patients make and keep appointments and that a report is received)

11. Milestone 9 (for specialty care): Milestone 9: Practice works with the primary care practices in its medical neighborhood to develop criteria for referrals for episodic care, co-management, and transfer of care/ return to primary care, processes for care transition, including communication with patients and family. a score of 3 is needed to complete Phase 4

12. Strategies for Meeting Milestone 9
Change Package –
Define the medical neighborhood with which the practice works most closely
Develop both personal and electronic relationships among medical neighborhood providers to ensure information sharing
Develop formal written agreements or compacts that define information needs of all parties
Formalize lines of communication with local care settings in which empaneled patients receive care to ensure documented flow of information and clear transitions in care.
Ensure that useful information is shared with patients and families at every care transition; partner with patients and families in developing processes and tools to make that happen
Engage payer disease management and complex care management staff to help avoid patient/family confusion

13.
The Advisory Board offers assistance with understanding and building a medical neighborhood. The following slide shows an infographic that can be downloaded and used to get the staff on board.

15. Milestone 10 (for specialty care): Practice identifies the primary care provider or care team of each patient seen and (where there is a primary care provider) communicates to the team about each visit/ encounter. a score of 3 is needed to complete Phase 3

16. Strategies for Meeting Milestone 10
Add “Who is your primary care physician (PCP)?” question to appointment information/form patient completes and/or to list of questions intake person asks.
Train all staff who conduct intake interviews to document the PCP in the patient’s medical record.
Add PCP’s phone number/ /fax number to patient’s record
Establish process for updating PCP after each visit by patient.
There are no specific strategies in the Change Package for this milestone, perhaps because it is a rather straightforward issue to solve.

17. Related Primary Care Milestones
Milestone 11: Practice facilitates referrals to appropriate community resources, including community organizations and agencies as well as direct care providers. (COVERED PREVIOUSLY as specialist milestone #8)
Milestone 12: Practice has defined its medical neighborhood and has formal agreements in place with these partners to define roles and expectations.
Milestone 13: Practice follows up via phone, visit, or electronic means with patients within a designated time interval (24 hours/ 48 hours/ 72 hours/ 7 days) after an emergency room visit or hospital discharge.
Milestone 14: Practice clearly defines care coordination roles and responsibilities and these have been fully implemented within the practice.
Milestone 11 is the same as specialty milestone #8 covered earlier in this web class. So let’s go to milestone 12.

18. Milestone 12: Practice has defined its medical neighborhood and has formal agreements in place with these partners to define roles and expectations. A score of 3 is needed to complete Phase 4.
Milestone 12 for primary care is similar to milestone 9 for specialty practices. Both focus on the medical neighborhood, and the referral and communication processes between providers.

19. Strategies for Meeting Milestone 12
Change Package –
Define the medical neighborhood with which the practice works most closely
Develop both personal and electronic relationships among medical neighborhood providers to ensure information sharing
Develop formal written agreements or compacts that define information needs of all parties
Formalize lines of communication with local care settings in which empaneled patients receive care to ensure documented flow of information and clear transitions in care.
Ensure that useful information is shared with patients and families at every care transition; partner with patients and families in developing processes and tools to make that happen
Engage payer disease management and complex care management staff to help avoid patient/family confusion
These are the same as the strategies shown previously for specialty milestone #9, although the text of the scoring is different. For primary care the emphasis will be on understanding referral providers (who to refer patients to for specialty care), and for engaging in complete, timely and thorough communication with those specialists about the patient(s). Keeping the patients and families engaged and informed will contribute to complete communication across providers (ie, sometimes the PATIENT/FAMILY provide the complete picture and information to their providers!)

20. Milestone 13: Practice follows up via phone, visit, or electronic means with patients within a designated time interval (24 hours/ 48 hours/ 72 hours/ 7 days) after an emergency room visit or hospital discharge. A score of 3 is needed to complete Phase 3.
Milestone 12 for primary care is similar to milestone 9 for specialty practices. Both focus on the medical neighborhood, and the referral and communication processes between providers.

21. Strategies for #13 (primary care)
Change package 1.5.1
Assign responsibility for care management of individuals at high risk for emergency department visits or hospital readmission
Follow up after every hospital discharge and ED visit with a phone call, home or office visit
Assure patients can get access to their care team when they need it to support reduction in emergency department use
Partner with community or hospital-based transitional care services
Routine and timely follow-up to hospitalizations
Routine and timely follow-up to emergency department visits
Encourage patients to rely on multiple team members as experts

22. Strategies for #13 (primary care) - continued
Change package 1.5.1
Establish a mutual understanding of the information that should be shared when care is transferred or shared among providers
Develop agreements with specialists in the community that identify goals for communication
Have someone talk with patient and family to prior to each transition so they understand what the next step is and what it may mean
Review when care transitions are NOT optimal and look for themes
Use pharmacists to co-manage chronic disease states under collaborative agreements
Pre-plan transition of care appointments when able to
Ensure that useful information is shared with patients and families at every care transition
Engage payer disease management and complex care management staff to help avoid patient/family confusion

23. Milestone 14: Practice clearly defines care coordination roles and responsibilities and these have been fully implemented within the practice. A score of 3 is needed to complete Phase 4.

24. Strategies for #14 (primary care)
Change package 1.5.3
Develop compacts between primary care and specialists
Assign responsibility to specific staff members for care coordination and referral management
Establish systems for two-way exchange of information within the medical neighborhood
Follow up on all referrals to assure loop closure on information flow to care team and to patients
Participate in Health Information Exchange if available.
Use structured referral notes to standardize information shared and facilitate appropriate referrals

25. Strategies for #14 (primary care - continued
Change package 1.5.3
Establish care coordination agreements with frequently used consultants that set expectations for documented flow of information and provider expectations between settings
Track patients referred to specialists through the entire process
Systematically integrate information from referrals into the plan of care.
Allow primary care team to request urgent appointments for specialist consults
Have a shared care plan for co-managed patients
Establish a mutual understanding of the information that should be shared when care is transferred or shared among providers
In specialty practices, for each referral, notify the referring care team of the date of scheduled appointments, as well as of any cancellations and no shows

26. This Photo by Unknown Author is licensed under CC BY-SA

27. Coming Next Week – Class 7 Person and Family-Centered Care
Specialty milestones 4, 5, 12, 17
Primary care milestones 4, 5, 7, 15, 17, 22