COordinatingReferrals EffectivelyCORE

1. COordinatingReferrals Effectively?CORE Carol VanDeusen Lukas, EdD Boston University Safety Net ACTION Partnership Funded by AHRQ ACTION under contract HHSA2902006000012 TO6 September 27, 2010

2. CORE team BUSPH/BMC central team: Carol VanDeusen Lukas, EdD, BUSPH, PI Mari-Lynn Drainoni, PhD, BUSPH, co-PI Charles Williams, MD, BMC Family Medicine, clinical redesign lead Andrea Niederhauser, MPH, BUSPH, project manager Clinical redesign team members: Christine Odell, MD, BMC Ambulatory Care Center Joseph Peppe, MD, South Boston Community Health Center Stephen Tringale, MD, Codman Square Health Center Ronald Iverson, MD, BMC Department of Obstetrics and Gynecology Francis Farraye, MD, BMC Department of Gastroenterology AHRQ task order officers Claire Weschler, MSEd, CHES Mary Barton, MD, MPP 2

3. Project aim: To improve referral processes between Primary & Specialty care AHRQ-sponsored ACTION task order Using SUTTP principles Five clinical sites Two specialty clinics: Obstetrics and Gynecology (OB/GYN) Gastroenterology (GI) Three family medicine primary care sites: Codman Square Health Center South Boston Community Health Center BMC Family Medicine Ambulatory Care Clinic (ACC) 3

4. Clinical redesign process Regular meetings with clinical redesign team to conduct the work of redesign MDs + with periodic participation of senior referral staff Meetings early in process with providers & with referral staff in each site for input Periodic meetings to brief health center clinical leaders + HealthNet + BMC clinical leaders/administrators 4

5. Why redesign? Current referral system fragmented; varies among & between primary care sites & specialties Patients often unclear about reason for referral, how to make appointment, what to do after seeing specialist Specialists do not consistently receive clear reason for the referral or adequate information on tests already done Primary care physicians do not receive information about outcome of referral visit Referral staff cope with multiple discordant processes & lost information 5

6. Intended benefits For patients – clearer instructions & improved timeliness For primary care providers&specialists – consistent, complete information from the other & clear outline of follow-up care plans For referral staff – a standard method of processing referrals & clear outline of handling no-show appointments For all parties – feedback on how the system is working for ongoing process improvement 6

7. Redesigned system:  primary care standard elements Patient contact number PCP name PCP pager Appointment needed by date Diagnosis Reason for referral/ question Labs included Patient handout printed 7

8. Redesigned system:  specialist standard elements Referral receipt & provider acknowledged Diagnosis provided, question answered Follow-up plans indicated for: Patient Specialist PCP Note signed by specialist within 2 weeks & available in electronic records in PCP office 8

9. Redesigned system:  building it into practice CORE standard elements embedded in: Referral form from PCP to specialist Letter from PCP to patient Consult report from specialist to PCP Service agreement among participating practices CORE user tools CORE summary sheet Referral guidelines Desk guide 9

10. Developing the implementation process Work to fit with existing structures & systems Clinical redesign team members – the clinicians in the participating sites – Help design the implementation process Play key roles in carrying it out Clinical redesign team lead has ongoing relationships with sites and with organizational leaders 10

11. Implementation process with users Introduce new system at regular provider meetings Clinical redesign team members are local implementation leads Written materials to support presentations Review with administrative & referral staff Make adjustments based on feedback Initial meetings and follow-up conversations Clinical redesign lead makes technical changes Provide feedback after two-month trial implementation 11

12. Progress after trial implementation: primary care 12

13. Progress after trial implementation: specialty care 13

14. Implementation challenges:  ….a work in progress Influence of electronic medical records Overlapping development & implementation of e-Referrals Working in larger hospital system Difficult organizational environment Provider resistance 14

15. Overlapping development & implementation with e-Referrals Some success in building CORE changes into e-Referrals system But, CORE implementation challenged by: Confusion at front-line between CORE &e-Referrals E-Referrals roll out problems delay CORE Some desired CORE changes could not be accommodated Monitoring reports generated by e-Referrals limited 15

16. Working in a larger hospital system ACC clinic records part of larger hospital system Limits to possible EMR changes in ACC because all providers across hospital use same system CORE cannot simply replace forms CORE not default, have to select from menu CORE referral form difficult because of limited text box capacity 16

17. Difficult organizational environment New BMC CEO Massachusetts health reform changes state financing at great loss to BMC Several reductions in force in course of project Restructuring in BMC ACC High stress levels from hiring freeze, diminished service capacity, leadership changes 17

18. Provider resistance In addition to previous challenges … Providers hard to get together Hard to convince of mutual benefits of new system Chose path of least resistance On PCP side, patient letter not automatic 18

19. Role of project team in implementation Central project team: Facilitated process , audited data, provided tools Met regularly with clinical redesign leads to troubleshoot After two months, full team met to address ambiguities, clarify some elements, remove others Clinical redesign leader provided TA, modified systems directly working closely with sites Clinical redesign leads provided feedback to their colleagues supported by audit data, crib sheet of why each element important & talking points 19

20. Continuing steps Feedback to providers and referral staff Feedback from providers and referral staff Brief clinical and administrative leaders Develop system for ongoing monitoring 20

21. On reflection… Clinical redesign team membership Life goes on in the organizations Iteration, adaptation and continued discovery 21