Presentation on theme: "MacColl Institute for Healthcare Innovation"— Presentation transcript:
1 Key Changes and Resources for Care Coordination (Reducing Care Fragmentation in Primary Care) MacColl Institute for Healthcare InnovationGroup Health Research Institute
2 The Patient-centered Medical Home Key Features:Engaged leadershipQuality improvement strategyEmpanelmentPatient-centered interactionsOrganized, evidence-based careCare coordinationEnhanced accessContinuous, team-based health relationships
3 Defining Care Coordination The deliberate organization of patient careactivities between two or more participantsinvolved in a patient’s care to facilitate theappropriate delivery of health care services.(McDonald, 2007)+++
4 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:SafePlanned and managed to prevent harm to patients from medical or administrative errors.EffectiveBased on scientific knowledge, and executed well to maximize their benefit.TimelyPatients receive needed transitions and consultative services without unnecessary delays.Patient-centeredResponsive to patient and family needs and preferences.EfficientLimited to necessary referrals, and avoids duplication of services.EquitableThe availability and quality of transitions and referrals should not vary by the personal characteristics of patients.
6 Key Changes Assume accountability Provide patient support Build relationships & agreementsDevelop connectivity
7 Assume Accountability Providers, especially primary care clinics, decide to improve care coordination.Develop a referral/transition tracking system.
8 Resource #1 NCQA Patient-Centered Medical Home 2011 Standards Test tracking and follow upReferral tracking and follow upCoordinate with facilities and care transitions
9 Resource #2 Measuring care coordination from patient’s perspective: ACESPickerPACICCAHPSCYSNCNPress GaneyAlso check out AHRQ’s Care CoordinationATLAS
10 Resource #3 Referral Tracking Guide How-to guide to setting up your own referral tracking systemUse existing practice management (or billing) systemUse paper tracking gridDescribes how to use the data to inform practice
11 Provide Patient Support Organize the practice team to support patients and families during referrals and transitions.Logistical “referral” coordinator:Tracks all referrals and transitionsProvides patient (and family) with information about referralAddresses barriers to referralsFollows up on missed appointments
13 Resource #4 Referral “Logistical” Coordinator Job Description Based on our review of relevant jobsQuestions for group:Do your clinics have someone filling this role?How is the role different/similar to our generic job description?
14 Resource #5 Referral “logistical” coordinator training includes: Why job is importantHow role interacts with the rest of the teamHow to liaison with other facilitiesUse and utilize the tracking systemUnderstand medical chartUnderstand insurance processesProvide pro-active patient support
15 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.
20 Medical Neighborhood ARHQ White Paper (Resource #10) Defines the medical neighborhoodDescribes potential approaches to overcoming barriers to high-functioning medical neighborhoodsTaylor 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. HHSA I TO2). AHRQ Publication No Rockville, MD: Agency for Healthcare Research and Quality. June 2011.
21 Resource #11 Compact: Primary Care - Specialty Care Compact Pre-consultationFormal consultation (in-person referral)Transfer of care from PCP → specialistCo-managementEmergency careMain goal of Colorado’s compact is to develop mutually agreed upon expectations
22 Resource #12 Approaches to strengthen PCP ↔ Specialist interface: Case studiesGuidelines for referralsForms (important info to include)Agreements/co-location/co-management
23 Service Agreement Example Case Study: Family Care Network in WA agreement with local cardiology group describes who/when/how for each:Emergency referralsEmergency testingRoutine consultationFollow-up careRe-referralInpatient care
24 Resources #13-14 Berta W et al Article #1: 24 key components to include in referralsArticle #2: 15 key components to include in consultative report
27 Develop ConnectivityDevelop 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 destinationKey milestones in the referral process can be trackedReferring clinicians and consultants can communicate with each other
28 Resource #16O’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.
29 Resource #17CA HealthCare Foundation: Bridging the Care Gap by Metzer and ZywiakDetails e-referral systems
30 E-Referral Case Studies Doc2Doc system in OKHumboldt County, CASan Francisco, CAHumboldt County’s workflow
32 E-Referral Improves Referral Tracking PCPs’ ratings of attributes of electronic referrals compared to prior referral methodsSource: 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),
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