continuity of care making connections: a small practice journey
DESCRIPTION
Continuity of Care Making connections: A small practice journey. R. Scott Hammond, MD Chair, CAFP PCMH Task Force Medical Director, SOC-PCMH Initiative, Colorado Associate Clinical Professor, Dept. of Family Medicine UCHSC Westminster Medical Clinic, Westminster, Colorado --PCMH Level 3 - PowerPoint PPT PresentationTRANSCRIPT
Continuity of CareMaking connections: A small practice journey
R. Scott Hammond, MDChair, CAFP PCMH Task Force
Medical Director, SOC-PCMH Initiative, ColoradoAssociate Clinical Professor, Dept. of Family Medicine UCHSC
Westminster Medical Clinic, Westminster, Colorado --PCMH Level [email protected]
PCMH Awareness in Colorado
Awareness of PCMH (very or somewhat familiar)
Embrace PCMH models
Likely to become PCMH/Support PCMH model
80%
72%
56%
39%
76%
77%
SpecialistsPCPs
Coordination of Care in Colorado
Care Coordination Challenge
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 seven different physicians and fills upwards of 20 prescriptions per year Partnership for Solutions, Johns Hopkins Univ. 2002
Continuity of Care Paradigm
Making ConnectionsCare coordinator job description and protocol consistent with available resources.External care coordination– Hospital and skilled nursing facilities– Specialists
Internal care coordination– High-acuity patients
Post-hospitalMulti-morbid diseasesFrequent ED utilization
Continuity of CareHospitals
Database– List of facilities and contact personnel
Informational continuity– Daily census of admits, discharges, updates
(hospitals, hospitalists, IPA)– ED/in-hospital medical information transfer
Care Coordination– Post hospital transition (discharge care plan)– List of ED patients over the past year
Friday, July 24, 2009
Page 1
Patient Admission
Patient presents to hospital
SELF REFERRAL
Patient presents to hospital
FROM OFFICE
Emergency Room
Discharged Home
Appointment with PCP/Specialist
Admission to Floor
Discharged to Skilled Nursing
Facility
Discharged to Home
Discharged to Long Term Care
Clinic: Medication notes faxed to hospital from PCP
Hospital: to notify of Admission to Hospitalist
Hospital: to provide updates regarding patient progress
Hospital: ER Notes faxed to Providers office
Hospital: to inform PCP office – fax, phone, email?
Clinic: Care Coordinator to fax medical info
Hospital: Case Manager to notify PCP office and
proved care plan
SNF: to notify and send discharge to PCP
SNF: to notify PCP -? Change PCP
Color Key:Hospital Action Green
Clinic Action BlueSNF Action Red
Patient: ______________________________________PCP ______________________Date:_____________Diagnosis:______________________________________________________________ Discharge Date: ____________
Discharge Summary received Laboratory/Diagnostic test received Requested Date: __________ Test _______________________
Status Information Needed Short Term Goal Long term goal
Functional Status ADL assessment
Medical Status DiagnosisCo-morbid conditionsPrognosisMedication ReviewAllergy ReviewAdvance Directives
Self-care Ability Current AbilityEducational needs
Social Support Primary CaregiverAbility/willingness to give careCommunity support
Disposition Prior residenceCurrent residenceFuture residence
Communication Language needsHealth beliefs
DME Current needsVendor
Current Functional Status
Cognitive Dress Eating Toileting Bathing
Independent Requires assist Unable
Independent Requires assist Unable
Independent Requires assist Unable
Independent Requires assist Unable
Independent Requires assist Unable
Continuity of CareHospitals
CO PCMH Pilot: Hospital Subgroup committee– Patient Identifier information
“wallet card” PCMH IDPatient education and educational materials from health plans
– Bidirectional communicationCare Coordination Form (hospital to PCP)ED Referral Form (PCP to hospital)
PCMH ID Wallet Card
Continuity of CarePCMH-N Specialists
Define, develop and vet a PCP-Specialty CompactOutreach
Preferred Specialist List
Implement PCP Transition Record PCMH-N Patient Referral Rx
Accountability PCP/Specialist Report Card
Colorado SOC-PCMH InitiativePrimary Care-Specialty Care Compact
Purpose and PrinciplesDefinitionsTypes of Care Transition Service Agreement– Transition of Care– Access– Collaborative Care Management– Patient Communication
Transition of Care Records (PCP and Specialist)
Colorado SOC-PCMH InitiativePrimary Care-Specialty Care Compact
Types of Care Transition – Pre-consultation exchange– Formal consultation– Co-management (Referral)
With Shared managementWith Principle Care of the diseaseWith Principle Care of the patient
– Complete transfer of care (Specialty Medical Home Network)
– Emergency Care
Transition of Care
Mutual AgreementMaintain accurate and up-to-date clinical record.Agree to standardized demographic and clinical information format such as the Continuity of Care
Record [CCR] or Continuity of Care Document [CCD]Ensure safe and timely transfer of care of a prepared patient
Expectations
Primary Care Specialty Care
PCP maintains complete and up-to-date clinical record including demographics.
Transfers information as outlined in Patient Transition Record.
Orders appropriate studies that would facilitate the specialty visit.
Informs patient of need, purpose (specific question), expectations and goals of the specialty visit
Provides patient with specialist contact information and expected timeframe for appointment.
Determines and/or confirms insurance eligibility
Provides single source referral contact person When PCP is uncertain of appropriate
laboratory or imaging diagnostics, assist PCP prior to the appointment regarding appropriate pre-referral work-up
Additional agreements/edits: _________________________________________________________________________________________________________________________________________________
Service Agreement– Transition of Care
1. Practice details – PCP, PCMH level, contact numbers (regular, emergency)2. Patient demographics -- Patient name, identifying and contact information,
insurance information, PCP designation and contact information.3. Diagnosis -- ICD-9 code 4. Query/Request – a clear clinical reason for patient transfer and anticipated goals
of care and interventions.5. Clinical Data
Problem list Medical and surgical history Current medicationImmunizations Allergy/contraindication list Care plan Relevant notes Pertinent labs and diagnostics tests Patient cognitive status Caregiver status Advanced directives List of other providers
6. Type of transition of care.7. Visit status -- routine, urgent, emergent (specify time frame). 8. Follow-up request
Service Agreement–PCP Patient Transition Record
PCMH Patient Referral RxPatient name: Gloria Date: 2/19/10 Appointment: within 1 weekSpecialist: Dr. Heart_ Test/Procedure: may do heart ultrasound or monitorReason for Referral/Consultation: determine medications needed to controlyour heart rate and whether you need a pacemaker___________________________________________________________________________________
Alternatives: watchful waiting______________________________________
Non-urgent referrals take about 4-5 days to process. You will be notified through the Patient Portal. If you do not have Internet, we will call you or mail your confirmation. Do not go or make an appointment for the visit/test until you have received your referral confirmation and insurance approval. If for some reason, you do not make or keep your appointment, please let us know so that we may cancel the referral and assist you in other ways.
Points 5 2.5 0 -5
Transition of care
Determines or confirms insurance eligibility
Always or almost always
Usually Occasionally Rarely
Ease of Communication
Single point of contact
Leave message with specific person
No specific contact
Communicates readily with PCP on pre-referral workup
Always or almost always
Usually Occasionally Rarely
Access
Insurance Participation
All All but Medicare
Missing 1 major carrier
Missing 2 major carriers
No-show notification
Always or almost always
Usually Occasionally Rarely
Access to scheduling
Within requested time frame
Within 1 week of requested time frame
Within 2 week > 2 weeks
Provides list of ‘neighborhood’ providers
Yes and more than 1 provider
Yes and 1 provider
No list No agreement with compact
First visit with physician
yes no
Readily available to PCP for questions/help
Always or almost always
Usually Occasionally Rarely
Comments
Points 10 5 0 -5 Comments
Transition of care
Sends complete patient information
Always or almost always
Usually Occasionally Rarely
Orders appropriate tests prior to referral
Always or almost always
Usually Occasionally Rarely
Informs patient of need, purpose, expectations and goals of the specialty visit
Always or almost always
Usually Occasionally Rarely
Access
No-show patient F/U
Always or almost always
Usually Occasionally Rarely
Requests appointments with reasonable time frames
Always or almost always
Usually Occasionally Rarely
Readily available to specialist for questions/help
Always or almost always
Usually Occasionally Rarely
Collaborative Care Management
SOC/PCMH Action Plan• Coordinate & simplify the message
(articles, newsletters, publications & website)
• Foster physician communication & culture
Messaging
• Presentations & Webinars• Parade of Homes• Mentoring• Speakers Bureau
Physician Education
• Work through existing initiatives and leadership• Support policies that further medical home adoption• Use elements of physician compact as foundation of
PCP/Spec coordination
System Approach/ Medical
Neighborhood
• Resource Advisors toolkit to provide orientation and resources on medical homes• Action Plans/Rapid Improvement Activities
• Hand-over for advanced QI (ie. IPIP, REC, CCHAP, other)
Practice Outreach/Medical
Homes
It can get dirty but change can be good
WMC Team