Key Changes and Resources for Care Coordination (Reducing Care Fragmentation in Primary Care)

1. Key Changes and Resources forCare Coordination(Reducing Care Fragmentation in Primary Care) MacColl Institute for Healthcare Innovation Group Health Research Institute http://www.improvingchroniccare.org

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 http://www.improvingchroniccare.org

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) + + + http://www.improvingchroniccare.org

4. What constitutes a high quality referral or transition? http://www.improvingchroniccare.org

5. The Care Coordination Model http://www.improvingchroniccare.org

6. Key Changes Assume accountability Provide patient support Build relationships & agreements Develop connectivity http://www.improvingchroniccare.org

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

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 http://www.improvingchroniccare.org

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 http://www.improvingchroniccare.org

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 http://www.improvingchroniccare.org

11. ProvidePatient 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 http://www.improvingchroniccare.org

12. Patient Support ≠ Case Management Case Load Clinical Care Management High-risk, multi-morbid patients Logistical Clinical Monitoring Self Mgmt Support Medication Mgmt Patients with common chronic illnesses Clinical Follow-up Care Clinical Monitoring Logistical 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 http://www.improvingchroniccare.org

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? http://www.improvingchroniccare.org

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 http://www.improvingchroniccare.org

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. http://www.improvingchroniccare.org

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. http://www.improvingchroniccare.org

17. ©2007 Care Transitions Program; Denver, Colorado. All rights reserved. http://www.improvingchroniccare.org

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

19. Build Relationships & Agreements Develop agreements to: Standardize information Set expectations Build relationships http://www.improvingchroniccare.org

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. HHSA290200900019I TO2). AHRQ Publication No. 11-0064. Rockville, MD: Agency for Healthcare Research and Quality. June 2011. http://www.improvingchroniccare.org

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 http://www.improvingchroniccare.org

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

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 http://www.improvingchroniccare.org

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 http://www.improvingchroniccare.org

25. http://www.improvingchroniccare.org

26. Resource #15 Reichman M http://www.improvingchroniccare.org

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 http://www.improvingchroniccare.org

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. http://www.improvingchroniccare.org

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

30. E-Referral Case Studies Doc2Doc system in OK Humboldt County, CA San Francisco, CA Humboldt County’s workflow http://www.improvingchroniccare.org

31. E-Referral Improves Specialty Access http://www.improvingchroniccare.org

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),614-619. http://www.improvingchroniccare.org

33. Contact us:www.improvingchroniccare.orgThank you http://www.improvingchroniccare.org