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Key Changes and Resources forCare Coordination

(Reducing Care Fragmentation in Primary Care)

MacColl Institute for Healthcare InnovationGroup Health Research Institute


The Patient-centered Medical HomeKey Features:

1. Engaged leadership

2. Quality improvement strategy

3. Empanelment

4. Patient-centered interactions

5. Organized, evidence-based care

6. Care coordination

7. Enhanced access

8. Continuous, team-based health relationships


Defining Care Coordination

The deliberate organization of patient care activities between two or more participantsinvolved in a patient’s care to facilitate theappropriate delivery of health care services. (McDonald, 2007)

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What constitutes a high quality referral or transition?

Institute of Medicine’s (IOM) report Crossing the Quality Chasm: A New Health System, for the 21st Century:

Safe Planned and managed to prevent harm to patients from medical or administrative errors.

Effective Based on scientific knowledge, and executed well to maximize their benefit.

Timely Patients receive needed transitions and consultative services without unnecessary delays.

Patient-centered

Responsive to patient and family needs and preferences.

Efficient Limited to necessary referrals, and avoids duplication of services.

Equitable The availability and quality of transitions and referrals should not vary by the personal characteristics of patients.


The Care Coordination Model


Key Changes

Assume accountability

Provide patient support

Build relationships & agreements

Develop connectivity


Assume Accountability

• Providers, especially primary care clinics, decide to improve care coordination.

• Develop a referral/transition tracking system.


Resource #1

NCQA Patient-Centered Medical Home 2011 Standards• Test tracking and follow up• Referral tracking and follow up• Coordinate with facilities and care transitions


Resource #2Measuring care coordination from patient’s perspective:• ACES• Picker• PACIC• CAHPS• CYSNCN• Press Ganey

Also check out AHRQ’s Care Coordination ATLAS


Resource #3

Referral Tracking Guide• How-to guide to setting up your own referral

tracking system– Use existing practice management (or billing)

system– Use paper tracking grid

• Describes how to use the data to inform practice


Provide Patient Support• Organize the practice team to

support patients and families during referrals and transitions.

• Logistical “referral” coordinator:– Tracks all referrals and

transitions– Provides patient (and family)

with information about referral– Addresses barriers to referrals– Follows up on missed

appointments


Patient Support ≠ Case Management

Clinical Care Management

Logistical

Case Load

High-risk, multi-morbid patients

Care Coordination

Clinical Follow-up Care

©MacColl Institute for Healthcare Innovation, Group Health Research Institute 2011

Patients with common chronic illnesses

All patients in panel who are involved in referral or transition process

Logistical

Logistical Clinical MonitoringMedication Mgmt

Clinical MonitoringSelf Mgmt Support

Self Mgmt Support


Resource #4

Referral “Logistical” Coordinator Job Description• Based on our review of relevant jobs

Questions for group:• Do your clinics have someone filling this role? • How is the role different/similar to our generic

job description?


Resource #5

Referral “logistical” coordinator training includes: • Why job is important• How role interacts with the rest of the team• How to liaison with other facilities• Use and utilize the tracking system• Understand medical chart• Understand insurance processes• Provide pro-active patient support


Resource #6

Patient preparation for referral visit: • Informs patients about logistics including what they need to do beforehand, what to bring, and where to go.• Prepares patients by describing expectations (reason for visit, goals of visit, next steps in treatment).•Empowers patients to ask questions during specialist appointment.


Resources #7-9

Evidence-based program for managing transitions:• Foster greater engagement of patients/families• Elevate status of family caregivers• Implement performance measurement• Build competency in care coordination• Explore use of technological solutions to communicate between settings• Align financial incentives

©2007 Care Transitions Program; Denver, Colorado. All rights reserved.

http://www.improvingchroniccare.org©2007 Care Transitions Program; Denver, Colorado. All rights reserved.

http://www.improvingchroniccare.orgColeman E. The Post-Hospital Follow-Up Visit: A Physician Checklist to Reduce Readmissions, CA Healthcare Foundation, Oct 2010


Build Relationships & Agreements

• Develop agreements to: – Standardize information– Set expectations– Build relationships


Medical Neighborhood

• ARHQ White Paper (Resource #10)– Defines the medical neighborhood– Describes potential approaches to overcoming

barriers to high-functioning medical neighborhoods

Taylor EF, Lake T, Nysenbaum J, Peterson G, Meyers D. Coordinating care in the medical neighborhood: critical components and available mechanisms. White Paper (Prepared by Mathematica Policy Research under Contract No. HHSA290200900019I TO2). AHRQ Publication No. 11-0064. Rockville, MD: Agency for Healthcare Research and Quality. June 2011.


Resource #11

Compact: Primary Care - Specialty Care Compact• Pre-consultation• Formal consultation (in-person referral)• Transfer of care from PCP → specialist• Co-management• Emergency care

Main goal of Colorado’s compact is to develop mutually agreed upon expectations


Resource #12

Approaches to strengthen PCP ↔ Specialist interface:• Case studies

– Guidelines for referrals – Forms (important info to include)– Agreements/co-location/co-management


Service Agreement Example

• Case Study: Family Care Network in WA agreement with local cardiology group describes who/when/how for each: – Emergency referrals– Emergency testing– Routine consultation– Follow-up care– Re-referral– Inpatient care


Resources #13-14

• Berta W et al– Article #1: 24 key components to include in

referrals– Article #2: 15 key components to include in

consultative report


http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2567257/figure/f1-0541432/


Resource #15

• Reichman M


Develop Connectivity

• Develop and implement an information transfer system.

• Standardize information.• Key elements of system:

– Integrates information needs and expectations (per agreements)

– Assures that information transmits to correct destination

– Key milestones in the referral process can be tracked

– Referring clinicians and consultants can communicate with each other


Resource #16• O’Malley et al describe the principal tasks for effective care

coordination as: – Maintaining patient continuity with the PCP/primary care team. – Documenting and compiling patient information generated within and

outside the primary care office. – Using information to coordinate care for individual patients and for

tracking different patient populations within the primary care office. – Referrals and consultations (initiating, communicating and tracking). – Sharing care with clinicians across practices and settings. – Providing care and/or exchanging information for transitions and

emergency care.

• New paper by O’Malley also work checking out: – “Referral and Consultation Communication Between Primary Care and

Specialist Physicians” Arch Intern Med. 2011;171(1):56-65.


Resource #17

• CA HealthCare Foundation: Bridging the Care Gap by Metzer and Zywiak– Details e-referral systems


E-Referral Case Studies• Doc2Doc system in OK• Humboldt County, CA• San Francisco, CA

Humboldt County’s workflow


E-Referral Improves Specialty Access


E-Referral Improves Referral Tracking

PCPs’ ratings of attributes of electronic referrals compared to prior referral methods

Source: Kim Y, Chen AH, Keith E, Yee HF, Kushel MB. Not Perfect, but Better: Primary Care Providers’ Experiences with Electronic Referrals in a Safety Net Health System. Journal of General Internal Medicine. Vol 24(5),614-619.


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