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 2

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

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 4

5. The Wider “Neighborhood” Patient Centered Medical Home Primary Care Providers Employers Hospitals/ Hospitalists/ Care Managers Home Health Nursing Homes Specialists Health Mane Parterships Home CarePharmaciesPayers 5

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 6

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 7

8. Referral and Consultation Communication Between 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 Reality 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 8

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

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 10

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? 11

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13. 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) Primary Care - Specialty Care Collaborative Guidelines 13

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) 14

15. Primary Care – Specialist Service Agreement 15

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19. PCP Toolkit Example 19

20. Specialist Toolkit Examples Specialty Provider ChecklistPCMH “Identifier ” 20

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? 21

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

23. www.mainequalitycounts.org 23

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