Continuity of CareImplementing Compacts: A small practice journey

R. Scott Hammond, MDChair, CAFP PCMH Task Force

Medical Director, SOC-PCMH Grant, Colorado

Associate Clinical Professor, Dept. of Family Medicine UCHSC

Westminster Medical Clinic, Westminster, Colorado --PCMH Level 3

Continuity of Care Paradigm

Continuity of Care

Informational continuity– Every provider caring for patient has access to

accurate information about patient’s previous care.

Relational or interpersonal continuity– On-going relationship between the patient and the

clinicians chosen by the patient as his/her usual

source of care.

Geographic continuity– Delivery of care in multiple locations by a team of

clinicians chosen by and known to the patient.

Systems Of Care-PCMH Grant,

Colorado

Planning Phase

– Research and Development

Systems of Care Poll (700 responses/10,725 physicians)

Focus groups

SOC-PCMH Summit 10-09

Action Plan

Implementation Phase

– Outreach, Promotion, Education of the PCMH and

Medical Neighborhood

Evaluation Phase

Colorado Systems of Care Poll -10/09

PCP Specialty

Aware of PCMH– Very familiar/somewhat 80% 38%

Concept of PCMH– Extremely/Very important 72% 76%

Definitely/probably will become PCMH after

reading description

56%

Willing to meet with PCP 79%

Communication satisfaction with facilities –

Total/very satisfied

15% 21%

Staff finds other office cooperative -

Always/regularly

40% 54%

Receives necessary information --

Always/regularly

51% 36%

PCP included in care by specialist 36%

Specialist care plan supported/followed by PCP 70%

Colorado SOC-PCMH Summit and

Action Plan

Summit– Practice constraints and loss of personal relationships

impede effective “hand-offs” and clinical communication

– Both PCPs and specialists wish to improve this relationship.

Action Plan– Focus on improving physician culture and

communicationEngage specialty societies, focus groups

Develop Primary care-Specialty care compact to standardize communication and expectations.

Develop informational continuity with medical facilities.

Pilot standards

Geographic continuityPrimary Care– Specialty Care Compact

Research

– Working models (Kaiser, QHN)

– Literature (Chen, Forrest, JHU, COPIC)

– ACP, TransforMed, NCQA

Development of Working Model

– 4 PCPs ( 3 PCMH FPs, 1 IM)

– 4 specialists (Cardiology, Oncology, Surgery, Endocrinology)

Testing

Primary Care-Specialty Care

Compact

Purpose and Principles

Definitions

Types of Care Transition

Service Agreement

– Transition of Care

– Access

– Care Management

– Medical Collaboration

– Patient communication

Transition of Care Records (PCP and Specialist)

Primary Care-Specialty Care

Compact

Types of Care Transition

– Pre-consultation exchange

– Formal consultation

– Co-management (Referral)

With Shared management

With Principle Care

– Complete transfer of care (Specialty Medical

Home Network)

– Emergency Care

Transition of Care

Mutual Agreement

Maintain accurate and up-to-date clinical record.

Agree to standardized demographic and clinical information format such as the Continuity of Care

Record [CCR] or Continuity of Care Document [CCD]

Ensure safe and timely transfer of care of a prepared patient

Expectations

Primary Care Specialty Care

PCP maintains complete and up-to-date

clinical record including demographics.

Transfers information as outlined in Patient

Transition Record.

Orders appropriate studies that would

facilitate the specialty visit.

Informs patient of need, purpose (specific

question), expectations and goals of the

specialty visit

Provides patient with specialist contact

information and expected timeframe for

appointment.

Determines and/or confirms insurance

eligibility

Provides single source referral contact person

When needed, be ready to communicate with

the PCP prior to the appointment to assist in

the preparation of patient.

Communicates appropriate pre-referral work-

up to PCP, as needed.

Additional agreements/edits: _____________________________________________________________

____________________________________________________________________________________

Service Agreement– Transition of Care

1. Practice details – PCP, PCMH level, contact numbers (regular, emergency)

2. Patient demographics -- Patient name, identifying and contact information,

insurance information, PCP designation and contact information.

3. Diagnosis -- ICD-9 code

4. Query/Request – a clear clinical reason for patient transfer and anticipated goals

of care and interventions.

5. Clinical Data

Problem list

Medical and surgical history

Current medication

Immunizations

Allergy/contraindication list

Care plan

Relevant notes

Pertinent labs and diagnostics tests

Patient cognitive status

Caregiver status

Advanced directives

List of other providers

6. Type of transition of care.

7. Visit status -- routine, urgent, emergent (specify time frame).

8. Follow-up request

Service Agreement–PCP Patient Transition Record

Geographic continuityHospitals

CO PCMH Pilot: Hospital Subgroup

committee

– Patient Identifier information

“wallet card” PCMH ID

Patient education and educational materials from

health plans

– Bidirectional communication

Care Coordination Form (hospital to PCP)

ED Referral Form (PCP to hospital)

Geographic continuityHospitals

Care coordinator job description and

communication policy

List of facilities and contact personnel

Informational continuity

– Daily census of admits, discharges, updates

(hospitals, hospitalists, IPA)

– Post hospital transition (discharge care plan)

– ED/in-hospital medical information transfer

Friday, July 24, 2009

Page 1

Patient Admission

Patient presents to

hospital

SELF REFERRAL

Patient presents to

hospital

FROM OFFICE

Emergency Room

Discharged Home

Appointment with

PCP/Specialist

Admission to Floor

Discharged to

Skilled Nursing

Facility

Discharged to

Home

Discharged to

Long Term Care

Clinic: Medication notes

faxed to hospital from PCP

Hospital: to notify of

Admission to Hospitalist

Hospital: to provide updates

regarding patient progress

Hospital: ER Notes faxed

to Providers office

Hospital: to inform PCP

office – fax, phone, email?

Clinic: Care Coordinator to

fax medical info

Hospital: Case Manager

to notify PCP office and

proved care plan

SNF: to notify and send

discharge to PCP

SNF: to notify PCP -

? Change PCP

Color Key:

Hospital Action Green

Clinic Action Blue

SNF Action Red

Geographic continuity -- WMCReferrals

Specialist Report Card (adapted from

Clinix)

Preferred Specialist List

PCMH Patient Referral Form (Specialist Rx)

Specialty Compact

It can get dirty but change can be

good

WMC Team