1. Exploring Ideas for Improving Care Coordination Eric A. Coleman, MD, MPH Associate Professor Divisions of Geriatric Medicine and Health Care Policy and Research University of Colorado Health Sciences Center

2. 4 Key Areas for Change 1) Develop systems to notify patients of test results 2) Develop processes for better communication between primary and specialty care 3) Medication reconciliation 4) Coordination outside of office hours

3. Lab Result Management “Where no news is not necessarily good news…”

4. Burden of Test Result Management Per week, full-time PCP needs to review: – 360 chemistry results (SMA7 = 7) – 460 hematology results – 12 pathology reports – 40 radiology reports

5. Physician Perspective 43% of physicians surveyed report being satisfied with the way they manage test results 83% report experiencing a delay in reviewing lab results with potential to adversely affect care Implications for: – Efficiency – Safety – Risk management

6. The Black Hole?? 25% of physicians routinely inform patients of normal lab results 67% of physicians routinely inform patients of abnormal lab results 24% had a reliable system for identifying patients overdue for f/u labs

7. What Can We Learn from the Literature? 33% of abnormal TSH values do not receive timely follow-up 36% of abnormal pap smear are ‘lost’ to follow-up 25% malpractice claims due to failures in follow-up

8. Lab Management—3 Main Steps Retrieve and review results Communicate and interpret results to patients Incorporate findings into care plan

9. Break It Down—Test Results Protocol for normal results, no action required Protocol for normal results, action required Protocol for abnormal results no action required Protocol for abnormal results action required Protocol for abnormal results urgent action required Protocol for detecting when test not obtained

10. Communication Strategies Pre-formatted letters for sharing results with patients on paper Portal to EMR to allow patients to view once MD as released Phone calls for abnormal results E-Visits for abnormal results (with appropriate time compensation)

11. Lab Tracking Tools Paper Forms EHRS/EMR Patient Portal/web access (after MD releases) MS Access MS Outlook

15. Using MS Outlook to Track Labs Most clinics already have the software – Low cost approach; – free self-guided tutorial – However, all tracking systems require up front time Track a test from the time it was ordered to the time that the results are given to the patient using built-in features Will provide reminders or warnings when a task is overdue or a test has not returned Can also generate mailing labels to mail results to patients

17. Improving the Referral Process

18. Communication Breakdown Lack of clarity over reason for referral Disruption in continuity of care Delayed diagnosis Unnecessary/duplicative testing Dissatisfaction by all parties

19. Generalist/Specialist Communication Specialists report receiving information 32% of the time Generalist report getting referral letter 55- 80% of the time Patients are a “silent partner” who may self- refer

20. Two to Tango 63% of PCPs dissatisfied 35% of Specialists dissatisfied Room for improvement on both ends

21. Improving the Referral Experience Redesign flow of information Referral agreements between IPA and Practice for how communication will occur Clearly stated referral questions and answers Friendlier consultant letter format State preferred method of communication

22. Referral Agreements Service requested: – Evaluation – Evaluation and initial management – Evaluation and ongoing management – Procedure – Second opinion – Other Reason for referral Preferred communication – Fax – Email – Voicemail – Mail – Other

24. Care Coordination Out of the Office

25. Develop a Flow Chart or ‘How To Guide” for Clinic How do I get an appointment? How do I get my labs? How do get I care from specialists? How do I get care after hours?

26. After Hours Flow diagram—care seeking after hours Answering machine that says “go to ED” not acceptable Don’t have too solve problem 100%--call back in a few hours to see how they are doing Initiate first steps of therapy (UTI, hyperglycemia) Malpractice concerns—need documentation

27. Out of Hours—Telephone Charting

30. Move to Action! What is the status quo in your clinic? What advice would your patients give us? What have you tried? – What went well? – What did you learn? What will be your next PDSA? What tools or resources will you need?

31. Medication Reconciliation

32. Medication Reconciliation What Are We Looking For? Create a single list Identify discrepancies (incompatible regimens) Drug/Disease=pertinent positives and negatives Drug/Drug=most common, most serious

33. Engaging the Patient Encourage patient to bring all medications or list to every encounter Provide with a dedicated tote bag Key=> must positively reinforce behavior Initial MA or RN review

34. Scripting Patient Care Coach or give permission to speak up: – Every time a prescriber takes out a prescription pad, ask “would you like to see my medicine list” or “will this new medication interfere with my current meds?”

35. My Medications are: Medication Dose ______________________________ Allergies: _____________________ Reason Side Effects ______________________________ Personal Health Record Remember to take this Record with you to all of your doctor visits