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Communication Between Primary Care Pediatricians and Specialists —Clarifying Expectations and Knowing When to Refer. Jennifer Lail, M.D., FAAP Florida Pediatric Medical Home Demonstration Project (C4K) Learning Session 2 April 27-28, 2012. Disclosure.

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Communication Between Primary Care Pediatricians and Specialists—Clarifying Expectations and Knowing When to Refer

Jennifer Lail, M.D., FAAP

Florida Pediatric Medical Home Demonstration Project (C4K)

Learning Session 2April 27-28, 2012


I have no relevant financial relationships with the manufacturers of any commercial products and/or provider of commercial services discussed in this CME activity. I do not intend to discuss an unapproved/investigative use of a commercial product/device in their presentation.

  • Discuss how Patient-Centered Medical Home model promotes communication and facilitates medical transitions—especially for children with Special Health Care Needs
  • Discuss practical examples of communication strategies between primary and specialty care
  • Discuss the role of the patient/family in co-managed, collaborative care
  • Consider improvements for your clinical setting
florida s cshcn 2009 10
Florida’s CSHCN, 2009-10
  • 606,215-- ages 2-17
  • CSHCN prevalence =15% (nat. avg. 15.1%)
  • CSHCN Prevalence by Age
    • Age 0-5 years =9.3% (9.3%)
    • Age 6-11 years=16.9% (17.7%)
    • Age 12-17 years= 18.8% (18.4%)
  • CSHCN Prevalence by Sex
    • Female =13.5% (12.7%)
    • Male=16.3% (17.4%)

Data Resource Center for Child and Adolescent Health

cyshcn 1 in 5 families has one camhi screener
CYSHCN: 1 in 5 families has one --CAMHI Screener
  • Condition lasting >1 yr. (physical,devel.behav.,emotional)


  • Needs more health care than other same-age kids
    • Medicine prescribed by a doctor
    • Limitation of function
    • Special therapy
    • Counseling

- McPherson, Arango, Fox: Pediatrics 1998; 102.

- The Child and Adolescent Health Measurement Initiative, 2009-10, NS-CSHCN,

cyshcn represent the whole health system in mh demands
CYSHCN represent the whole health system in MH demands
  • Family and patient see “whole picture”- expect seamless care.
  • High severity; 30% in registry have >2 specialty providers
  • Exacerbation may require ED use, admission
  • Barriers to access (physical, financial, MD availability)
  • Require primary-specialty access and collaboration
  • Issues with compliance, consent
  • Patient and Physician education is a key to outcome
a medical home model supports collaboration communication and co management
A Medical Home Model Supports Collaboration, Communication and Co-management
  • MH knows who needs the most care
  • Family is equal partner in the care process
  • Specialist records are accessible (letter, fax-back, electronic)
  • Referrals are tracked, start-to-finish
  • Specialty followup done in MH (weight checks, labs, hospital followup)
  • MH can synthesize thoughts from multiple specialists
  • Family has help for referrals, services, equipment
medical home involves changing systems
Medical Home involves Changing Systems
  • Build Electronic Health Records
  • Use the “Medical Neighborhood”
  • Use Evidence-Based Care for populations
  • Organize Care with Teamwork
  • Increase Safety, decrease duplication
  • Link between institutions and people
  • Fund preventive & non-procedural care
essential processes in a medical home system and neighborhood
Essential Processes in a Medical Home System (and Neighborhood)
  • Relationships
  • Ready Access
  • Registry and Care Coordination
  • Records
  • Resources
  • Reimbursement
  • Recruitment
relationships are established
Relationships are established
  • Med. Center Specialists
  • Community Specialists
  • School Nurses
  • Title V, State supports
  • PT, OT, Dental, Speech/Communication
  • Support Organizations
  • Home Health, Durable Equipment


ready access to specialty care
Ready Accessto Specialty Care
  • Care Coordinators!
  • Access to Med Center EMR
  • Directories of Specialists
  • Back-lines of Specialists, schedulers
  • Access for URGENT needs (“line-cutting”)
  • Phone consult for advice, stabilization
  • Knowledge to do preliminary workup
registry knowing who needs co management
Registry -- Knowing Who Needs Co-management
  • Multiple Diagnoses
  • Technological dependence
  • Family/Social complications
  • Language/Literacy barriers
  • Multiple ED visits/ admissions
registry communicating with specialty care
Registry—Communicating with Specialty Care
  • Do Pre-visit Contacts for Specialist reports
  • File complexity scores
  • Help with referrals-is the Specialist “on-plan”?
  • Specialist gets needed clinical data and clear goals for the consult
  • Track referrals to completion
  • Assure we get consult report
build your registry in the exam room
Build your Registry in the exam room
  • “Yikes! Complex child, 10 minute appt.!”
  • Paper: MD completes Form with CS
    • Form to Care Coordinator (CC)
    • CC enters into Registry
    • CC marks as “Special” in Admin
  • EMR: Patient Message to Care Coord
    • MD completes Autotext Form w/ CS
    • CC enters into Registry
    • CC marks as “Special” in Admin/EMR

Schedule a Chronic Care Management visit with a PVC prior

care coordination the left ventricle of the medical home
Care Coordination --the Left Ventricle of the Medical Home
  • Care Coordinators maintain registry, know dx’es
  • Separate from Advice Nurses
  • Direct Phone Extension
  • Brochures and Business Cards
  • CC’s know who is “on plan”,

and wait-times

  • Our CC’s know the Specialists’ CC’s!!
records how medicine communicates
Records: How Medicine Communicates
    • HIPAA
    • Adolescent Confidentiality
    • Docs don’t know each other
    • Non-interoperability of EMR’s
    • 69% of PCP’s sent hx and reason for consult; 35% of Spec. received it
    • 81% of Spec. sent results to PCP; 62% received it.*

* O’Malley and Reschovsky, Arch.Int.Med, 2011

* –O’Malley and Reschovsky, Arch.Int.Med, 2011

specialists as resources
Specialists as Resources
  • Peds. Specialty data base
    • Fax numbers
    • Schedulers
    • Wait lists
    • Emails for “urgent visits”
  • Find good collaborators—refer to them!
  • Use comanagement agreements
  • Use referral letters/faxes/emails
cshcn directory of resources 2010
CSHCN Directory ofResources2010




Alternative Medicine

Augm. Comm/AssistiveTechnology




Blind/Visual Impairment

Breast Feeding Support/Supplies/Home Care


Carseats for CSHCN

Cerebral Palsy

Childcare Resources



Compounding Pharmacies

Deaf/Hearing Impairment

Dentistry (see also Oral Surg.)


Developmental Eval./Therapy

Developmental Peds /Peds Rehab

Eating Disorders



Financial Planning


Genetic Testing/Counseling

Group Homes

G-Tube and Trach Care


Handicapped Parking Permits

Health Departments

Home Health Care/Equipment

Inclusion (see Transitions)

Intervention (Early)

Language Barrier/Resources


Massage Therapy

Multiple Births

Music Therapy

Newborn Care





Oral Surgery



Parent Education

Parent-to-Parent Connections

Physical Therapy/Sports Injury


Prenatal/Postnatal Counselling



Rare Disorders

Recreation for CSHCN

Respite/Residential Care

Safety and Hotlines

School Systems

Smoking Cessation

Social Services/Abuse/Domestic Violence

State of NC programs for CSHCN


Substance Abuse



Travel Nurse



Vocational Rehab

-Index from CHPA Internal Directory of Resources, 2010, Chapel Hill, NC

who s in charge primary care specialists family
Who’s in CHARGE? Primary Care, Specialists, Family?
  • WHO:
    • Vaccinates?
    • Monitors safety, growth, dental care, school performance, friendships, bullying?
    • Prevents pregnancy, watches for STI’s?
    • Prepares for transition to adult care?
      • Self-management skills?
      • Guardianship, Competency?
      • Financial/Insurance coverage?
ideal model of comanagement
Ideal Model of Comanagement
  • “Perfect” model depends on:
    • Stated needs and preferences of pt./family
    • Clinical situation involved
    • Disease process timeline
    • Professional judgement of MD’s involved
    • Geography and Specialist availability
the needs and the leads change over time
The Needs and the Leads change over time……
  • Youth education around conditions, meds, risks
  • Help with: SSI, Disab. Determ., Voc. Rehab, Insurance, Handicapped Parking, Guardianship
  • Options of Adult Providers
  • Medical Summary
  • Build Youth and Parent confidence
red flags when is co management needed urgently
Red flags: when is co-management needed urgently?
  • Kids whose care seems to “belong” to no one
  • Kids with:
    • Multiple ED visits for specialty problems
    • Multiple preventable admissions
    • Multiple “bounce-backs”
  • Kids who only come to primary care for urgent visits and don’t receive primary care at a specialist
  • Kids who miss multiple specialty appointments
medical home involves changing attitudes
Medical Home involves Changing Attitudes
  • Focus on the Patient/Family
  • Improved access/availability
  • Empanelment- “my doctor, my nurse”
  • Whole person care vs. “1 problem-10 min.”
  • QI embedded in your system
  • More thinking, fewer tests
reimbursement a new frontier
Reimbursement-a new frontier
    • Population Health
    • Patient Experience
    • Per Capita Cost
  • FFS, face-to-face care >>> “Bundled Episodes of Care”
  • “Value = Health Outcomes achieved per dollars spent”*
  • Cost and Savings Attribution-who spent it--- who saved it?

*What Is Value in Health Care? Michael E. Porter, Ph.D., N Engl J Med 2010; 363:2477-2481 December 23, 2010


Recruitment:Ways to Work Together“The Patient-Centered Medical Home Neighbor—The Interface of the PCMH with Specialty/Subspecialty Practices”

Preconsultation exchange: “curbside”

Formal consultation: PCP as primary manager, Specialist as consultant (ex., PET placement)

Co-management: PCP comanages with Specialist

For Shared Management of the disease (ex., Type 1 DM)

With Principal care for the disease (ex., Leukemia)

With Principal care of the patient for a consuming illness, limited time period (ex., Prematurity)

Transfer of care --American College of Physicians, 2010


J.L., 4 year old girl with MR of ? etiology, severe sz disorder, osteopenia, GTube, recent adm. for spont. hip fx and post-op pneumonia. . . (Neuro, Ortho, Endocrine, Surgery are consults)Calls for appt. for fever and cough. . .

  • Extra time is scheduled for J.L. 
  • Front desk knows she’s in wheelchair and watches for her arrival with her 2 sibs 
  • Discharge summary is on chart for your review
  • You ask CC to get most recent XR results and labs from on-line connection with Med Center EMR
  • Your clinical dx: pneumonia rx: antibiotics and fup 1 day 
  • Mom reports she has bisphosphonate infusion in 2 weeks at hospital; consultants #’s are in your pocket. 
  • Phone call to Pulm. CC arranges consult on infusion day to eval. and consider vibratory vest. 
  • CC tracks referrals and sends you reminder of visit 
  • Pulm. sends on-line report about consult
  • ED visit, admission are avoided; fup care is synchonized for patient, and Pulmonary advice/care prevents further pneumonias 
a medical neighborhood needs
A Medical Neighborhood Needs:
  • EMR interoperability
  • Planned care—assimilate multi-source info
  • Care coordination agreements
  • Continuing Ed. for Primary Care
  • Care coordinators across systems
  • Assured, HIPAA secure, 2-way communication
  • Financial and Legal support for collaboration, communication, non-face-to-face care
  • Support for PCMH as provider of “Whole Person Primary Care”
how primary care can help
How Primary Care Can Help
  • Use Evidence-Based Care Guidelines
  • Expand office hours for better continuity, less ED use
  • Use a registry of CSHCN
  • Develop Care Coordination for pt. and referral support
  • Do prelim. workup; COMMUNICATE essential info pre-consult
  • Offer followup help (weights, labs, injections)
  • Do ED and hospital followups
how specialists can help
How Specialists Can Help
  • Alerts of ED visits, adm., status change
  • Education, metrics for evidence-based care
  • COMMUNICATE directives for f/up
  • Note Lab & imaging needs
  • Notification of referrals for secondary dxes
  • Followup at MH for self-referrals
  • “Lunch and Learn” & “Hand-holding”
a medical home improves chronic condition care
A Medical Home Improves Chronic Condition Care
  • family satisfaction
  • inpatient stays
  • ED utilization
  • pharmacy spending
  • Better coordination of primary and specialty care
  • Avoid duplication of services, tests
  • Opportunity to address comorbid conditions
culture of collaborative care as the norm
“Culture of Collaborative Care”as the Norm

“Chapel Hill Peds patients EXPECT that we will be in communication with each other and have a sense of comfort that we are—behind the scenes—somehow connected and working together in their best interest.”

--Dr. Sarah Armstrong, Director, Healthy Lifestyles Program, Duke University Health System

“I think that the Medical Home gives us comfort as specialists that the patient’s whole realm will be cared for in a meaningful manner—a trach or a syndrome doesn’t keep them from being part of a larger community”.

--Dr. Amelia Drake, Chief, Pediatric Otolaryngology, UNC Hospitals

“My family, with all its challenges, is a success story, but part of that success is because we have had a Medical Home”… Libby
keep up the great work
Keep up the Great Work!!
  • Recruit your staff, families
  • Report your small victories
  • Inform insurers of your efforts
  • Expect “late-adopters”
  • Use MH resources from AAP
  • Don’t reinvent the wheel-

“steal shamelessly”

  • MH site, PVC form)
  • (MH index)
  • (ACP position paper)
  • Coordinating Care in the Medical Neighborhood: Critical Components and Available Mechanisms (AHRQ white paper on MH)
  • (AHRQ PCMH site)