1. Reducing Care Fragmentation: PRESENTATION ON COORDINATING CARE MacColl Institute for Healthcare Innovation Group Health Research Institute

2. Raise your hand if the following are not rare events in your practice: 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.

3. The Good Old Days

4. Current Fragmentation of Care Patients experience and clinicians operate in “silos” of care. Referral networks are large 1 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.

5. Patients Report Experiencing Poor Coordination Source: Commonwealth Fund Survey of Public Views of the U.S. Health Care System, 2008. Percent U.S. adults reported in past two years: No one contacted you about test results, or you had to call repeatedly to get results Test results/medical records were not available at the time of appointment Your primary care doctor did not receive a report back from a specialist Any of the above Doctors failed to provide important medical information to other doctors or nurses you think should have it Your specialist did not receive basic medical information from your primary care doctor

6. Commonwealth Survey of PCPs Percent reporting that they receive information back for “almost all” referrals (80% or more) to Other Doctors/Specialists: Source: 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.

7. 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..

8. How often do you get the information you need after referral? What do you think your patients would say about their experience?

9. Why work on Care Coordination? Safety & quality Practice environment Patient experience Resources

10. 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

11. 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) + + +

12. What constitutes a high quality referral or transition? Institute of Medicine’s (IOM) report Crossing the Quality Chasm: A New Health System, for the 21 st 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. Patient- centered 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.

13. The Care Coordination Model

14. Key Changes Assume accountability Provide patient support Build relationships & agreements Develop connectivity

15. #1 Assume Accountability Decide as a primary care clinic to improve care coordination. Develop a referral/transition tracking system.

16. #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

17. Patient Support ≠ Case Management Clinical Care Management Logistical Clinical Monitoring % of panel <5% 10% 20% Care Coordination Clinical Follow-up Care Medication Mgmt ©MacColl Institute for Healthcare Innovation, Group Health Research Institute 2011 Self-mgmt Support Clinical Monitoring

18. #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

19. 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.

20. #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

21. 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.

22. 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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