1. Key Changes and Resources for Care Coordination (Reducing Care Fragmentation in Primary Care)
MacColl Institute for Healthcare Innovation
Group Health Research Institute

2. The Patient-centered Medical Home
Key Features:
Engaged leadership
Quality improvement strategy
Empanelment
Patient-centered interactions
Organized, evidence-based care
Care coordination
Enhanced access
Continuous, team-based health relationships

3. 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) + + +

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

5. The Care Coordination Model

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

7. Assume Accountability
Providers, especially primary care clinics, decide to improve care coordination.
Develop a referral/transition tracking system.

8. Resource #1 NCQA Patient-Centered Medical Home 2011 Standards
Test tracking and follow up
Referral tracking and follow up
Coordinate with facilities and care transitions

9. Resource #2 Measuring care coordination from patient’s perspective:
ACES
Picker
PACIC
CAHPS
CYSNCN
Press Ganey
Also check out AHRQ’s Care Coordination
ATLAS

10. Resource #3 Referral Tracking Guide
How-to guide to setting up your own referral tracking system
Use existing practice management (or billing) system
Use paper tracking grid
Describes how to use the data to inform practice

11. Provide Patient Support
Organize the practice team to support patients and families during referrals and transitions.
Logistical “referral” coordinator:
Tracks all referrals and transitions
Provides patient (and family) with information about referral
Addresses barriers to referrals
Follows up on missed appointments

12. Patient Support ≠ Case Management
Case Load
High-risk, multi-morbid patients
Clinical Care Management
Logistical
Clinical Monitoring
Self Mgmt Support
Medication Mgmt
Patients with common chronic illnesses
Clinical Follow-up Care
Logistical
Clinical Monitoring
Self Mgmt Support
All patients in panel who are involved in referral or transition process
Care Coordination
Logistical
©MacColl Institute for Healthcare Innovation, Group Health Research Institute 2011

13. Resource #4 Referral “Logistical” Coordinator Job Description
Based on our review of relevant jobs
Questions for group:
Do your clinics have someone filling this role?
How is the role different/similar to our generic job description?

14. Resource #5 Referral “logistical” coordinator training includes:
Why job is important
How role interacts with the rest of the team
How to liaison with other facilities
Use and utilize the tracking system
Understand medical chart
Understand insurance processes
Provide pro-active patient support

15. Resource #6 Patient preparation for referral visit:
Informs patients about logistics including what they need to do beforehand, what to bring, and where to go.
Prepares patients by describing expectations (reason for visit, goals of visit, next steps in treatment).
Empowers patients to ask questions during specialist appointment.

16. Resources #7-9 Evidence-based program for managing transitions:
Foster greater engagement of patients/families
Elevate status of family caregivers
Implement performance measurement
Build competency in care coordination
Explore use of technological solutions to
communicate between settings
Align financial incentives
©2007 Care Transitions Program; Denver, Colorado. All rights reserved.

17. ©2007 Care Transitions Program; Denver, Colorado. All rights reserved.

18. Coleman E. The Post-Hospital Follow-Up Visit: A Physician Checklist to Reduce Readmissions, CA Healthcare Foundation, Oct 2010

19. Build Relationships & Agreements
Develop agreements to:
Standardize information
Set expectations
Build relationships

20. Medical Neighborhood ARHQ White Paper (Resource #10)
Defines the medical neighborhood
Describes potential approaches to overcoming barriers to high-functioning medical neighborhoods
Taylor EF, Lake T, Nysenbaum J, Peterson G, Meyers D. Coordinating care in the medical neighborhood: critical components and available mechanisms. White Paper (Prepared by Mathematica Policy Research under Contract No. HHSA I TO2). AHRQ Publication No Rockville, MD: Agency for Healthcare Research and Quality. June 2011.

21. Resource #11 Compact: Primary Care - Specialty Care Compact
Pre-consultation
Formal consultation (in-person referral)
Transfer of care from PCP → specialist
Co-management
Emergency care
Main goal of Colorado’s compact is to develop mutually agreed upon expectations

22. Resource #12 Approaches to strengthen PCP ↔ Specialist interface:
Case studies
Guidelines for referrals
Forms (important info to include)
Agreements/co-location/co-management

23. Service Agreement Example
Case Study: Family Care Network in WA agreement with local cardiology group describes who/when/how for each:
Emergency referrals
Emergency testing
Routine consultation
Follow-up care
Re-referral
Inpatient care

24. Resources #13-14 Berta W et al
Article #1: 24 key components to include in referrals
Article #2: 15 key components to include in consultative report

26. Resource #15
Reichman M

27. Develop Connectivity
Develop and implement an information transfer system.
Standardize information.
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

28. Resource #16
O’Malley et al describe the principal tasks for effective care coordination as:
Maintaining patient continuity with the PCP/primary care team.
Documenting and compiling patient information generated within and outside the primary care office.
Using information to coordinate care for individual patients and for tracking different patient populations within the primary care office.
Referrals and consultations (initiating, communicating and tracking).
Sharing care with clinicians across practices and settings.
Providing care and/or exchanging information for transitions and emergency care.
New paper by O’Malley also work checking out:
“Referral and Consultation Communication Between Primary Care and Specialist Physicians” Arch Intern Med. 2011;171(1):56-65.

29. Resource #17
CA HealthCare Foundation: Bridging the Care Gap by Metzer and Zywiak
Details e-referral systems

30. E-Referral Case Studies
Doc2Doc system in OK
Humboldt County, CA
San Francisco, CA
Humboldt County’s workflow

31. E-Referral Improves Specialty Access

32. E-Referral Improves Referral Tracking
PCPs’ ratings of attributes of electronic referrals compared to prior referral methods
Source: Kim Y, Chen AH, Keith E, Yee HF, Kushel MB. Not Perfect, but Better: Primary Care Providers’ Experiences with Electronic Referrals in a Safety Net Health System. Journal of General Internal Medicine. Vol 24(5),

33. Contact us: www.improvingchroniccare.org Thank you