Quality Improvement Strategies for enhancing Care coordination with Specialists

1. Quality Improvement Strategies for enhancing Care coordination with Specialists Lisa M. Letourneau, MD, MPH November 4, 2011

2. Objectives • Discuss interactions among integrated care team, patients and specialists • Share best practices • Problem-solve on ways to improve shared treatment planning, care coordination

3. The Medical Home: A Model for Change! Employers & payers pay for desired services because providers demonstrate value AND reduce spending = Payment Reform Providers transform practice, create value with viable & sustainable payment for desired services = Practice Transformation AND

4. “It Takes a Village” • Medical Home model is also about relationships • The effectiveness of the PCMH model to promote integrated, coordinated care throughout the healthcare system depends on the availability of a “hospitable and high-performing medical neighborhood.” • Elliott Fisher MD, MPH, NEJM, 2009

5. The Wider “Neighborhood”

6. Reality of Care Coordination • The typical primary care physician has 229 other physicians working in 117 practices with which care must be coordinated. Pham et. al Ann Int Med. 2009 • In the Medicare population, the average beneficiary sees 7 different physicians and fills upwards of 20 prescriptions per year Partnership for Solutions, Johns Hopkins Univ. 2002

7. The Neighbors • Consistently voice concerns about referral information they receive • Often believe they are currently meeting primary care expectations • Have wide variety of practice capacities & infrastructure

8. Reality Referral and Consultation CommunicationBetween Primary Care and Specialist Physicians Perception PCPs: 69.3 % reported they "always" or "most of the time" send notification of patient's history and reason for consultation to specialists Specialists: 80.6 % said they "always" or "most of the time” send consultation results to the referring PCP • Specialists: 34.8 % said they receive info from PCPs "always" or "most of the time • PCPs: 62.2 % reported getting info from specialists "always" or "most of the time” Arch Intern Med. 2011;171(1):56-65

9. Trust Mutual respect Safe Leveraged services Safe environment Agreements Communication “Neighborly” Characteristics

10. Primary Care - Behavioral Health Referrals “Unique” challenges: • Widely dispersed network • Variable availability • Psychiatrists, psychologists – limited • LCSWs, MSWs, LCPC,… - many! • Limited information on effectiveness • Confidentiality concerns

11. Small Group Exercise - #1 (15 mins) • How effective are referrals for your patients? How do you know? • What is happening in your community that might impact referral/coordination processes? • How does practice ensure that behavioral health is addressed/coordinated when referring to non-behavioral health providers? • How do you identify, address, and communicate patient goals for specialty consultation?

13. Primary Care - Specialty Care Collaborative Guidelines • Purpose and Principles • Definitions • Types of Care Transitions • Service Agreements • Transition of Care • Access • Collaborative Care Management • Patient Communication • Transition of Care Records (PCP and Specialist)

14. Primary Care - Specialty Care Compact Types of Care Transition • Pre-consultation exchange • Formal consultation • Co-management (Referral) • With Shared management • With Principle Care of the disease • With Principle Care of the patient • Complete transfer of care (Specialty Medical Home Network)

15. Primary Care – Specialist Service Agreement

19. PCP Toolkit Example

20. Specialist Toolkit Examples • PCMH “Identifier” • Specialty Provider Checklist

21. Small Group Exercise - #2 (15 mins) • Considering PCP-Specialist Toolkit,what can be done in your practice (redesign/QI strategies) to improve specialty referral process? • What can be done to improve coordination of care following specialty referrals? • Are there specific steps that could be taken to improve behavioral health referrals?

22. Making Forward Progress • “I’ve got it, too, Omar…a strange feeling like we’ve just been going in circles.” • The Far Side

23. www.mainequalitycounts.org

24. Contact Info / Questions • Lisa Letourneau MD, MPH • LLetourneau@mainequalitycounts.org • 207.415.4043 • Maine PCMH Pilot • www.mainequalitycounts.org (See “Programs”  PCMH)