1

Jennifer Abraham MD, FACP

Medical Director, Kern Medical Center Health Plan

10/26/2009

PROVIDER PRACTICE REDESIGN USING A MULTI-FACETED STRATEGY

2

Specialty Care Challenges in Kern

3rd largest county in US spanning over 8,000 square miles Widely dispersed population of ~800,000 Lack of specialty care providers who see uninsured and

under-insured patients Kern Medical Center is the only county hospital in Kern

County For many specialties, KMC is the sole provider in the county

of specialty services for unfunded and underfunded patients Neighboring county was also using some of Kern’s specialty

clinics on a contractual basis. Wait times to be seen in some specialty clinics were

unacceptably long10/26/2009

3

Cause Of MortalityMortality Rate per 100,000 population

Rank out 58 Counties in California

All Cancers 183.3 47

Heart Disease 232.4 58

Stroke 51.3 47

Diabetes 34.2 56

Chronic Lower Respiratory Disease 69.6 55

Chronic Liver Disease and Cirrhosis

15.4 49

Influenza/Pneumonia 28.4 57

Alzheimer’s Disease 37.4 56

Kern County Selected Health Outcomes

Source: 2009 County Health Status Profiles, California Department of Public Health

10/26/2009

4

Coverage Initiative

A five-year section 1115 Medicaid Demonstration

Approved 9/1/05 for 3-year implementation Section 1115 Research & Demonstration

Projects: Provides the Secretary of Health and Human Services broad authority to approve projects that test policy innovations likely to further the objectives of the Medicaid program.

The Demonstration provides $180 million in federal funds

10/26/2009

5

Coverage Initiative Goals

Expand the number of Californians who have health care coverage

Strengthen and build upon the local health care safety net system

Improve access to high quality health care and health outcomes for individuals

Create efficiencies in the delivery of health services that could lead to savings in health care costs

Provide grounds for long-term sustainability of the programs funded under the Coverage Initiative

10/26/2009

6

Background on Kern Medical Center Health Plan (KMCHP)

The Coverage Initiative Program in Kern County Manage care of 5,000 patients Community clinics contract with KMC to provide

primary care for KMCHP patients Components of KMCHP:

Primary care home assignment Intensive care management for frequent hospital users Provider Practice Redesign: expanding the scope of

Primary care providers Information sharing between community clinics and

KMC 10/26/2009

Provider Practice Redesign

Objectives

Allow specialists to focus on most severe cases

Expand Access to Specialty Care Services

Decrease denied and deferred referrals

Build consensus about guidelines for delivery of care

Consensus Care

Guidelines

Information

Exchange

Community Grand

Rounds

Phone/ Chart

Consults

Mini Fellowship

s

Strategy

7

10/26/2009

8

Provider Practice Redesign

Model originally implemented for the LAC+USC Camino de Salud Network in LA in 2007

Model started with Rheumatology and later expanded to Cardiology

Outcomes: 444 patients screened by the Cardiology and

Rheumatology Champions 2/3 of patients managed in their primary care

home rather than being referred to specialty care10/26/2009

9

Creating Guidelines

Targeted specialties chosen by analyzing referral center data for specialties with highest referrals and longest wait times: Cardiology Endocrinology Orthopedics Neurology Rheumatology

Primary care providers and specialists attend “Grand Rounds Meetings” to discuss specific challenges within those specialties

Guidelines created by pulling together evidence-based guidelines and data from published resources

Guidelines are reviewed by all providers and modified to meet needs of specialist and limitations of safety net clinics

10/26/2009

Guidelines

Guidelines are disease-specific Delineate management roles for primary care provider

vs. champion vs. specialist dependent on acuity Outlines diagnostics needed before consult Allows for more management within the primary care

setting Allows referrals to be appropriate and more focused

on most severe cases Reduces number of denied and deferred specialty

referrals

10

10/26/2009

11 10/26/2009

12 10/26/2009

Champion Process13

Mini-fellowships: Community clinic providers complete curriculum and undergo training under specialist working at KMC

Mini-fellowship Curriculum Incentives to complete curriculum

Pre- and Post- tests 10 CME credits

Reading Materials Increased reimbursement through KMC

Lecture by the specialist and clinic shadow day(s)

Access to specialists for phone consults & chart reviews

Process:

Mini-Fellowship

Curriculum & Training

PCP becomes a Champion with clinical

confidence to adhere to guidelines

Champion can manage higher acuity patients

by having access to

specialist for chart reviews

and phone consultations10/26/2009

14

Reimbursements

Specialty Care Champions can bill for a higher reimbursement through the KMCHP to compensate for increased time and management

Specialists can bill for a phone consultation and patient review

Billing Codes: Outpatient Consultation Code: 99241-99245 Phone consultation Code: 99358

10/26/2009

15

Methods of Consultation

Advantages Disadvantages

Telephone Calls

•Easy to implement•Less security concerns

•Both parties need to be available at the same time

E-Referral System

•Secure system•Referrals and consults can be sent over the same system

•Requires a system that has the appropriate capabilities•May require significant investment

E-mail •Almost everybody has email•Can respond at own convenience

•Security problems •Requires implementing encryption method

Pager •Can reach providers even if they are not by their phones

•PCPs may find it inconvenient because call back can be delayed

Fax •Easy to implement•Doesn’t require anybody to learn a new program

•Faxes can get lost or be difficult to read•Would need a secure fax site

10/26/2009

16

Expectations of the Champion

Expectation of the Champion Method of Monitoring

Stronger understanding of managing and treating patients for specific disease

Pre- and post test scores

Adherence to referral guidelines Regular chart audits

Documentation of all Champion visits Champion codes required for higher reimbursement

Gradually be able to manage increasingly complex patients

Number of referrals over time to the specialist

10/26/2009

17

Information Sharing

E-referral system Updating, training, and expansion to more clinics

Challenge in primary care providers sending patients to KMC and receiving: Specialty consult notes Lab or radiology results ordered by the specialist

Expanding KMC records viewing systems to the community clinics Will improve coordination of care and require less reliance on

faxing of results and consult notes Decreases duplication of labs and other services Improve patient safety and point of service quality of care

10/26/2009

18

Implementing PPR in LA vs Kern

10/26/2009

More clinics and providers in the CDSN service area Specialty departments in LA vs 0.1 providers at KMC In Kern, some rural clinics are 2-3 hours from county

hospital and are staffed only with NP/PA’s most days Adaptations in the Model for Kern County

Guideline development without champion Clinic referral guidelines that are problem-based to

decrease misdirected referrals Webinar use for Grand Rounds Travel to clinic sites

19

Conclusion

Provider practice redesign Increasing scope of primary care physicians Improving compensation to primary care physicians Developing guidelines for referral to clinics Expanding e-referral use Evaluation measures

Improve access to specialists Decrease wait times

Improving communication between specialists and primary care Improving information exchange

Decrease duplication of services Decrease overall cost of care

10/26/2009

20

Questions?

10/26/2009