Disclosure Information eConsult: Utilizing Technology to Bridge the Integration Gap Ricardo Mendoza, MD, Christopher Benitez, MD, Clayton Chau, MD, PhD, Paul Giboney, MD, Gary Tsai, MD Continuing Medical Education committee members and those involved in the planning of this CME Event have no financial relationships to disclose. Ricardo Mendoza, MD, Christopher Benitez, MD, Clayton Chau, MD, PhD, Paul Giboney, MD, Gary Tsai, MD: I have no financial relationships to disclose - and I will not discuss off label use and/or investigational use in my presentation eConsult: Utilizing Technology to Bridge the Integration Gap Ricardo Mendoza, MD Christopher Benitez, MD Clayton Chau, MD, PhD Paul Giboney, MD Gary Tsai, MD The challenge: How does a large, historically fragmented health care system address the issues of: Long wait times for specialty services Lack of coordinated care between County and Community Providers High no-show rates to specialty clinics Large variation in care delivery processes Objectives: Describe how eConsult can be implemented across large scale health, mental health, and substance use disorder systems of care, and how it can facilitate more effective management of patients with a broad range of comorbid mental health and substance use disorder conditions. Describe how eConsult is being utilized in LA County to achieve the Triple Aim of Healthcare Reform and how these initiatives will be monitored to assess efficacy. Describe how eConsult can be adapted to effectively support the care of cross-cultural patients when utilized across large systems of care with a culturally diverse workforce. Format: Quick history of LA Countys DHS specialty care improvement initiative Facilitated panel discussion Audience participation Question and answer The DHS effort to improve specialty care: The Black Hole 350,000+ referrals to specialty care annually Long Wait times for specialty clinic visits(2011) Gastroenterology 162 days Nephrology 86 days Podiatry 222 days Urology 208 days Cardiology 140 days Dermatology 208 days Gynecology 109 days Neurology 225 days Access to specialty care is consistently recognized as one of the top problems in the safety net. Referral Disruptive Innovation Investment in Patient Centered Medical Neighborhood (PCPs and Specialists). Specialty Primary Care Workgroups eConsult web based system for non-urgent, non-emergent, outpatient requests for specialty care assistance. Investment in Patient Centered Specialty Scheduling Reduction in process variation Reduction in no-show rates Improved patient experience Principles Effective Practice Practical real world improvement Specialty Primary Care (SPC) Workgroups Collaboration across facilities and disciplines Triple Aim Equity/Reduced variability Expected Practices / DHS Clinical Care Library Impact SPC Workgroups 31 Workgroups with 180+ participants Developing Expected Practices Determining DHS-wide approaches to common issues and problems clarifying clinical interventions and scope of care. 90+ Expected Practices already posted on DHS Clinical Care Library. Identifying opportunities to collaborate between facilities and better use DHS resources. Establishment of inter-facility handoffs of Urology patients from lower level to higher level facilities. Novel diabetic management strategies Teleretinal Diabetic Retinopathy Screening Program Clarifying scope of care in cataracts and diabetic foot screening to focus resources on patients most in need of intervention. eConsult HIPAA secure, web-based clinical conversation portal. Advantages PCP and Specialist collaboration Improved PCP clinical capability Relationship building Troubleshooting of system issues Improved responsiveness to requests for specialty assistance Reduction in avoidable specialty visits Improves effectiveness of specialty clinic visits (when they are indicated) Provides ability to send consult notes (from specialty visit) back to PCP The DHS eConsult Network Submitting Sites 4 Medical Centers 2 Multi-specialty Ambulatory Care Centers 17 DHS Health Centers 170 Community Partner (My Health LA) sites 14 Department of Public Health Clinics 14 Juvenile Courts Health Services Clinics 9 Sheriffs Department (Medical Services Bureau) clinics Specialty Care 54 Specialty Services >300 eConsult reviewers located at 10 different DHS facilities eConsult These locations can be envisioned together as a Patient Centered Medical Neighborhood 3,000+ Providers have submitted at least one eConsult DHS Clinical Care Library How eConsult Works Patient Scheduled for Specialist or PCP treats in Medical Home Next steps determined Dialogue between PCP and specialist Specialist reviews & responds to PCP within 4 days PCP submits eConsult request for assistance What does eConsult look like? eConsult Timeline Began in July, 2012 with 2 specialty services (Neurology and Dermatology) and 2 PCP sites (Long Beach CHC, Queenscare) 230 Sites! Specialties on eConsult Impact - Responsiveness Via Paper and RPS Responsiveness = Weeks/Months.and beyond! Responded to over 14,000 eConsult requests last month alone. To date in over 210,000 eConsult submissions, the average time of response (in calendar days) by our specialists = 2.5 Days ! eConsult Dispositions Specialty Change 6% Cancelled / 6months no activity 5% 210,000+ eConsults Access to Specialty Care eConsult provides access t0 specialty care in multiple ways - Rapid access to specialty expertise 2.5 days on average - Ability for specialists to expedite cases needing more rapid specialty attention and to designate specific face to face visit instructions based on clinical need. - Ability for PCPs to deliver specialty care in the Medical Home - Reduction in wait times for routine face to face specialty care visits (because we are using specialist time more efficiently) DHS Appointment Service Center (DHS-ASC) Patient Centered Specialty Scheduling For patients identified through eConsult 9,000/month DHS - ASC has the ability to schedule anywhere in the system Appointments are scheduled after personal patient contact GOALS Improved patient experience Quick scheduling turn around times Less variation in process Lower no show rate More effective work, not just more efficient work Program Impact Primary Care Quick access to specialty expertise Connected to larger system of care (reduced isolation) Opportunity to enhance clinical capability (eConsult CME) Reduced wait times Improved scheduling process Ability to see status of request/scheduling - improved care coordination Time investment in submitting eConsult More conditions managed in Medical Home more balls in PCPs court. Challenge in ordering specialty labs or diagnostics. Co-Management of complex patients Improved ability to meet patients needs Specialty Care Ability to extend expertise over a larger population of care. Ability to triage Reduced wait times Reduced no shows Face to face visits are more productive Better information Pre-Visit Testing Completed Avoidance of inappropriate referrals Opportunity to teach/educate PCP Residents/Fellows Increased complexity of clinic patients. Time investing in reviewing eConsult Improved ability to meet patients needs Program Impact Patient - Reduced wait times for specialty care - Less travel - Fewer days off work - Medical Home usually more culturally attuned - PCP more capable / empowered - Care better coordinated - transitions of care better managed, process more transparent - Specialist more informed when sees patient - Fewer specialty visits required to devise treatment plan