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Transforming the Way We Work Together An Evening with Family Physicians & Specialists

Session Proceedings: Detailed Summary

Tuesday, October 17th, 2017

Transforming the Way We Work Together: An Evening for Family Physicians & Specialists Page | 2 Session Proceedings – Detailed Summary

Thank You!

Dear Colleagues,

I am sending this report of our event on October 17th: “Transforming the Way we Work Together: An Evening for Family Physicians and Specialists.” I am pleased to provide this full summary of the session including the range of comments and feedback to you.

This event was a fitting way to mark the 5-year anniversary of SCOPE. It is a testament to our growth as a community of family physicians. Together, we have increased the level of knowledge, intelligence and built support for what we all need to do to improve our system on behalf of our patients. To date, SCOPE has almost 200 physicians registered with the majority using SCOPE services on a regular basis. A recent survey completed by 80% of SCOPE physicians confirmed that the SCOPE program has significantly reduced wait times for referrals, and without this program patients would have been sent to the emergency room.

The October 17th session was in response to family physicians’ requests to build relationships between themselves and specialists by improving the interaction between these two groups. The evening was a notable success in both the numbers of participants (44 family physicians and 14 specialists) and the relevance of the evening to both groups. Many of you asked for regular events of this nature.

This report highlights the common pain points around the referral process – the opportunity for greater standardization of processes, leverage streamlined technology to communicate with one another, and need for enabling enhanced levels of understanding and relationships. This report summarizes priorities to begin the process of improvement.

The next step will start with a Working Group of family physicians and specialists who will tackle each of the recommendations and present their progress by email and at a future event in the spring. Some of the recommendations dovetail with initiatives already in development such as the roll-out of a city-wide Specialist Directory.

In the meantime, thanks to all of you for taking the time and making the effort to add your voice to this crucial conversation. I will keep you posted.

Thank You,

Pauline

Dr. Pauline Pariser, MASc, MD, CCFP, FCFP Primary Care Lead, Mid-West Toronto Sub-Region Associate Medical Director, Primary Care Lead, UHN (SCOPE) Associate Professor, Department of Family and Community Medicine - University of Toronto


Transforming the Way We Work Together An Evening with Family Physicians & Specialists – Session Overview

On October 17th, 2017 SCOPE hosted a session bringing together primary care providers, specialists, and external stakeholders to explore opportunities to further advance relationships, and identify innovative practices to improve access to specialist care.

44 Family

Physicians

10 Specialists on Two

Panels

4 Additional

Specialists in Break Out Groups

The session confirmed the need for primary care providers (PCP) and specialists to work together, engaged a panel of specialists in a conversation about key opportunities for improving access, and hosted group discussions between specialists and primary care providers that identified key challenges with the current access to specialist process, and explored key priorities to improve and transform how they work together.

Setting the Stage

In Dr. Christopher Chan’s opening presentation of the Nephrology/SCOPE e-consult collaboration, he captured the real opportunity for how primary care and specialists can work together: Enhancing the level of collaboration, enabling more seamless flow of information, developing meaningful relationships, and building new ways to connect and respond to questions more quickly. We will recruit up to 25 SCOPE MDs to participate in this pilot.

Confirming the Need – Hearing from Our Specialist Panels

10 specialists presented their views of the current specialist referral process and identified their thoughts on opportunities for improvement.

Consistently, there is a recognition and understanding that we are not providing the level of service to primary care providers we would want. This is reflected in the following quotes:

“We do so poorly”

“Need to reduce the frustration of not knowing who to send clients to”

“Stop practicing 1970 style medicine”

There is a clear need and desire to improve timely, appropriate access to specialist care.

Key messages from panel discussions:

Appreciate Limited Resource Reality. Limited resources must push the system and providers to look at new ways of working to improve not only efficiency on the part of specialists, but also build capacity and enhance knowledge within primary care.

Need to Build on Successes. Not starting from scratch. There is an opportunity to advance and spread existing models (e.g., ISAEC, central intake, e-consult).

Opportunity to Build More Integrated Service Models. Adoption of coordinated/centralized intake models have benefits but will require a focus on improving education and supports to primary care providers to successfully deploy.

Need to Reduce Technology Silos to Simplify the Referral Process. Need more involvement of PCPs and specialists to ensure computer platforms do not create more work, but enhance referral efficiency and effectiveness.

Opportunity for Bi-Directional Flow of Information to Support Decisions. Specialist need access to accurate, concise information, and PCPs need to know what information is required and how key decisions are made. Information must flow both ways.

Recognize the Value and Challenges with Relationship-Based Referrals. Need more standardized processes and tools to enable navigation and communication as part of the referral process but not at the expense of prior relationships. Increase availability by providing back line access to specialists.


Specialist Pre-Event Survey

A Specialist Division Survey, reflecting feedback from six specialty groups, provided important insights.

33 of the 35 responding

specialists are accepting referrals

Key Ideas for Improving the Referral Process

Standardized referral process and tools (forms)

Tools to streamline info flow (no faxing, create back-line)

Central intake services & provider registry

Guidelines outlining info required for referral (cheat sheet)

Address specialist barriers (catchment wait time vs. acuity)

Expand telehealth and e-consult programs

Breakout Session Key Learnings

Family physicians and specialists were assigned to four groups (psychiatry, surgery, and two medicine groups) and participated in interactive breakout sessions to learn, share ideas, and identify priorities for action that will improve access to specialist care. The following summarizes key challenges and nine priorities for action.

Need Key Challenges Priorities for Action

Know Which Specialists To

Refer To

Difficulty knowing appropriateness of the referral Limited knowledge of resources and processes

available to link a PCP to a specialist Specialist office variation creates added work for PCP Catchment and hospital boundaries create challenges

Establish list/directory of resources (hospital, community) - contact #s, standardized rules, practices, wait time info

Know What Information To

Provide

Lengthy and very different referral forms across specialties/specialists often require unrelated information and are difficult to complete

Automate/standardize referral form ensuring key info is collected

Able to Ask Questions to

Confirm Appropriateness

of Referral

Challenges in connecting with specialists creates added work and waste time for PCPs and their offices

Lack of two-way communication from hospitals/ specialists leads to delays that could be easily solved

Notes from specialists are not detailed and may not include proper contact information if the primary care provider has follow-up questions

New communication tools (website, email, back-channel phone #)

Leverage e-Consult to resolve questions quickly

Use ONEmail for timely direct communication

Referral Process is Simple and Streamlined

Current referral process creates added work for PCP and their offices – limited degree of standardization

May result in multiple referrals for a single patient leading to unnecessary workload and more no shows

Delayed, or lack of response, results in additional follow-up that is inefficient for PCP and specialist

Multiple systems used to support referrals increase workload and creates a barriers to refer

Establish central referral office to increase efficiency of referrals

Develop a standard and integrated common referral tool and communication process

Build Knowledge and Capacity of

Providers

Limited relationships or knowledge gaps results in access barriers and/or delays

PCPs may find it difficult to manage patients without greater advice or connection to a specialist (e.g., some patients may need ongoing follow-up)

Need greater levels of communication post-referral

Advance mentorship and knowledge development - link specialists to PCPs

Support events to share ideas, networking, co-design of solutions

Session Evaluation

99% Agreed or Strongly Agreed that session was relevant to practice, met expectations, and appreciated interactions/learning about upcoming events. Next time – Rotate groups, more time with panelists. We look forward to your participation at the next SCOPE event and building a plan to advance recommendations.


Transforming the Way We Work Together An Evening for Family Physicians & Specialists

On October 7th, 2017, primary care providers, specialists, and external stakeholders came together to explore opportunities to further advance relationships and identify innovative practices to improve access to specialist care (see Appendix A for a List of Participants). The session showcased a new opportunity to improve access to chronic kidney consultations, engaged specialists in a conversation about key opportunities for improving access, and enabled group discussions to identify key challenges with the current access to specialists care and identified priorities for action.

5:30 – 5:40 Dinner and Networking

5:40 – 5:45 Welcome and Introductions Dr. Pauline Pariser - Clinical Lead, Mid-West Sub-Region

5:45 – 5:55 Introduction to Project Dr. Christopher Chan – Nephrology

5:55 – 6:30

Panel Discussion Dr. Susan Abbey – Psychiatry Dr. Raj Rampersaud – Orthopedics Dr. David Urbach – Surgery Dr. Tara O’Brien – Internal Medicine Dr. Peter Rossos – Gastroenterology Q & A Period

6:30 – 6:55

Break-Out Session Nash Syed - Introduce Break Out Session Exercises

Meet Your Specialists! Psychiatry, Surgery and Medicine

6:55 – 7:30

Panel Discussion Dr. Vicky Stergiopoulus – Psychiatry Dr. Jean Wang – Hematology Dr. Kirsten Wentlandt – Palliative Care Dr. Robert Wald – Cardiology Dr. Dana Jerome – Rheumatology Q & A Period

7:30 – 7:55 Break-Out Session Meet Your Specialists! Psychiatry, Surgery and Medicine Psychiatry

7:55 – 8:00 Closing Remarks Dr. Pauline Pariser - Clinical Lead, Mid-West Sub-Region

Thank you for your participation and insights. Please see Appendix B for the SCOPE Engagement Evaluation Summary.


Presentation & Discussion from Dr. Chan – Nephology/SCOPE Collaboration

Dr. Christopher Chan provided an overview of his nephrology demonstration project –Nephrology/SCOPE e-consult collaboration

Dr. Chan started his presentation by confirming that primary care providers and specialists have many things in common – one of which is the desire to get patients connected to care sooner. Unfortunately, referrals from primary care providers to specialists sometimes go “into the ether”. This creates the need and opportunity to enhance the level of collaboration, enable more seamless flow of information, develop meaningful relationships, and build new ways to connect and respond to questions more quickly between primary care providers and nephology specialists.

Dr. Chan and his colleagues developed Nephrology/SCPOPE e-consult collaboration - a central nephology referral and triage process that supports e-consult integration, onboarding of primary care providers and nephrologist, retrospective chart audits of referrals, and prospective audits of e-consult usage. While the collaboration is intended to provide easier, more timely access to services, Dr. Chan is also hoping to use data from the system to determine the burden of CKD as this is currently not well documented or understood.

Dr. Chan is launching this project and is recruiting up to 25 primary care providers to participate in this pilot.

Hearing from Our Specialist

10 specialists presented their view of the current specialist referral process and identified their thoughts on opportunities for improvement.

Dr. Susan Abbey – Psychiatry Dr. Raj Rampersaud – Orthopedics Dr. David Urbach – Surgery Dr. Tara O’Brien – Internal Medicine Dr. Peter Rossos – Gastroenterology

Dr. Vicky Stergiopoulus – Psychiatry Dr. Jean Wang – Hematology Dr. Kirsten Wentlandt – Palliative Care Dr. Robert Wald – Cardiology Dr. Dana Jerome – Rheumatology

Consistently, there is a recognition and understanding that we are not providing the level of service to primary care providers we would want (“we do so poorly”, “need to reduce the frustration of not knowing who to send clients to”, “stop practicing 1970 style medicine”). There is a clear need and opportunity to improve timely and appropriate access to specialist care. The focus must be on improving communication (e.g., email, “answer phone when there is a question”) and to work more collaboratively with primary care (e.g., processes to learn from each other and exchange ideas). The following reflects some key thoughts from specialists.

Appreciating Limited Resources. While there is a clear goal for minimizing waits associated with a specialist referral, it is must also be understood and appreciated that there are limited resources that need to be stretched to meet the needs (e.g., only one specialist available to triage referrals).

- Limited resources must push the system and providers to look at new ways of working to improve not only efficiency on the part of specialists, but also build capacity and enhance knowledge within primary care.

Building on Successes. There are a number of efforts and achievements to transform how we work together (e.g., Access CAMH creates an initial and coordinated access point; UHN is seeking to create one-stop shop telephone numbers to improve access; UHN is sending psychiatrists to some FHTs in the area; provincial programs have centralized intake; ISAEC model for lower back pain; new emerging role of e-consult and the supporting eHealth platform).

- Explore opportunities for better supporting primary care providers, enabling earlier intervention.


Leveraging More Integrated Service Models. The system is struggling to build more integrated models that ensure the right resources and skills are leveraged, to better understand the referral processes and who to send patients to, and ultimately to improve timely appropriate access to care.

- Create a more coordinated/centralized intake model (e.g., Ontario Bariatric Network) that leverages team-based practices versus individual specific referral destinations. Many services are currently developing team-based referral models that enable primary care providers to request the first next appointment from a group of specialist at a hospital versus referrals to a specific physician. However, adoption to these new systems require broad education and investment in supports to primary care providers to successfully deploy.

Reducing Technology Silos to Simplify the Referral Process. With the development of various solutions, there has not always been a planned approach for joining the respective information system platforms and processes resulting in more work for referring primary care providers. The group acknowledged challenges that limit the adoption and use of these new platforms (e.g., systems all need their own passwords requiring providers to learn many, many passwords) and creates duplication of efforts (e.g., systems and applications are not connected or integrated requiring information to be re-entered).

- Need for greater alignment of supporting information systems to make it easier and efficient to complete and track a referral.

- Need more involvement of PCPs and specialists to ensure computer platforms do not create more work, but enhance referral efficiency and effectiveness.

Enabling Bi-Directional Flow of Information to Support Decisions. Specialist must be enabled to make the right triaging decision through access to accurate, concise information (e.g., need to know why the patient is being referred, what prior studies have been completed, what is the referring provider seeking from the referral). Access to incomplete information or hard to read information (e.g., bad faxes or scans) makes it difficult to support timely and effective decisions. Specialists must also be more transparent on what information is needed through more clearly documented, communicated and well understood referral and triage rules, and build processes to ensure information is provided and available, in a useful format.

- Specialist need access to accurate, concise information, and PCPs need to know what information is required and how key decisions are made. Information must flow both ways.

Recognizing the Value and Challenges with Relationship-Based Referrals. There is tremendous value in referral relationships between primary care providers and specialists due to an understanding or prior knowledge of who to refer to or how to complete a referral. However, when these relationships do not exist, it can become very challenging to refer a patient.

- More standardized processes and tools to enable navigation and communication as part of the referral process, but not at the expense of prior relationships.

- Specialists also discussed the need for enhancing navigation to system resources is a priority, and building a “back-line” to enable primary care providers and specialist to communicate more easily must be an important focus.


Division Survey Results Summary

A Specialist Division Survey was responded to by 35 specialists to gain their view of community referral access, concerns and limitations in providing care to patients, effectiveness of the communication processes, and identification of ideas to improve the referral process. The following summarizes survey responses.

1. Are you currently accepting community-based referrals: A majority of specialists polled indicated that they are accepting referrals (33 of 35 polled)

2. Access challenges noted by specialists:

Timely access to assessment and intervention services

Current capacity is limited as it is focused on existing and hospital based services

Limitations in being able to support referrals from outside catchment areas

3. Current wait time: Weeks for urgent cases; months for moderate needs; up to a year+ for non-urgent

4. Views on concerns and limitations in providing care to patients from the community:

Concern that the referring diagnosis is incorrect in a high number of referrals (e.g., over 50%)

Inappropriate use of MRIs and imaging

Inappropriate referrals or duplicate referrals sent to multiple specialists to consult for the same condition, not indicating WSIB, or underlying medicolegal, or second opinion being requested

Incomplete referrals: insufficient information for triage, poor quality of the referral letter

Patients from outside of local jurisdiction

Poor access to previous patient evaluations: reports, labs, imaging and procedures

Limitations of the reporting system to access information (e.g., pathology system)

Unable to manage acuity and meet wait-time expectations based on current national guidelines

Limitations in clinic space and availability to meet demand

5. Views on effectiveness of communication related to the referral process:

For many, communication is still fax based or personal email. Generally limited information of family physician concerns or how to best assist the family physician in managing patient

Most referrals have limited description of symptoms, and often incorrect diagnosis. The reason for referral is often vague and accompanied by many pages of faxed material that may not be relevant. Need relevant investigations and background details

Some specialist offices have a well-defined triage tool but are sometimes not given adequate details to support proper triage. Need for all parties to understand triage rules

Some specialist offices have established a booking office for new patient referrals that has improved communication and coordination. However, an outstanding issue is that the appointment time and details is often communicated to the family physician who may not pass on the information to the patient resulting in a no-show

Ability to work with primary care offices to address referral omissions is variable. While some primary care provider offices are highly engaged, some are nearly unreachable and essential ignore feedback resulting in issues being repeated. Some specialist offices have attempted to provide 'decline letters' explaining why they won't see the patient

Need for the primary care physician and specialist to understand respective goals of the referral


Some key suggested information to complete a referral were provided. These include:

Clear and specific reason for referral, especially when other parties are also involved

List of other practitioners involved and their roles in care

Purpose of the referral request (e.g., to provide information or a request to assume care)

Whether the referring provider is ok if referral is dealt with through other means (e.g. as phone consult, e-consult)

Direct contact information for the sender of the referral (that avoids "press 1", being on hold, etc.) so that information can be easily clarified - ideally electronic communication

The usual "face-sheet" information - past medical history, meds, lab results, allergies, imaging etc.

Investigations and letters from other consultants

6. Views and ideas for how to improve the referral process:

Standardized referral process and tools (forms)

Develop greater standardization of the referral process

Standard referral online form to be filled out by referral MD with check list to ensure completeness

Enhance accountability of the referring physician to reduce duplication of services

Tools to streamline info flow (no faxing, create back-line)

Leverage electronic tools to streamline referrals (e.g., eliminate fax), support notification processes about the status of a referral, and enable two-way communications about issues/concerns in real time (e.g., centralized web-based intake with resource matching and triage capabilities

Streamline referral process and improve communication about wait time

Central intake services & provider registry

Central registry that provides a list of consultants, their current wait times, the type of referrals that they will accept and the required supporting documentation

Establish central intake services (e.g., common intake point for a group of specialists with a support team) to enhance coordination and management of referrals

Guidelines outlining info required for referral (cheat sheet)

Improve the referral letter process to clearly outline the clinical issues and the history

A cheat sheet that includes general guidelines on what to include for a referral for a specific diagnosis or concern

Improve primary care knowledge regarding access to non-surgical care

Improve network for information sharing and knowledge development

Address specialist barriers (catchment, wait time vs. acuity)

Support specialists to manage barriers to care. Includes managing catchment decisions, and helping to address wait list vs. acuity pressures experienced by specialists

Expand telehealth and e-consult programs

Expand telehealth and e-consult programs to support the referral process


Breakout Session Key Learnings

Family physicians and specialists were assigned to four groups (psychiatry, surgery, and two medicine groups) and participated in interactive breakout sessions to learn, share ideas, and identify priorities for action to improve access to specialist care. The following summarizes the key discussions (see Appendix C for a Summary of Breakout Discussions by Specialty Groups).

Break Out Session I – Identifying Access to Specialist Challenges & Impact

Break out participants were asked to identify key challenges to accessing specialist referrals (pain points),

and identify the impact of this access challenge on patients, families, or providers. Responses have been

grouped into the following five categories:

Need Key Challenges

Know Which Specialists To Refer To

Limited knowledge of current and approved resources that are available to link a provider, patient or family to services (e.g., what services are available, who is accepting referrals, who should the primary care provider refer to, what are the specialists areas of focus, what information is required as part of the referral). Leads to primary care providers/admin staff spending countless hours searching for resources, and patients being bounced around. Many providers have created their own ‘resource list’, but a city-wide or provincial current directory resources would be helpful.

Specialist offices may run offices differently (e.g., variation in how they want to be contacted, differences in triage practices, variation in who specialist will speak to) leads to poor coordination. Need to create standards that everyone meets, regardless of who the provider is. Opportunity to create specialist-level standards and move away from individual practices with high variability.

Catchment areas and hospital boundaries create challenges. There is a lack of a clear boundary, and sometimes patients are in-between hospitals and not able to be referred to certain programs. Primary care providers are often unsure of where to send the patient.

Know What Information To Provide

Lengthy referral forms often require unrelated information. Forms can be different for every hospital. Leads to a lot of time by primary care provider/assistant to complete the forms.

Lack of understanding or transparency of referral/triage criteria creates access barriers and delays. Required information and rules need to be clear to support referral and triage process (e.g. like the SickKids model). Specialists should identify everything they want and need to avoid delays.

Have created systems on systems on systems – lots of layers (e.g., password issues). Need one integrated system. Hard to keep track of the different processes and procedures. Need to pursue greater integration of information systems (e.g., hospital EMRs, OLIS, primary care provider EMRs).


Able to Ask Questions to Confirm Appropriateness

of Referral

Notes from specialists are not detailed and may not include proper contact information if the primary care provider has questions. Primary care providers would appreciate if specialist could include their email contact (or other relevant contact information) on the referral if additional questions are required (e.g., medication related). Primary care providers/admin are often not able to get by the clinic desk at the hospital/office.

Lack of follow-up from a hospital or specialist office after patient’s appointment. There is sometimes difficulty receiving notes or obtaining a follow-up appointment after the specialist consultation. Primary care providers are often unsure of when the patient will be followed-up or when they will be out of the specialist system and transitioned back. The patient is unsure of who their next appointment is with - the specialist or the primary care provider.


Need to move from individual specialist to team-based models to support more timely access. Need greater acceptance of a team based model by primary care providers and patients that can support more timely access to care and services by referral to a group as opposed to individuals.

Current referral process creates added work for primary care providers. There is a concern that referrals may fall through the cracks creating anxiety of whether the patient’s referral has been received. This may lead additional effort by primary care offices to track referrals and follow-up with specialist, creating additional work for specialist offices. Need to be clearer about who notifies the patient about the appointment (specialist or primary care provider).

Delayed, or lack of response, following a referral. Leads to added time to already long waits, confusion on the part of providers/patients, and can result in providers referring patients to multiple specialists.

Send out multiple referrals for a patient to different specialist hoping one will “stick”. The multiple referrals are sometimes not cancelled leading to an increase in the number of no-shows, redundant and wasteful work, and reduces system capacity.

Build Knowledge and Capacity of Providers

Lack of two-way communication from hospitals/specialists leads to delays that could be easily solved via a call or email. Primary care providers may have simple, but important, questions (e.g., is the patient still in the system). Primary care providers find they are required to make a referral for a condition/ question that could have been solved over the phone or email.

Patients may require ongoing specialist assistance (multiple follow-up appointments) but are only seen for an initial appointment. Primary care providers find it difficult to manage patients that require additional or ongoing follow-up, but are unable to receive it. Patients can often ‘slip through the cracks’.


Break Out Session II – Identifying Priorities for Action

Break out participants were also asked to identify priorities for action, and identify the top priorities the group felt should be acted upon immediately. The top priorities have again been grouped into categories:

Need Priorities for Action

Know Which Specialists To

Refer To

Establish List/Directory of Resources – Hospital and Community. Create a list of Mental Health resources (hospital-based, community, programs) with contact numbers, catchment maps, availability and direct links to referral forms (e.g., provide specialist contact numbers post-discharge; identify clinics that have low barrier access; specify groups/programs with short wait times if follow-up is required; availability of OHIP-covered services and other specialty resources). Develop and communicate standardized triage rules. Access to inform will lead to quicker, more efficient access to the most appropriate services for patients.

Know What Information To

Provide

Automate and Standardize Referral Form Ensuring Key Information is Collected. Develop a standardized referral from for all referrals (medical, surgical, psychological) across Ontario (e.g., standardized e-referral, well defined communication processes). A common form will improve quality of data collected, reduce time chasing referral information, and limit unnecessary workload.

Able to Ask Questions to

Confirm Appropriateness

of Referral

New Communication Tools to Improve Communications Between Providers. Improve timely and efficient communication between providers (e.g., website information, email, back-channel phone access). In addition, engagement events support the sharing of ideas, increase networking and knowledge building opportunities, and support the ability to provide feedback. Improve referral follow-up processes.

Leverage e-Consult to Resolve Questions Quickly. Advance e-Consult capacity, supporting tools and education to help get to the issue quicker, and enable access from anywhere (at home/ at night).

Use ONEmail for Timely Direct Communication. Get all physicians on ONEmail to improve more timely and direct communication. ONEmail improves, simplifies and secures communication. Create a back-channel process.


Establish Central Referral Office to Increase Efficiency of Referrals. Leveraging a central referral to ensure information goes to the right person enabling timely triage. This will reduce time spent by primary care providers when a very clear process is utilized.

Develop a Standard and Integrated Common Referral Tool and Communication Process. Develop common approaches to communicate electronically. Support improved technology and information sharing interfaces between systems (e.g., EMRs, referral systems), and leverage existing technology platforms (e.g., telemedicine) to improve consultation capacity and efficiency.

Build Knowledge and Capacity of

Providers

Advance Mentorship. Advance mentorship opportunities by linking specialists to primary care to assist with general questions, one-off’s. This helps to build knowledge and capacity of the primary care provider by enabling them to learn from, and count on, if they have a quick question. This may also result in a avoiding an inappropriate or unnecessary referral.

Enable Knowledge Development. Support engagement events to share ideas, increase networking, and co-design of solutions


Appendix A: List of Participants

The following participants were invited to the SCOPE session.

Session Participants:

Susan Au Yacoob Barmania Lorena Barrientos John Beattie Subita Behki Claudio Borgono Susan Brunt Reena Chada King Sun Chan Margaret Chu Laura Clark Jayne Davis Sarah Doyle Hedi Erenrich William Etzkorn

Jindrich Fiala Fred Freedman Vera Fried KanYing Fung Lorne Greenspan Rachelle Grossman Jordan Hakami Paul Hasson Eric Hatashita Edward Hussman Karen Ko Vera Kohut Dominic Li Susy Lin Vivian Liu

Jean Marmoreo Rui Martins Michelle Mason Silvy Mathew Elizabeth McKeown Claire Murphy Peter Sauret David Satok Osama Shabash Danesh Sood Alain Sotto Daniel Toledano Marvin Waxman Susan Westlake

Specialist Participants:

Susan Abbey, Psychiatry, UHN

Christopher Chan, Nephrology, UHN

Natasha Gakhal, Rheumatology Program, WCH

Dana Jerome, Rheumatology Program, WCH

Arno Kumagai, Representative of the Department of Medicine

Tara O'Brien, Internal Medicine, WCH

Raja Rampersaud, Orthopedics

Peter Rossos, Chief Medical information Officer, Gastroenterology

John Semple, Head Division of Plastic Surgery, WCH

Vicky Stergiopoulos, Physician-in-Chief, Psychiatry, CAMH

David Urbach, Surgery, Robert Wald, Cardiology Jean Wang, Hematology Kirsten Wentlandt, Palliative

Care, UHN

SCOPE Team:

Pauline Pariser Mary Carlos Maggie Rybak Frances Simone Jamie Smith Ian Stanaitis Haley Walsh

Guests/Presenters:

Greg Stevens, Director, Primary Care, TC LHIN

Nash Syed, Corpus Sanchez International


Appendix B: SCOPE Engagement Event – Evaluation Summary

The following reflects session evaluation results (n=30).

Evaluation Criteria Strongly Disagree

Disagree Agree Strongly

Agree

The program met my expectations 16 (53%) 14 (47%)

The program was well organized 9 (30%) 21 (70%)

There were adequate opportunities to interact with my peers

6 (20%) 24 (80%)

The information I learned will be used in my practice

1 (3%) 13 (44%) 16 (53%)

The breakout discussion was relevant to family medicine

10 (33%) 20 (67%)

The topics covered are relevant to my practice 8 (27%) 22 (73%)

What was the most effective part of the program? Why?

Breakout sessions with specialists present at the table - Discussing problems/challenges and possible solutions - Opportunity to speak directly with specialists (face-to-face) - Understanding both sides

Specialist panel followed by open Q&A - Expectations for referrals were made clear

Interaction with specialists – building connections/network Learning about upcoming programs (e.g. psych bridging/mentorship program) Dr. Chan’s excitement regarding nephrology announcements Meeting my FP colleagues Very relevant to my daily practice

What was the least effective part of the program? Why?

Should be able to rotate tables and meet different specialists during the breakout sessions Panels

- More interaction with panelists required - Specialists should have been better prepared – state clear problems and recommend options - Some specialists only telling us how to refer - Hard to hear - Points blurred together

Breakout sessions and discussing priorities, what will come of it? Not enough time Many opinions, limited time, not sure everything was efficiently covered Need a larger room, noisy at the breakout sessions Not having access to programs that were brought up right now (mental health, surgery, etc.)


Please list any topics you would llike to see addressed in future programs:

Paediatrics (common paeds complaints, derm – rash, psych) Another ‘Specialists’ evening (orthopaedics – upper & lower limb, spine, maxillofacial – who does what,

central intake options) Hematology, general & benign (x8) Pain management vs. practices/policies Clinical Update events (hematology, rheumatology, psych) CME’s/Educational events

General Comments

Excellent program and evening Very good, please continue these Always a learning experience! Thank you for getting us all together!


Appendix C: Summary of Breakout Discussions by Specialty Groups

Interactive sessions were conducted where family physicians and specialists came together to learn, share ideas, and identify priorities for action to improve access to specialist care. Two questions were asked of break out groups:

Identify key challenges to accessing specialist referrals (pain points), and identify the impact of this access challenge on patients, families, or providers; and

Identify priorities for action, and identify the top priorities the group felt should be acted upon immediately.

The following provides a summary of discussions from the Psychiatry, Surgery, and two Medicine Groups.

Specialty Access to Specialist Challenges & Impact Priorities for Action

Psychiatry Finding community-based psychiatrists willing to take on new patients. A concern was noted that some patients do not want to visit a hospital due to stigma associated with CAMH. Primary care providers have found they have better luck with being able to book follow-up appointments with community-based psychiatrists.

Delayed, or lack of response, following a referral. Lack of timely response leads to added time to already long waits, and potentially primary care providers referring patients to multiple hospitals/sites.

Catchment areas and hospital boundaries create challenges. There is a lack of a clear boundary, and sometimes patients are in-between hospitals and not able to be referred to certain programs. Primary care providers are often unsure of where to send the patient.

Lack of follow-up from CAMH after a patient’s appointment. There is sometimes difficulty receiving notes or obtaining a follow-up appointment after the specialist consultation. Primary care providers are often unsure of when the patient is being followed-up or will be out of the system. The patient is unsure of who their next appointment is with - the specialist or the primary care provider.

Notes from specialists are not detailed and don’t include proper contact information if the primary care provider has questions. PCPs would appreciate if specialist could include their email contact on the referral if additional questions are required (e.g., medication related). Primary care providers/admin are often not able to get by the clinic desk at the hospital/office.

Lengthy referral forms often require unrelated information. Forms can be different for every hospital. Leads to a lot of time by primary care provider/assistant to complete the forms.

Patients may require ongoing psychiatric assistance (multiple follow-up appointments) but are only seen for an initial appointment. Primary care providers

Improved Access to Information. Create a list of Mental Health resources (hospital-based, community, programs) with contact numbers, catchment maps, availability and direct links to referral forms (e.g., provide specialist contact numbers post-discharge; identify clinics that have low barrier access; specify groups/programs with quick wait times if follow-up is required; availability of OHIP-covered psychotherapy and other specialty resources). This will lead to quicker, more efficient access to the most appropriate program(s) for patients.

Improving Communications Between Providers. Properly communicate resources that are available, and new programs to primary care providers (e.g., website, email, engagement/educational events). In addition, engagement events would allow the primary care providers to hear from both sides, increase networking and knowledge building opportunities, and support the ability to provide feedback.

Advance mentorship opportunities by linking psychiatry to primary care to assist with general questions, one-off’s. This helps to build knowledge and capacity of the primary care provider by


find it difficult to manage patients that require psychiatric follow-up, but are unable to receive it. Patients can often ‘slip through the cracks’.

Lack of two-way communication from hospitals leads to delays that could be easily solved via a call or email. Primary care providers may have simple, but important, questions (e.g., is the patient still in the system). Primary care providers find they are required to make a referral for a condition/ question that could have been solved over the phone or email.

Some therapies are very challenging to access leading to difficulty in knowing where to refer and/or long wait times (e.g., CBT, ADHD). Leads to primary care providers referring to multiple programs at different hospital – wasting time and draining resources.

Limited knowledge of what resources are available to link a provider, patient or family to (e.g., what services are available, who should the primary care provider refer to, what are the specialists areas of focus). Leads to primary care provider/admin spending countless hours searching for resources, and/or patients being bounded around. Many providers have created their own ‘resource list’, but a city-wide one would be helpful.

enabling them to learn from, and count on, if they have a quick question. This may also result in a avoiding an inappropriate or unnecessary referral.

Surgery Management of referral process (central intake, triage referral) creates added work for primary care providers (e.g., send out a consult and have to track). Concern that referrals may fall through the cracks. Need to be clearer about who tells the patient about the appointment (specialist or primary care provider).

Status of referral must be viewed as crucial communication. Primary care providers may not know if referral made it to the specialists. Need to know the status of a referral.

Specialist offices may run offices differently (e.g., variation in how they want to be contacted, differences in triage practices) leading to inefficient coordination. Need to create standards that everyone meets, regardless of who the provider is. Opportunity to create specialist-level standards and move away from individual practices that have a high degree of variability.

Delays in accessing/obtaining a surgical date. Lack of access to a surgical date leads to difficulty in patient being able to plan their life; creates fragmentation in care; or increases patient anxiety, costs, delays LTD approval.

System is provider centric and not patient-centric. Leads to waste of time and money.

Lack of understanding or transparency of referral/triage criteria creates access barriers. Required information and triage rules need to be clear to support referral and triage process (e.g. like

Break out participants were also asked to identify priorities for action, and identify the top priorities the group felt should be acted upon immediately. Top priorities identified by the Surgery group included: Leveraging a central referral to

ensure information goes to the right person enabling timely triage. This will reduce time spent by primary care providers when a very clear process is utilized.

Automate and standardize the referral form to ensure pertinent information is collected. Develop a standardized referral from for all referrals (medical, surgical, psychological) across Ontario (e.g., standardized e-referral, interaction communication processes). A common form will improve quality of data collected, reduce time chasing referral information, and limit unnecessary workload.

Develop common approaches to communicate; supported by improved interfaces


the SickKids model). Specialists should identify everything they want and need to avoid delays.

Need to move from individual specialist to team-based models to support more timely access. Need greater acceptance of a team based model by primary care providers and patients to ensure more timely access to care and services.

(information, people, technology). Focus on advancing interfaces with different EMRs.

Additional priorities identified by the Surgery Group included:

Develop common referral patterns/pathways for common procedures

Connect technology/information-sharing systems (e.g., referral applications, EMRs) to reduce workload and reliance on fax based systems.

Advance relationship-management processes and culture to advance a front-line service focus.

Develop expectations or standards related to response time.

Enhance communication processes to know that the referral has been received and what are the next steps (e.g., eCHIN model).

Medicine (Group 1)

Don’t know what sub specialist do and what do they need to support triage review. Leads to more work to find the right specialist.

No confirmation that specialist have received a referral. Leads to more work for primary care office.

Don’t know who the sub-specialist are – need for a central directory (Ontario-wide). Must include new graduates. Leads to delays in care for the patient.

Specialist receive referrals for patients who have seen many other specialist. Leads to specialists having to review and “weed through” all consults and limits system resources.

Different referral forms for different specialists. Leads to more work for my office.

Access to sub-specialist care is long (wait list of 18 months). Patients can wait very long, and it may not be the right sub-specialist leading to additional, and potentially avoidable, delays.

Have created systems on systems on systems – lots of layers (e.g., password issues). Need 1 system. Hard to keep track of the different processes and procedures.

Send out multiple referrals for a patient to different specialist hoping one will “stick”. The multiple

Break out participants were also asked to identify priorities for action, and identify the top priorities the group felt should be acted upon immediately. Top priorities identified by the Medicine group (1) included: e-Consult – enable broad

access and use. Participants said they would use it.

Get all physicians on ONEmail. Reduce layers, makes it easier to communicate. Should link OLIS, ONEmail, and EMR.

Create backline to make it easier to call if more information is required. Create a back channel process.

Additional priorities identified by the Medicine Group (1) included:

Able to send note(s) back to primary care physician to ask for additional information.


referrals are sometimes not cancelled leading to redundant and wasteful work and reduces capacity.

Different or changing catchment areas. Leads to more work and wasted time to deal with the changes.

Specialist that never consult back or don’t do consult letters.

Specialist refuse to speak to anyone but a physician. Takes longer to coordinate time.

Handwritten notes/faxed from specialist – hard to translate. Need to call time to translate notes wasting time of both providers.

Specialist are also challenged by supply and demand pressures. Primary care providers may feel that specialist do not want to see patient, but it is a matter of capacity. Need to try to allocate and utilize resources as a system to enable better coordination.

Difficult to find out who is available, and more difficult to know which colleagues have retired. Leads to more work to find the right specialist.

Primary care offices go online and search for the best way to refer but information is not always available. Leads to more work to find the right specialist.

Work-up has been done and sent but specialist re-do diagnostics (e.g., “draw 10 vials) – consults should have been use. Inefficient use of resources and/or lack of understanding for why tests are being done leads to confusion.

Specialist may ask “Please send new referral for a follow-up” for a patient that is already a patient. Creates a feeling of added work and frustration for provider and patient.

If specialists picked-up the phone to answer questions, referrals may be changed and/or eliminated. Potential to avoid some patients waiting for unnecessary or inappropriate referrals.

Using e-Consult is time consuming (for a $16 fee). Lots of cut and paste. Need to streamline e-consult processes to get greater uptake.

Understand specialist triaging process – be transparent.

Explore mechanism to deal with triage quickly and easily – ½ day clinics.

Need to know who does what (specialist and sub-specialist).

Create central point of access.

Establish response time via a service level response. There was some concern that this could put undue pressure or set up to fail. Note: SLA would be set by the specialist provider.

Leverage apps (Chronic Kidney) to educate and guide when to refer, what information is required.

Develop clear standards for workup to ensure specialist have what they need as part of the referral.

Attachments are disappearing as part of referrals resulting in having to send a referral multiple times. Need to ensure technology works.

Confirming membership to circle of care to enable access to data and communications (e.g., lab data).

Integration of information systems (hospital EMR, OLIS, primary care provider EMR).

Medicine (Group 2)

Break out participants were asked to identify key challenges to accessing specialist referrals (pain points), and identify the impact of this access challenge on patients, families, or providers.

Medicine Group 2 agreed to four major pain points not in any particular order:

Timeliness of referrals – where to send urgent referrals

Follow-up on referrals – it goes into the abyss, did they get it? Who’s contacting the patient?

Rejected referrals – not knowing why, getting the rejection after the referral has been sitting for weeks, so many sub-specialists

Specialist taking more ownership of the referrals. Need assistance from specialists to say why the referral is rejected, and offer advice or names of sub specialists that will take the referral.

Improved communication – ONE Mail. ONEmail improves, simplifies and secures communication.

e-Consult helps to get to the issue quicker, and enables


No one to consult with – who do I call if I have questions?

Responses for the Medicine group (2) included: Lack of general specialists. Many rejected referrals

which delays the patient getting services and is time consuming for providers to fill out multiple referrals and search for someone to accept patient.

Not knowing specialists anymore (no hospital privileges and retiring physicians that they did know). Physicians don’t have the same faith that the referral will be handled or know the process of new specialists.

Not knowing what physicians specialize in. Getting bounced from specialist to specialist trying to find out who does what.

Not knowing where to send urgent referrals other than the ED. Patients may end up in the ED because physicians have anxiety over what to do with patients.

Timeliness of referrals – no sense of when referrals will be handled. A lot of anxiety of whether the patient’s referral has been received leads to referring to multiple specialists to see who gets to the patient first creating duplication and reducing system capacity.

Don’t know who to refer to, who is accepting referrals, where are they? Frustrating for providers – results in wasted time searching. Need a Directory of Providers.

Rejected referrals. Can receive a declined referral 2 weeks to 2 months after it has been sent because the specialist is either full or they are a sub-specialist and cannot take the patient leading to delayed access to care. Need for specialist to take more ownership of referrals to support re-referrals if they are unable or not the right provider.

Many patients need services outside Toronto and not aware of where to send them. Forcing patients to travel or multiple referrals since primary care providers aren’t aware of their processes.

Specialists sending appointments to primary care providers to contact the patient – specialist not contacting the patient directly.

Triage isn’t happening for weeks so there is a delay in hearing whether the referral was correct.

Language barriers impact access to care. Need to know what languages specialists speak. Patients aren’t able to communicate with their specialist.

access from anywhere (at home/ at night).

Additional priorities identified by the Medicine Group included:

Need to know the status of the referral. Referrals need to be reviewed on a more regular basis. This will enable knowing sooner whether the referral is accepted and reduce delays for the patient.

Mandate notification receipt of the referral and create some form of timeline. Patient/providers would know if the referral is received, accepted or declined within a satisfactory timeframe and there is an opportunity to provide more information if the patient needs to be seen sooner than the timeline provides.

Specialists to contact the patient directly and then inform provider of date. Specialist notification will save time, prevent no shows since the patient is aware of the appointment, and enable better communication for the patient.

Establish specialist referral guidelines (e.g., when to refer, how long things take) as part of standards (at a specialty level, not physician level).

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