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The Specialist and the Patient-Centered Medical Home... the need for Neighbors. Carol Greenlee MD Co-Chair PCMH-N Work Group for the American College of Physicians Vice Chair Council of Subspecialty Societies, ACP Chair Clinical Integration Committee, Mesa County Physicians IPA

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the specialist and the patient centered medical home the need for neighbors

The Specialist and the Patient-Centered Medical Home...the need for Neighbors

Carol Greenlee MD

Co-Chair PCMH-N Work Group for the American College of Physicians

Vice Chair Council of Subspecialty Societies, ACP

Chair Clinical Integration Committee, Mesa County Physicians IPA

Private Practice, Western Slope Endocrinology

Paper to Practice

  • Overview of current care coordination issues
  • What is possible…a better way
    • Overview of the ACP PCMH-Neighbor model
    • Focus on the Referral Process (starting point)
  • Barriers to making it happen
there are many stories we can tell
There are many stories we can tell
  • Joe
    • 67 yo AA male referred because of a 1.1 cm pituitary tumor found incidentally
      • MRI report no other records
    • Very low testo <20, LH <1, normal prolactin and other pituitary tests
    • Pt denies prostate issues, desires Testosterone therapy
    • Look in hospital computer lab data base for baseline PSA, CBC, etc reveals very high PSA, call to urologist attached to the PSA
    • Pt had metastatic Prostate cancer on Androgen suppressive therapy
  • Barbara
    • 62 yo C female with CI sent from SNF with only a med list including glipizide and ss insulin; no one at the SNF knows why she was sent; No answer at PCP office
    • Review of HIE shows 57 pages of reports including a large pituitary mass of 3.2 cm, osteoporosis and diabetes: what is the question ?
    • Hours of searching, sent note to referring SNF physician on summary of findings and asking for clarification of reason for referral; no response
    • Note to self “never again….”
too many stories
….too many stories
  • Ella
    • 53 yo female with severe form of asthma; has been to Jewish and has home monitoring devices; goes into “yellow and red” zones; can’t get into PCP for 2 months nor into her local pulmonologist for 3 months
    • Goes to ER in order to get the script for the prednisone she knows she needs
    • No one monitoring, no f/u
  • Bill
    • 80 yo male with end-stage ischemic heart disease has a very astute internist who has discussed care with him and together they have decided he does not need preventive screening tests at this point
    • Has routine f/u with his cardiologist and asks him about need for screening tests with PSA ordered, patient sent for pulmonary function tests and to GI for colonoscopy
gaps in care coordination referrals how it works or not now
Gaps in Care coordination/referrals How it Works (or not) now
  • Forreferred patients:
    • 68% of specialists reported receiving no information from the primary care provider prior to referral visits:
    • 25% of primary care providers had received no information from specialists 4 weeks after referral visits:
    • 28 % of primary care and 43% of specialists are dissatisfied with the information they receivefrom each other.Gandi et. al. J Gen. Int. Med. 2000
  • 25%-50% of referring physicians did not know if patients had seen a specialistMehrotra, A., Forrest, C.B., Lin, C.Y. (2011). Dropping the Baton: Specialty Referrals in the United States. The Milbank Quarterly, 89 (1), 39-68.
  • No SYSTEM, No STANDARDS….only ASSUMPTIONS:depends on diligence of individual clinician

Referral and Consultation CommunicationBetween Primary Care and Specialist PhysiciansO’Malley, AS, Reschovsky JD. Arch Intern Med. 2011;171(1):56-65



34.8 % of specialists said they receive it "always" or "most of the time.

SOC/PCMH Poll indicates 37% of specialists receive necessary information

62.2 % of PCPs reported getting it "always" or "most of the time.”

SOC/PCMH Poll indicates PCPs receive info 52% of time.

  • 69.3 % of PCPs reported they "always" or "most of the time" send notification of a patient's history and reason for consultation to specialists.
  • 80.6 % of specialists said they "always" or "most of the time” send consultation results to the referring PCP

We need better

    • Hand-offs
      • Communication(more than information exchange)
    • Shared Care Plans
      • Coordinated Care
      • Integrated with patient self-management /crisis care plans
pcmh neighbor model policy paper
PCMH-Neighbor Model/Policy Paper
  • Supports the importance of Medical Neighbors
    • An infra-structure or framework to support Care Coordination and Communication
    • Improve Care Transfers and Transitions to enhance Safety and Stewardship
    • Restore Professional Interactions needed for Patient Centered Care
  • Definition of PCMH-Neighbor
  • Describes the Types of Interactions between PCMH practices & Specialty Practices
  • Principles Care Coordination Agreements
pcmh neighbor definition practices that
PCMH-Neighbor DefinitionPractices that:

Communicate, coordinate and integrate bidirectionally with PCMH as well as with patient

Ensure appropriate & timely consultations and referrals

Ensure effective flow of information

Address responsibility in co-management situations

Support patient centered care

Support the PCMH practice asthe “hub” of care and provider of whole person primary care to the patient

care coordination agreements provide foundation of definitions expectations
Care Coordination AgreementsProvide foundation of Definitions & Expectations

Types of Interactions (defines the role of the specialist)

Pre-visit assistance to expedite/prioritize care

Consultation (cognitive, procedural, “e-referral”)


Shared care

Principal care (of the disorder/ of the patient)

Responsibility for the elements of care

Expectations for information exchange

Defined Referral Process

The clinical question/ synopsis

Closing the Loop

Ongoing/sustained care coordination and communications

Shared Plan of Caer


Care Coordination Agreement

    • Platform that everyone agrees to work from (system)
      • Standardized Definitions/Formats/Expectations
  • Care Plan (Comprehensive)
    • Coordinated Care (practice & patient)
      • Individualized Care
pre consultations exchange
Pre-consultations Exchange

Intended to expedite/prioritize care

Referral guidelines

Recommendations for what preparation and/or data will best facilitate the referral evaluation and /or management (what to send with the referral)

Example for prep: Chronic diarrhea referred for colonoscopy: be sure stool culture neg

Example for data: Short stature/growth delay: send growth chart

Example VA: “filters”: back pain (criteria) ; hepatitis clinic (attend class before appt-Patient Decision Aid)

Utilize providers at the top of their license (‘neurosurgeons not seeing muscle strain’)

Urgent Cases

Expedite care

Improved hand-offs with less delay and improved safety

Coordinated visits (“virtual Mayo clinic”)


Diabetes ed/endocrinologist

formal consultation
Formal Consultation

Cognitiveconsultation (advice)

To obtain specialist’s opinion on a patient’s diagnosis, abnormal lab or imaging study result(s), treatment or prognosis

Limited to one or a few visits that focus on answering a discrete question.

eConsultation: provide advice/recommendations without an office visit

Procedural consultation

To obtain a technical procedure for diagnostic, therapeutic or palliative purposes

Include detailed report back to referring physician

Examples: Colonoscopy, Bone Marrow Biopsy, MRSA infection with recurrent carbuncles

non face to face consultation including e consultations
Non-Face-to-Face Consultationincluding e-Consultations
  • Reduce unnecessary specialty visits
  • Streamline patient care decisions
  • Key Elements
      • Answer clinical question, and tailor to specific patient characteristics
      • Non-binding… convert eConsult to standard visit if too complex
      • Compensated time and effort
      • Exchange records and responses
        • Documentation: “Based on the information I received, I recommend…”
co management

Shared Care for the disease (PCP responsible for Elements of Care)

Principal care for the disease. (Specialist responsible for Elements of Care for that disorder or set of disorders)

Principal care of the patientfor a consuming illness for a limited period of time (specialist serves as first contact but patient maintains PCP as Home)

co management oncology examples
Co-Management Oncology examples:
  • Shared Care for the Disease
    • CLL
  • Principal Care of the Disease
    • Ductal carcinoma in situ (non-invasive breast cancer – DCIS)
  • Principal Care of the Patient
    • Metastatic colon cancer with adjuvant chemotherapy
1 define the types of referral and co management agreements available
1) Define the types of referral and co-management agreements available
  • fluid (dynamic) to adapt to changes in patient or disease status
  • clearly communicated and understood by all parties including the PCMH and the specialty practice as well as patients and their families and caregivers.
where to start with care coordination agreements the referral process
Where to start with Care Coordination AgreementsThe Referral Process:

The Agreements define what is expected

What to send with the referral

What to expect in return

Who is doing what

Lead to a Shared Plan of Care

The Components of the Referral Process:

Prepared Patient (informed , appropriate timing and specialty)

Core Data Set (‘fixtures” of patient’s medical history)

Referral Request (the type, the clinical question + data)

Specialty Response (“critical elements” and summary of the specialist’s thought process)

referral request elements
Referral Request Elements
  • Type of service/co-management requested
  • Clinical question or reason for referral
    • Ideally a summary or synopsis of events
  • Core Data Set (reconciled med list, allergies, etc)
  • Data set for clinical question
  • Urgent (recommend direct contact) or routine
  • Contact info for more information
  • Think HAND OFF
critical elements of response
Critical Elements of Response
  • Answer the clinical question/ address the reason for referral
    • Summary or Synopsis (include some thought process)
  • Recommend type of interaction/ form of co-management
  • Confirm existing, new or changed diagnoses; include “ruled out”
  • Medication /Equipment changes
  • Testing results, testing pending, scheduled or recommended (including how/who to order)
  • Procedures completed, scheduled or recommend
  • Education completed, scheduled or recommended
  • Any recommended services or actions to be done by the PCMH
  • F/u scheduled or recommended
referral request
Referral Request

Clinical question or reason for referral: “Please help determine which next treatment option is best suited for a 62 year old first grade teacher who has had diabetes for past 10 years. She was allergic to SU; had diarrhea with metformin, edema with Actos and is now on Lantus insulin 60 units once daily with widely fluctuating glucose levels and A1c of 10.2%. She is reluctant to check her BG or take injections during the work day due to working with children and the demands of school teacher.” ( note: this also “turns the patient into a person”)

Type of Referral: Shared Co-management

Core Data: attached

Pertinent Data: lab flow sheet attached

Patient considerations: Please call after 3 PM due to work hours

Contact for more info: back line number is 123-456-8901

referral response
Referral Response
  • Answer to clinical question:Based on her need for mealtime insulin but reluctance/inability to administer injections during work day as first grade teacher, we have opted for her to try Premixed insulin before breakfast and dinner.
  • Diagnosis: no change
  • Testing: pocA1c 9.6%
  • Medication changes:
    • Stop Lantus insulin
    • Start Humalog mix 75/25 as 20 units ac bid
  • Self management:
    • Titration sheet for insulin adjustments
    • Patient to measure BG before lunch and at bedtime and FBS
  • F/U: 2 weeks
requests for cognitive consult
Requests for Cognitive Consult

“thyroid” “thyroid issues” “abnormal thyroid”

“26 yo female with severe thyrotoxicosis 5 months postpartum”

“68 yo man new onset thyroid swelling and tenderness”

32 yo female with repeatedly normal thyroid levels is convinced her fatigue, weight gain and hair loss is due to thyroid and wants a trial on thyroid hormone. Would appreciate consultation to reassure patient that thyroid disorder not being missed.”

requests for procedural consults
Requests for Procedural Consults

“eyes” “ vision” “thyroid” “gallbladder”

68 yo female with sudden reduction in visual acuity with eye pain

24 yo male with 3 cm left thyroid nodule and FNA cytology suspicious for thyroid cancer

39 yo female with severe RUQ pain, abnormal US and known diabetes

requests for radiology
Requests for Radiology
  • Clinical Question
    • Determines what and how imaging done (technical)
      • “A CT scan is not a CT scan, an MRI is not an MRI”
    • Helps referring clinician get the information they need (interpretation)
    • HUGE cost impact
      • 76% of radiology orders result in call back to ordering practice
      • Wrong technique:
        • Repeat studies
        • Delay in treatment
        • Radiation exposure
closing the loop
Closing the Loop
  • Referral request sent
    • Must include clinical question or synopsis of reason for referral
  • Referral request received and reviewed
    • Appt made with confirmation of appt and date sent back to referring practitioner
    • Apptdeclined due to inappropriate referral (wrong specialist, etc) and referring practice notified
    • Patient defers making appt or cannot be reached and referring practice notified
  • Referral response sent(must address clinical question/reason for referral)
    • Referral Note sent to referring clinician and PCP
    • Notification of No Show or Cancellation (with reason, if known)
just the beginning
Just the beginning…..

The Referral Process is just the beginning….a way to get started…

The Neighbor model establishes the processes for connections and agreements for the ongoing professional interactions and relationships between physicians and patients

what else is possible
What else is possible ?

Non-face-to-face consults

Non-face-to-face follow up/alternative visits

Enhanced shared-care arrangements

Enhanced access

Win-Win-Win arrangements (patient-physician-purchaser/payer)

Repatriate primary care (patients stuck in specialty follow up)

More appropriate specialty visits



How to establish and enforce Care Coordination Agreements

Diversity of Specialties

Cognitive vs Procedural



FFS mentality ($$/min)/procedures vsOverload of uncompensated time


My Practice vs My System

Technology Barriers

Information not enough- need communication


“Administrative waste”

Need for practice transformation


Effort and cost

faqs from specialists
“FAQs” from Specialists
  • “Why would a busy PCP ever do this ?” (“PCPs will never do this”)
  • “Won’t I be setting myself up for litigation if I do an e-consult, what if I don’t have all the information ?”
  • “Isn’t this just another way for them to try to pay us less and make us do more for nothing?”
  • EMR issues: “where to put any of this in EMR?”
    • “EMR venders treat the referral process as an administrative task, not a clinical issue”
    • *ACP has many recommendations regarding ‘helpful’ changes to EMR format to help with referral process and communication, working with HIMSS……
ncqa specialty practice recognition
NCQASpecialty Practice Recognition
  • Track &Coordinate Referrals
    • Referral Process & Agreements
    • Referral content
    • Referral Response
  • Provide Access& Communication
    • Access
    • Electronic Access
    • Specialty practice responsibilities
    • CLAS
    • The Practice Team
  • Identify& Coordinate Patient Populations
    • Patient information
    • Clinical data
    • Coordinate patient populations
  • Plan & Manage Care
    • Care planning & self-care support
    • Medication management
    • Electronic prescribing
  • Track & Coordinate Care
    • Test tracking & follow up
    • Referral tracking & follow up
    • Coordinating Care Transitions
  • Measure & Improve Performance
    • Measure Performance
    • Measure patient/family experience
    • Implement & Demonstrate Continuous Quality Improvement