1. High Value Consultation and Referral Fellowship HVC Curriculum 2016-2017 Presentation 6 of 7

2. Learning Objectives Describe the essential role of communication in high value care coordination. Define the types of referrals and the specialist’s role in each. List the components of a high value referral response. Describe several existing processes developed to promote high value in the referral process.

3. What is the problem? Harms from poor referral communication Treatment delays or mistakes Duplicative or unnecessary testing Duplicative or unnecessary treatments Patient/family confusion about the care plan Any others you have experienced? Where are the gaps in referral communication in your system?

4. Steps Toward High Value Care Step one: Understand the benefits, harms, and relative costs of the interventions that you are considering Step two: Decrease or eliminate the use of interventions that provide no benefits and/or may be harmful Step three: Choose interventions and care settings that maximize benefits, minimize harms, and reduce costs (using comparative-effectiveness and cost-effectiveness data) Step four: Customize a care plan with the patient that incorporates their values and addresses their concerns Step five: Identify system level opportunities to improve outcomes, minimize harms, and reduce health care waste

5. Case #1 Specialty-specific inpatient consultation case Consult called without a clear clinical question Discuss how you currently handle this problem as a fellow Provide examples of where consults without a clear question and timeline have led to delayed care and/or poor outcomes Brainstorm about potential solutions to this problem at your institution using your experience as a resident and fellow to inform your solution

6. Types of Referrals and Roles Preconsultation Consultation Medical (cognitive) consultation (advice on diagnosis or treatment) Procedural consultation Co-management Shared care of the condition Principal care (assume care of the condition)

7. Preconsultation Intended to expedite/prioritize care Previsit Advice Does the patient need a referral? Which specialty is most appropriate? Recommendations for what preparation and/or “pertinent” data will best facilitate the referral evaluation and/or management (what to send with the referral) or help with when to refer. Previsit Review Is the clinical question clear? Is the necessary data attached? Communication about necessary testing may help expedite care and reduce unnecessary testing. Triage urgency.

8. High Value Referral Response Answer the clinical question/address the reason for referral Summary or Synopsis (include some thought process) Clear indication of diagnosis/evaluation and/or treatment plan What is the specialist going to do What is the patient instructed to do What does the referring physician need to do and when What follow-up is needed and with whom

9. Case #2 Specialty-specific outpatient referral case Hand out sample referral responses and copies of the referral response checklist Critique sample referral responses and apply the template to them to improve the quality of “closing the loop” communication Reflect on your recent experience as a referring provider to identify information you would find most helpful in a referral response

10. Care Coordination Impacts Quality For referred patients: 68% of specialists reported receiving no information from the primary care provider prior to referral visits 25% of primary care providers had received no information from specialists 4 weeks after referral visits 28% of primary care and 43% of specialists are dissatisfied with the information they receive from each other 25%-50% of referring physicians did not know if patients had seen a specialist 3

11. Outpatient Care Coordination How do you work with your primary care colleagues to coordinate care for your patients? Is communication through a shared EMR or paper chart sufficient? How often do you find that the referring physician has ordered too few or too many tests prior to your visit? How often do you run into problems where patients come to you with too little or too specific information about what to expect at their visit?

12. Limitations of Shared EMR Missing elements: System-wide referral policy Standardization of referral procedures Clarity in roles and responsibilities A Patient-Centered approach

13. Case #3 You have taken care of a 62-year-old woman with type 2 DM, hypertension, and hyperlipidemia for over 1 year now. She came to you with an HgbA1c of 11.6%. She received diabetic and nutritional education and was started on insulin therapy and has shown good engagement in self- management. She is now stable with an HgbA1c of 7.2% without untoward side effects such as severe hypoglycemia.

14. Case #3 The CEO of the health system tells all the clinical leaders that they have to make sure that new consultations are seen within 7 days. The Chief of Endocrinology holds a meeting with all the faculty and fellows. She says we have to meet the CEO’s request, but we cannot add new physicians at this time. Thus, you must make more availability for new patients.

15. Small Group Work 1)Discuss how we currently decide to send patients back to the referring physicians. 2)Discuss how we communicate with the referring physician about the hand-off. 3)Discuss how we tell a patient whom we have worked with to improve their care that we are no longer seeing them. 4)Discuss how we make sure that the patient and referring physician know when to send the patient back to you. 5)Discuss when the conversation about sending a patient back to their referring physician should occur with the patient.

16. Processes can help Have a Policy or Platform that everyone agrees to work from with: Standardized Definitions Agreed-upon expectations regarding communication and clinical responsibilities A clear clinical question or summary of reason for referral Appropriate data provided (use of ACP HVCC Pertinent Data Sets or referral guidelines) Appropriate patient preparation Defined role for the specialist A clear and detailed referral response Referral Tracking

17. High Value Care Coordination Project Elements of a good referral: 1.Communication 2.Appropriate and Adequate Information 3.Collaboration for Continuous Care The Toolkit includes checklists and guidance for referring providers and consulting providers and is freely available at https://hvc.acponline.org/physres_care_coordination.html https://hvc.acponline.org/physres_care_coordination.html

18. In Summary Communication (not just information sharing) is essential for good care coordination and high value consultation and referral Processes and policies aimed at enhancing the quality of communication between clinicians may help Preconsultation may be a practical way to promote high value consultation and referrals

19. Action Plans to Improve Referral and Consultation Process START: STOP:

20. References 1.Salerno SM, Hurst FP, Halvorson S, Mercado DL. Principles of effective consultation: an update for the 21st-century consultant. Arch Intern Med. 2007;167:271-275. 2.Lee T, Pappius EM, Goldman L. Impact of inter-physician communication on the effectiveness of medical consultations. Am J Med. 1983;74:106-112. 3.Goldman L, Lee T, Rudd P. Ten commandments for effective consultations. Arch Intern Med. 1983;143:1753-1755. 4.Courtesy and Conflict in General Medical Consultation. Clay Beveridge, MD http://www.eric.vcu.edu/home/resources/consults/Courtesy_Conflict.pdf 5.Gandhi TK, Sittig DF, Franklin M, Sussman AJ, Fairchild DG, Bates DW. Communication breakdown in the outpatient referral process. J Gen Inter Med. 2000;15:626-631. 6.Mehrotra A, Forrest CB, Lin CY. Dropping the baton: specialty referrals in the United States. Milbank Q. 2011;89:39-68.