The Medical Neighborhood: The Medical Neighborhood: Ensuring Continuity of Care with Ensuring Continuity of Care with

Hospital and Specialist Hospital and Specialist NeighborhoodsNeighborhoods

R. Scott Hammond MD, FAAFPR. Scott Hammond MD, FAAFPChair, CAFP PCMH Task Force Chair, CAFP PCMH Task Force

Medical Director, SOCMedical Director, SOC--PCMH Initiative, ColoradoPCMH Initiative, ColoradoAssociate Clinical Professor, Dept. of Family Medicine Associate Clinical Professor, Dept. of Family Medicine

UCHSCUCHSCshammond@evcohs.comshammond@evcohs.com

Caitlin Barba, MPHCaitlin Barba, MPHPCMH Project Manager, Westminster Medical ClinicPCMH Project Manager, Westminster Medical Clinic

caitlinbarba@yahoo.comcaitlinbarba@yahoo.com

Continuity of Care ParadigmContinuity of Care Paradigm

WMC TeamWMC Team

4

PCMH and the Medical NeighborhoodPCMH and the Medical Neighborhood

Reality of Care CoordinationReality of Care Coordination

The The typical primary care physician has 229 typical primary care physician has 229 other physiciansother physicians working in 117 practices with working in 117 practices with which care must be coordinated.which care must be coordinated.

Pham et. al Ann Pham et. al Ann IntInt Med. 2009Med. 2009

In the Medicare population, the In the Medicare population, the average average beneficiary sees seven different physiciansbeneficiary sees seven different physicians and fills upwards of 20 prescriptions per yearand fills upwards of 20 prescriptions per year

Partnership for Solutions, Johns Hopkins Univ. 2002Partnership for Solutions, Johns Hopkins Univ. 2002

Colorado SOC/PCMH InitiativeColorado SOC/PCMH Initiative Coordination of Care 2009Coordination of Care 2009

Making ConnectionsMaking ConnectionsCare coordinator job description and protocol Care coordinator job description and protocol consistent with available resources.consistent with available resources.External care coordinationExternal care coordination–– Hospital and skilled nursing facilitiesHospital and skilled nursing facilities–– Specialists Specialists

Internal care coordinationInternal care coordination–– HighHigh--acuity patientsacuity patients

PostPost--hospitalhospitalMultiMulti--morbid diseasesmorbid diseasesFrequent ED utilizationFrequent ED utilization

–– Patient Navigator/Disease Management/Patient Navigator/Disease Management/Health CoachingHealth Coaching

Geographic continuity Geographic continuity ---- WMCWMC HospitalsHospitals

List of facilities and contact personnelList of facilities and contact personnelRelational ContinuityRelational Continuity–– Patient Identification of PCP Patient Identification of PCP

Patient education by practices, plans, hospitalsPatient education by practices, plans, hospitals““wallet cardwallet card”” PCMH IDPCMH ID

Informational continuityInformational continuity–– Daily census of admits, discharges, updates Daily census of admits, discharges, updates

(hospitals, hospitalists, IPA)(hospitals, hospitalists, IPA)–– Post hospital transition (Discharge care plan)Post hospital transition (Discharge care plan)–– BiBi--directional Communication (Forms)directional Communication (Forms)

ED/inED/in--hospital medical information transferhospital medical information transfer

PCMH without a neighborhoodPCMH without a neighborhood

Primary CarePrimary Care--Specialty Care Specialty Care Collaborative Guidelines Collaborative Guidelines

Purpose and PrinciplesPurpose and PrinciplesDefinitionsDefinitionsTypes of Care Transition Types of Care Transition Service AgreementService Agreement–– Transition of CareTransition of Care–– AccessAccess–– Collaborative Care ManagementCollaborative Care Management–– Patient CommunicationPatient Communication

Transition of Care Records (PCP and Specialist)Transition of Care Records (PCP and Specialist)

THE PATIENT-CENTERED MEDICAL HOMENEIGHBOR:

THE INTERFACE OF THE PATIENT- CENTERED

MEDICAL HOME WITHSPECIALTY/SUBSPECIALTY PRACTICES

A Position Paper of theAmerican College of Physicians

2010

WMC Medical Neighborhood WMC Medical Neighborhood AllergyAllergy--Immunology (P)Immunology (P)CardiologyCardiologyDermatologyDermatologyGastroenterology Gastroenterology HematologyHematology--OncologyOncologyMental Health (P)Mental Health (P)Nephrology Nephrology NeurologyNeurologyOphthalmology Ophthalmology Pulmonary (P)Pulmonary (P)Surgery Surgery –– GeneralGeneral–– OrthopedicsOrthopedics–– Spine (2)Spine (2)–– Plastics and HandPlastics and Hand–– UrologyUrology

40+ Physicians14 Specialty offices

1 Hospital

WMC Medical Neighborhood WMC Medical Neighborhood

Medical Neighbor SuccessesCardiology Calls before invasive interventions and

to discuss care plan

Dermatology Refers treatment of other lesions back to PCP

Gastroenterology Working on TCR and care plan re: colonoscopy guidelines

Neurology Decrease in secondary referrals

Ophthalmology Faxes diabetic retinal exam reports

Surgery – Orthopedics Sends patients back for continuing care with plan; decrease in secondary referrals

Urology Collaborative teamwork, TCR

Coordinated CareCoordinated Care

Building a NeighborhoodBuilding a Neighborhood

Phase 1: Planning

Phase 2: Implementation

Phase 3: Evaluation (and Continuous Implementation)

Phase 4: Sustainability and Continuous Improvement

Phases and The 5 APhases and The 5 A’’ss

ADVISE: The Implementation Message

You as PCPs survive and thrive!You as PCPs survive and thrive!Benefits to a PCMHBenefits to a PCMH--NN–– PatientsPatients

Activated, prepared, engagedActivated, prepared, engaged–– Specialty Care PhysiciansSpecialty Care Physicians

Maintain autonomy, known for quality care, more Maintain autonomy, known for quality care, more exclusive patient volume from PCPexclusive patient volume from PCP

–– Practice of MedicinePractice of MedicineReclaim the joy of medicine, camaraderie, why you Reclaim the joy of medicine, camaraderie, why you went into medicine went into medicine

–– Health CareHealth CareSolvency, sustainabilitySolvency, sustainability——jump start, pioneeringjump start, pioneering——itit’’s s the way of the future! the way of the future!

Transition of CareTransition of Care

Mutual AgreementMutual Agreement

•• Maintain accurate and upMaintain accurate and up--toto--date clinical record.date clinical record.•• Agree to standardized demographic and clinical information formaAgree to standardized demographic and clinical information format such as the Continuity of Care t such as the Continuity of Care

Record [CCR] or Continuity of Care Document [CCD]Record [CCR] or Continuity of Care Document [CCD]•• Ensure safe and timely transfer of care of a prepared patientEnsure safe and timely transfer of care of a prepared patient

ExpectationsExpectations

Primary CarePrimary Care Specialty CareSpecialty Care

PCP maintains complete and upPCP maintains complete and up--toto--date clinical date clinical record including demographics.record including demographics.Transfers information as outlined in Patient Transfers information as outlined in Patient Transition Record.Transition Record.Orders appropriate studies that would facilitate the Orders appropriate studies that would facilitate the specialty visit.specialty visit.Informs patient of need, purpose (specific question), Informs patient of need, purpose (specific question), expectations and goals of the specialty visitexpectations and goals of the specialty visitProvides patient with specialist contact information Provides patient with specialist contact information and expected timeframe for appointment.and expected timeframe for appointment.

Determines and/or confirms insurance eligibility Determines and/or confirms insurance eligibility Identifies a single referral contact person to Identifies a single referral contact person to communicate with the PCMHcommunicate with the PCMHWhen PCP is uncertain of appropriate laboratory or When PCP is uncertain of appropriate laboratory or imaging diagnostics, assist PCP prior to the imaging diagnostics, assist PCP prior to the appointment regarding appropriate preappointment regarding appropriate pre--referral workreferral work--up up

ADVISE: Collaborative Guidelines

Access Access Mutual AgreementMutual Agreement

•• Be readily available for urgent help to both the physician anBe readily available for urgent help to both the physician and patient via phone or ed patient via phone or e--mail.mail.•• Provide visit availability according to patient needs.Provide visit availability according to patient needs.•• Be prepared to respond to urgencies. Be prepared to respond to urgencies. •• Offer reasonably convenient office facilities and hours of opOffer reasonably convenient office facilities and hours of operation.eration.•• Provide alternate backProvide alternate back--up when unavailable for urgent matters.up when unavailable for urgent matters.

ExpectationsExpectations

Primary CarePrimary Care Specialty CareSpecialty Care

Communicate with patients who Communicate with patients who ““nono--showshow”” to to specialists.specialists.Determines reasonable time frame for specialist Determines reasonable time frame for specialist

appointment.appointment.Provide a secure email option for communication with Provide a secure email option for communication with

patient and specialist.patient and specialist.

Notifies PCP of first visit Notifies PCP of first visit ‘‘nono--showsshows’’ or other actions or other actions that place patient in jeopardy.that place patient in jeopardy.Provides visit availability according to patient needs.Provides visit availability according to patient needs.Be available to the patient for questions to discuss the Be available to the patient for questions to discuss the

consultation.consultation.Schedule patientSchedule patient’’s first appointment with requested s first appointment with requested

physician.physician.Be available to PCP for preBe available to PCP for pre--consultation exchange by consultation exchange by

phone and/or secure email.phone and/or secure email.When available and clinical practical, provide a secure When available and clinical practical, provide a secure

email option for communication with established patients email option for communication with established patients and provider.and provider.Provides PCP with list of practice physicians who agree Provides PCP with list of practice physicians who agree

to compact principles.to compact principles.

ADVISE

Collaborative Care ManagementCollaborative Care ManagementMutual AgreementMutual Agreement

•• Define responsibilities between PCP, specialist and patient.Define responsibilities between PCP, specialist and patient.•• Clarify who is responsible for specific elements of care (drug Clarify who is responsible for specific elements of care (drug therapy, referral management, diagnostic testing, therapy, referral management, diagnostic testing,

care teams, patient calls, patient education, monitoring, followcare teams, patient calls, patient education, monitoring, follow--up).up).•• Maintain competency and skills within scope of work and standarMaintain competency and skills within scope of work and standard of care.d of care.•• Give and accept respectful feedback when expectations, guidelinGive and accept respectful feedback when expectations, guidelines or standard of care are not metes or standard of care are not met•• Agree on type of specialty care that best fits the patientAgree on type of specialty care that best fits the patient’’s needs.s needs.

ExpectationsExpectations

Primary CarePrimary Care Specialty CareSpecialty Care

Follows the principles of the Patient Centered Medical Home or Follows the principles of the Patient Centered Medical Home or Medical Home Index.Medical Home Index.Manages the medical problem to the extent of the PCPManages the medical problem to the extent of the PCP’’s scope of s scope of practice, abilities and skills.practice, abilities and skills.Follows standard practice guidelines or performs therapeutic trFollows standard practice guidelines or performs therapeutic trial ial of therapy prior to referral, when appropriate, following evidenof therapy prior to referral, when appropriate, following evidencece--based guidelines.based guidelines.Reviews and acts on care plan developed by specialist.Reviews and acts on care plan developed by specialist.Resumes care of patient when patient returns from specialist caResumes care of patient when patient returns from specialist care.re.Explains and clarifies results of consultation, as needed, withExplains and clarifies results of consultation, as needed, with the the patient. Makes agreement with patient on longpatient. Makes agreement with patient on long--term treatment plan term treatment plan and followand follow--up.up.

Reviews information sent by PCPReviews information sent by PCPAddresses referring provider and patient concerns.Addresses referring provider and patient concerns.Confers with PCP or establishes other protocol before orders Confers with PCP or establishes other protocol before orders additional services outside practice guidelines. Obtains proper additional services outside practice guidelines. Obtains proper prior prior authorization.authorization.Confers with PCP before refers to secondary/tertiary specialistConfers with PCP before refers to secondary/tertiary specialists for s for problems within the PCP scope of care and uses a preferred list problems within the PCP scope of care and uses a preferred list to to refer when problems are outside PCP scope of care. Obtains refer when problems are outside PCP scope of care. Obtains proper prior authorizationproper prior authorization when needed.when needed.Sends timely reports to PCP to include a care plan, followSends timely reports to PCP to include a care plan, follow--up and up and results of diagnostic studies or therapeutic interventions.results of diagnostic studies or therapeutic interventions.Notifies the PCP office or designated personnel of major Notifies the PCP office or designated personnel of major interventions, emergency care or hospitalizations.interventions, emergency care or hospitalizations.Prescribes pharmaceutical therapy in line with insurance formulPrescribes pharmaceutical therapy in line with insurance formulary ary with preference to generics when available and if appropriate towith preference to generics when available and if appropriate topatient needs. patient needs. Provides useful and necessary education/guidelines/protocols toProvides useful and necessary education/guidelines/protocols toPCP, as neededPCP, as needed

ADVISE

Patient Communication Patient Communication Mutual AgreementMutual Agreement

•• Engage and utilize a secure electronic communications platform fEngage and utilize a secure electronic communications platform for high risk patients such as or high risk patients such as ReachMyDoctorReachMyDoctor or CORHIO.or CORHIO.

•• Prepare the patient for transition of care.Prepare the patient for transition of care.•• Consider patient/family choices in care management, diagnostic tConsider patient/family choices in care management, diagnostic testing and treatment plan.esting and treatment plan.•• Provide to and obtain informed consent from patient according toProvide to and obtain informed consent from patient according to community standards.community standards.•• Explores patient issues on quality of life in regards to their sExplores patient issues on quality of life in regards to their specific medical condition and shares pecific medical condition and shares

this information with the care team.this information with the care team.

ExpectationsExpectations

Primary CarePrimary Care Specialty CareSpecialty Care

Explains specialist results and treatment plan to Explains specialist results and treatment plan to patient, as necessary.patient, as necessary.Engages patient in the Medical Home concept. Engages patient in the Medical Home concept.

Identifies whom the patient wishes to be included in Identifies whom the patient wishes to be included in their care team.their care team.

Informs patient of diagnosis, prognosis and followInforms patient of diagnosis, prognosis and follow--up up recommendations.recommendations.Provides educational material and resources to Provides educational material and resources to

patient.patient.Recommends appropriate followRecommends appropriate follow--up with PCP.up with PCP.Will be accountable to address patient phone Will be accountable to address patient phone

calls/concerns regarding their management.calls/concerns regarding their management.Participates with patient care team.Participates with patient care team.

ADVISE

22 Elements, 8 SectionsSpecialist-to-PCP

• Practice information• Patient demographics as name, DOB• ICD-9 Diagnosis codes• Reason for referral and clear goals of care and interventions• Clinical Data

• Medical history, current medications• Labs or diagnostic test results• Care team = other doctors who see the patient

• Recommendations for treatment• Who is responsible for followup, monitoring the patient and when• Patient’s treatment goals, education materials given to patient• Medication changes, new diagnoses, changed diagnoses

• Technical procedures completed• Communication preferences: fax, letter, email, phone• Type of Care Transition

• Defining the Relationship (Ex. co-management with principle care)• Definitions were developed by the American College of Physicians

ADVISE: TRANSITION OF CARE RECORD

Phases and The 5 APhases and The 5 A’’ss

Specialist Score CardSpecialist Score Card•• Mirrors the Compact with 4 sectionsMirrors the Compact with 4 sections•• Quarterly TCR audits, Patient Satisfaction surveysQuarterly TCR audits, Patient Satisfaction surveys•• ““MustMust--HaveHave””(s)(s)•• Neighbor thresholds Neighbor thresholds

ASSESS: Measurement

Evaluation & MeasurementEvaluation & MeasurementASSESS: Measurement

Evaluation & MeasurementEvaluation & MeasurementASSESS: Measurement

ASSESS: Measurement

Evaluation & MeasurementEvaluation & Measurement

Orthopedic 1

Orthopedic 2

Oncology

Dermatology

Cardiology

Surgery 1

Neurology

Orthopedic 3

Ophthalmology

Urology

Top bar: Q2 Middle bar: Q3       Bottom bar: Q4

ASSESS: Measurement

ASSIST: Medical Neighborhood ToolkitMedical Neighborhood Toolkit

FacilitationFacilitation– Compact (SOC(SOC--PCMH Initiative)PCMH Initiative)–– Proposed Timeline / Gantt ChartProposed Timeline / Gantt Chart–– Medical Neighborhood InvitationMedical Neighborhood Invitation–– Medical Neighborhood Introduction GuideMedical Neighborhood Introduction Guide–– Medical Neighborhood Practice Profile (SOCMedical Neighborhood Practice Profile (SOC--PCMH Initiative)PCMH Initiative)

ImplementationImplementation–– Care Coordination Policy and ProtocolCare Coordination Policy and Protocol–– ACP Care Transition Definitions & ScenariosACP Care Transition Definitions & Scenarios–– Score Card Excel TemplateScore Card Excel Template–– Score Card Word TemplateScore Card Word Template–– PCP Quarterly Memos WorksheetPCP Quarterly Memos Worksheet–– Transition of Care Record ChecklistsTransition of Care Record Checklists

PCP ProviderPCP ProviderReferral CoordinatorReferral CoordinatorMedical Assistant Transition of Care RecordMedical Assistant Transition of Care RecordSpecialistSpecialist

–– Patient Satisfaction SurveyPatient Satisfaction Survey–– Patient information pamphlet about the NeighborhoodPatient information pamphlet about the Neighborhood–– PCPPCP--Specialist Fax Sheet (PCMH identifier)Specialist Fax Sheet (PCMH identifier)–– PCPPCP--Specialist NewsletterSpecialist Newsletter–– PCMHPCMH--ID Card example (Health ID Card example (Health TeamWorksTeamWorks))

ASSIST: PCP Toolkit ExamplePCP Toolkit Example

ASSIST: Specialist Toolkit ExamplesSpecialist Toolkit ExamplesSpecialty Provider ChecklistSpecialty Provider Checklist PCMH “Identifier”

ARRANGESpread to other SpecialtiesSpread to other Primary Care officesPayment reformContinuous quality improvementRefining ToolkitExpand Compact to other transition types

What did we learn?What did we learn?Not aware of PCMH or Medical Neighborhood Not aware of PCMH or Medical Neighborhood conceptconceptMost willing to participate and believe they are or can Most willing to participate and believe they are or can fulfill most expectationsfulfill most expectations–– ““A slam dunkA slam dunk”” , , ““Ideal in principleIdeal in principle””

Interpretation of the Interpretation of the CompactCompact not straight forwardnot straight forwardUnclear about definitions of transitions/management Unclear about definitions of transitions/management relationships and patientrelationships and patient--centered carecentered careWide variety of practice infrastructure, capacities, Wide variety of practice infrastructure, capacities, effort and barriers to changeeffort and barriers to change–– Staffing, technology, teamworkStaffing, technology, teamwork–– Systems improvement (QI) not on radar!Systems improvement (QI) not on radar!–– OverwhelmedOverwhelmed

Specialists cater to many differing PCP requestsSpecialists cater to many differing PCP requestsTransition of Care Record and QI Transition of Care Record and QI are main points of are main points of conversationconversation

References References •• AnnisonAnnison, Michael H., and Dan S. , Michael H., and Dan S. WilfordWilford. . Trust Matters: New Directions Trust Matters: New Directions

in Healthcare Leadership. in Healthcare Leadership. San Francisco, CA: San Francisco, CA: JosseyJossey--Bass Inc Bass Inc Publishers, 1998.Publishers, 1998.

•• K. Davis, C. Schoen, and K. K. Davis, C. Schoen, and K. StremikisStremikis, How the Performance of the , How the Performance of the U.S. Health Care System Compares Internationally 2010 U.S. Health Care System Compares Internationally 2010 Update, Update, The Commonwealth FundThe Commonwealth Fund, June 2010., June 2010.

•• StarfieldStarfield et al. Ambulatory Specialist Use By Patients in US Health et al. Ambulatory Specialist Use By Patients in US Health Plans: Correlates and Consequences. Submitted 2008. Plans: Correlates and Consequences. Submitted 2008.

•• Quality of Health Care Advisory Committee Quality of Health Care Advisory Committee –– Subcommittee on Best Subcommittee on Best Practices and Adverse Events. Practices and Adverse Events. ““Report to the Commissioner Report to the Commissioner of Public Health: Transitions of Care & Health Care Handoffs.of Public Health: Transitions of Care & Health Care Handoffs.”” Connecticut Department of Public Health Connecticut Department of Public Health (2008): 1(2008): 1--23. 23.

•• Fisher, Elliott. Fisher, Elliott. ““Building a Medical Neighborhood for the Medical Building a Medical Neighborhood for the Medical Home.Home.”” New England Journal of Medicine New England Journal of Medicine 359.12 (2008): 359.12 (2008): 12021202--1205. 1205.

•• Forrest, Christopher. Forrest, Christopher. ““A Typology of SpecialistsA Typology of Specialists’’ Clinical Roles.Clinical Roles.”” Archives of Internal MedicineArchives of Internal Medicine 169.11 (2009): 1062169.11 (2009): 1062--1068.1068.

•• Anderson, Gerard, and Jan Horvath. Anderson, Gerard, and Jan Horvath. ““The Growing Burden of The Growing Burden of Chronic Disease in America.Chronic Disease in America.”” Public Health Reports 119 Public Health Reports 119 (2004): 263(2004): 263--270. 270.

•• Fenton, W. S. (2003), Shared decision making: a model for the Fenton, W. S. (2003), Shared decision making: a model for the physicianphysician––patient relationship in the 21st century?. patient relationship in the 21st century?. ActaActa PsychiatricaPsychiatrica ScandinavicaScandinavica, 107:, 107: 401401––402.402.