1. Continuity of Care Making connections: A small practice journey R. Scott Hammond, MD Chair, CAFP PCMH Task Force Medical Director, SOC-PCMH Initiative, Colorado Associate Clinical Professor, Dept. of Family Medicine UCHSC Westminster Medical Clinic, Westminster, Colorado --PCMH Level 3 shammond@evcohs.com

2. PCMH Awareness in Colorado

3. Coordination of Care in Colorado

4. Care Coordination Challenge The typical primary care physician has 229 other physicians working in 117 practices with which care must be coordinated. Pham et. al Ann Int Med. 2009 In the Medicare population, the average beneficiary sees seven different physicians and fills upwards of 20 prescriptions per year Partnership for Solutions, Johns Hopkins Univ. 2002

5. Continuity of Care Paradigm

6. Making Connections Care coordinator job description and protocol consistent with available resources. External care coordination –Hospital and skilled nursing facilities –Specialists Internal care coordination –High-acuity patients Post-hospital Multi-morbid diseases Frequent ED utilization

7. Continuity of Care Hospitals Database –List of facilities and contact personnel Informational continuity –Daily census of admits, discharges, updates (hospitals, hospitalists, IPA) –ED/in-hospital medical information transfer Care Coordination –Post hospital transition (discharge care plan) –List of ED patients over the past year

9. Patient: ______________________________________PCP ______________________Date:_____________ Diagnosis:______________________________________________________________ Discharge Date: ____________  Discharge Summary received  Laboratory/Diagnostic test received  Requested Date: __________  Test _______________________ StatusInformation NeededShort Term GoalLong term goal Functional Status  ADL assessment Medical Status  Diagnosis  Co-morbid conditions  Prognosis  Medication Review  Allergy Review  Advance Directives Self-care Ability  Current Ability  Educational needs Social Support  Primary Caregiver  Ability/willingness to give care  Community support Disposition  Prior residence  Current residence  Future residence Communication  Language needs  Health beliefs DME  Current needs  Vendor Current Functional Status CognitiveDressEatingToiletingBathing  Independent  Requires assist  Unable  Independent  Requires assist  Unable  Independent  Requires assist  Unable  Independent  Requires assist  Unable  Independent  Requires assist  Unable Patient contacted: Date______________ Appointment: Date:_________________ Referral requested: Date: ____________

10. Continuity of Care Hospitals CO PCMH Pilot: Hospital Subgroup committee –Patient Identifier information “wallet card” PCMH ID Patient education and educational materials from health plans –Bidirectional communication Care Coordination Form (hospital to PCP) ED Referral Form (PCP to hospital)

11. PCMH ID Wallet Card

12. Continuity of Care PCMH-N Specialists Define, develop and vet a PCP-Specialty Compact Outreach Preferred Specialist List Preferred Specialist ListImplement PCP Transition Record PCP Transition Record PCMH-N Patient Referral Rx PCMH-N Patient Referral RxAccountability PCP/Specialist Report Card PCP/Specialist Report Card

13. Colorado SOC-PCMH Initiative Primary Care-Specialty Care Compact Purpose and Principles Definitions Types of Care Transition Service Agreement –Transition of Care –Access –Collaborative Care Management –Patient Communication Transition of Care Records (PCP and Specialist)

14. Colorado SOC-PCMH Initiative Primary Care-Specialty Care Compact Types of Care Transition –Pre-consultation exchange –Formal consultation –Co-management (Referral) With Shared management With Principle Care of the disease With Principle Care of the patient –Complete transfer of care (Specialty Medical Home Network) –Emergency Care

15. Transition of Care Mutual Agreement Maintain accurate and up-to-date clinical record. Agree to standardized demographic and clinical information format such as the Continuity of Care Record [CCR] or Continuity of Care Document [CCD] Ensure safe and timely transfer of care of a prepared patient Expectations Primary CareSpecialty Care  PCP maintains complete and up-to-date clinical record including demographics.  Transfers information as outlined in Patient Transition Record.  Orders appropriate studies that would facilitate the specialty visit.  Informs patient of need, purpose (specific question), expectations and goals of the specialty visit  Provides patient with specialist contact information and expected timeframe for appointment.  Determines and/or confirms insurance eligibility  Provides single source referral contact person  When PCP is uncertain of appropriate laboratory or imaging diagnostics, assist PCP prior to the appointment regarding appropriate pre-referral work-up Additional agreements/edits: _____________________________________________________________ ____________________________________________________________________________________ Service Agreement– Transition of Care

16. 1. Practice details – PCP, PCMH level, contact numbers (regular, emergency) 2. Patient demographics -- Patient name, identifying and contact information, insurance information, PCP designation and contact information. 3. Diagnosis -- ICD-9 code 4. Query/Request – a clear clinical reason for patient transfer and anticipated goals of care and interventions. 5. Clinical Data Problem list Medical and surgical history Current medication Immunizations Allergy/contraindication list Care plan Relevant notes Pertinent labs and diagnostics tests Patient cognitive status Caregiver status Advanced directives List of other providers 6. Type of transition of care. 7. Visit status -- routine, urgent, emergent (specify time frame). 8. Follow-up request Service Agreement–PCP Patient Transition Record

18. PCMH Patient Referral Rx Patient name: Gloria Date: 2/19/10 Appointment: within 1 week Specialist: Dr. Heart_ Test/Procedure: may do heart ultrasound or monitor Reason for Referral/Consultation: determine medications needed to control your heart rate and whether you need a pacemaker_____________________ ______________________________________________________________ Alternatives: watchful waiting______________________________________ Non-urgent referrals take about 4-5 days to process. You will be notified through the Patient Portal. If you do not have Internet, we will call you or mail your confirmation. Do not go or make an appointment for the visit/test until you have received your referral confirmation and insurance approval. If for some reason, you do not make or keep your appointment, please let us know so that we may cancel the referral and assist you in other ways.

19. Points 5 2.5 0 -5 Transition of care Determines or confirms insurance eligibility Always or almost always UsuallyOccasionallyRarely Ease of Communication Single point of contact Leave message with specific person No specific contact Communicates readily with PCP on pre- referral workup Always or almost always UsuallyOccasionallyRarely Access Insurance Participation AllAll but Medicare Missing 1 major carrier Missing 2 major carriers No-show notification Always or almost always UsuallyOccasionallyRarely Access to scheduling Within requested time frame Within 1 week of requested time frame Within 2 week> 2 weeks Provides list of ‘ neighborhood ’ providers Yes and more than 1 provider Yes and 1 provider No listNo agreement with compact First visit with physician yesno Readily available to PCP for questions/help Always or almost always UsuallyOccasionallyRarely Comments

20. Points 10 5 0 -5 Comments Transition of care Sends complete patient information Always or almost always UsuallyOccasionallyRarely Orders appropriate tests prior to referral Always or almost always UsuallyOccasionallyRarely Informs patient of need, purpose, expectations and goals of the specialty visit Always or almost always UsuallyOccasionallyRarely Access No-show patient F/U Always or almost always UsuallyOccasionallyRarely Requests appointments with reasonable time frames Always or almost always UsuallyOccasionallyRarely Readily available to specialist for questions/help Always or almost always UsuallyOccasionallyRarely Collaborative Care Management

21. SOC/PCMH Action Plan Coordinate & simplify the message (articles, newsletters, publications & website) Foster physician communication & culture Messaging Presentations & Webinars Parade of Homes Mentoring Speakers Bureau Physician Education Work through existing initiatives and leadership Support policies that further medical home adoption Use elements of physician compact as foundation of PCP/Spec coordination System Approach/ Medical Neighborhood Resource Advisors toolkit to provide orientation and resources on medical homes Action Plans/Rapid Improvement Activities Hand-over for advanced QI (ie. IPIP, REC, CCHAP, other) Practice Outreach/Medical Homes

22. It can get dirty but change can be good

23. WMC Team