How to Improve Engagement with Community Physicians

Thursday, May 21st 2015 | 1:00PM - 2:00PM CDT

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Your Presenters

Francisco Loya, MD, MBACEO, EmCare Hospital MedicineFrancisco.Loya@emcare.com

Mirza BaigChief Technology Officer, EmCare Hospital MedicineMirza.Baig@emcare.com

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Attendees Will Learn:

The opportunity cost associated with unmanaged

referral processes

Best practices for managing direct admissions for

hospital care and referrals from physician to physician

New tools which can impact referral preference as well

as satisfaction

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Types of Integration• technology, branding, process flow,

management information systems, physicians' liaisons, referral services, medical staff development

Non-economic

• monetary payments to physicians for services, improvementsEconomic

• systems to coordinate patient care, scheduling and registration, information systems, care standards, quality programs, service lines, case management

ClinicalSource: Milbank Q. 2008 Sep; 86(3): 375–434. doi: 10.1111/j.1468-0009.2008.00527.x PMCID: PMC2690342 Hospital-Physician Collaboration: Landscape of Economic Integration and Impact on Clinical Integration. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2690342/

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Types of Referrals

MANY TO ONE

MANY TO ONE

MANY TO MANY

MANY TO MANY

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The Impact of an Unmanaged Referral Process

Poor continuity

of care

Delayed care

Medical errors

Redundant testing

Wasted resources

Lower patient

satisfaction

Lower rate of referrals/ admissions

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Poor Communication Impact on Sentinel Events

“The Joint Commission Sentinel Event database suggests poor communication contributes to nearly 70% of sentinel events, surpassing other commonly identified issues such as patient assessment and procedure compliance.”

Source: http://www.ncbi.nlm.nih.gov/books/NBK43683/

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Direct vs. E.D. Admissions136.3 million

E.D. visits annually in the US (44.5 visits per 100

persons) 1

11.9% of visits result in

hospital admission1

Only 27% of patients are seen

in fewer than 15 minutes1

According toER Wait Watcher 2

National average24 minutes

Wyoming = 15 min.Washington D.C. = 53 min

Overcrowding in the E.D.

1 CDC: Emergency Department Statistics (2011) http://www.cdc.gov/nchs/fastats/emergency-department.htm2 ProPublica: https://projects.propublica.org/emergency/

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Transition to More Direct Admissions

Direct admission

can improve:E.D. wait

timesPatient

experienceQuality and continuity

of care

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Physician Referrals as a Measure of Engagement: Gallup Study

“Engaged physicians gave the hospital an average of 3% more outpatient referrals and 51% more inpatient referrals than physicians who were not engaged or who were actively disengaged.”

Gallup Article: Want to Increase Hospital Revenues? Engage Your Physicians. By Jeff Burger and Andrew Giger.http://www.gallup.com/businessjournal/170786/increase-hospital-revenues-engage-physicians.aspx

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Physician Referrals: The Opportunity

Source: Projecting US Primary Care Physician Workforce Needs: 2010-2025 http://annfammed.org/content/10/6/503.full Alternate Source: NCHS Data Brief Number 105, September 2012: Generalist and Specialty Physicians: Supply and Access, 2009–2010 http://www.cdc.gov/nchs/data/databriefs/db105.htm calculations indicate PCP visits at 533,612 and specialist visits at 1,129,794 for a population of 320,873,156 (http://www.census.gov/popclock/)

462 Million PCP Visits

161 Million

Referrals 516 Million Specialist

Visits

(Projecting 565 Million by 2025)

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Referral Management in the U.S.

Exchanging patient

information

PCP to Specialist66% refer to a

colleague

Specialist to PCP50% refer to a

colleague

Non-Colleague

34%Colleague66%

Non-Colleague

50%Colleague

50%

Often citing reasons such as of “ease of communication” and “share my medical record system”

Source: J Gen Intern Med. 2012 May;27(5):506-12. doi: 10.1007/s11606-011-1861-z. Epub 2011 Sep 16. Reasons for choice of referral physician among primary care and specialist physicians. Retrieved May 11, 2015 at http://www.ncbi.nlm.nih.gov/pubmed/21922159

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The Problem with Referrals…

Only 16% of referrals are completed

electronically1

3 of every 10 tests are

reordered3

Redundant tests cost $8 billion per

year (2.7% of inpatient costs)4

20% of patients

referred to a specialist don’t

show up where they’re

referred2

Direct communication

between hospitalist and

PCP only in 3% - 20% of discharges5

Sources:1. Gaps in Referral Process between US Medical Providers http://www.practicefusion.com/pages/pr/survey-gaps-in-referral-process-between-us-medical-

providers.html?_sm_byp=iVVfD1PnJkMktqqV 2. Specialty Referral Completion among Primary Care Patients http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1934973/ 3. A Healthy System,” Technology CEO Council http://www.techceocouncil.org/reports/tcc_reports/ 4. Health Affairs. Improving Safety And Eliminating Redundant Tests: Cutting Costs In U.S. Hospitals. http://content.healthaffairs.org/content/28/5/1475.full and J Am Med

Inform Assoc. 2010 May-Jun;17(3):341-4. doi: 10.1136/jamia.2009.001750.A preliminary look at duplicate testing associated with lack of electronic health record interoperability for transferred patients. http://www.ncbi.nlm.nih.gov/pubmed/20442154

5. Deficits in communication and information transfer between hospital-based and primary care physicians http://www.ncbi.nlm.nih.gov/pubmed/17327525

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Poor Follow-up Leads to Readmissions and Medication Errors

Source: http://www.commonwealthfund.org/~/media/Files/Publications/Case%20Study/2011/Apr/1473_SilowCarroll_readmissions_synthesis_web_version.pdfHiMSS paper Reducing Readmissions Top Ways Information Technology Can Help The Hospital Readmission (sources New England Journal of Medicine, Journal of Hospital Medicine and The Commonwealth Fund) http://www.himss.org/files/himssorg/content/files/controlreadmissionstechnology.pdf

50.2% of those readmitted never had a follow-up visit with a PCP

Patients lacking PCP follow up were 10 times more likely to be readmitted (adjusted 21% readmission) versus 3% with timely PCP follow-up

About 23% of follow-up patient appointments were missing test results and medical records

About 60% of medication errors occur during transitions of care (annual cost of $3.5 billion)

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Reducing Readmissions Through Integration and Technology

Source: http://www.commonwealthfund.org/~/media/Files/Publications/Case%20Study/2011/Apr/1473_SilowCarroll_readmissions_synthesis_web_version.pdfHiMSS paper Reducing Readmissions Top Ways Information Technology Can Help The Hospital Readmission (sources New England Journal of Medicine, Journal of Hospital Medicine and The Commonwealth Fund) http://www.himss.org/files/himssorg/content/files/controlreadmissionstechnology.pdf

“Integrating hospital and outpatient care is key to reducing readmissions.”

The Commonwealth Fund

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Solution?

Need a solution to:

Enhance communication

between physicians

Create “stickiness” in your referral

network

Expand your referral footprint

Close the loop at time of discharge

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Solution: Many to Many Referrals

• Enhance communication between physicians

• Create “stickiness” in your referral network

• Expand referral footprint

• Enhance communication between physicians

• Create “stickiness” in your referral network

• Expand referral footprint

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Consult And Referral Management App

Communicate and share

data securely

Collaborate on patients

for continuity of care

Connect with providers within and outside of network

Construct a trusted

network of providers

CLOSE THE LOOP BROADCAST NETWORK CHAT INSTANTLY

Maximize revenue by

tracking referral

sources and patterns

Decide how and when

you want to receive alerts

Empower your staff to take referral actions on your behalf

Securely access your

referrals and data

from anywhere

Change the way you manage referrals

ANALYZE GET NOTIFIED DELEGATE USE ANY DEVICE

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CARMA Home Health Process Flow

Under Review

Step 2

TCM

MCC

InitiatedCase Manager Evolution

Health

Step 1

AcceptedAssign

NP

Step 3

Forward Schedule Visit

NP Visit on XX/XX

Step 4

NP

5 users, 20+ distinct actions5 users, 20+ distinct actions

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Relevant stakeholders receive real-time updatesRelevant stakeholders receive real-time updates

CARMA Process Flow: Hospice

“PANIC” Hospice Center

MIH ParamedicMedical Care Coordinator

GOALPatient remains  in 

Care Plan

HospiceNurse

Patient’s Caretaker

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Solution: Many to One Referrals

• Reduce E.D. wait times and overcrowding

• Enhance patient satisfaction

• Improve quality and continuity of care

• Reduce E.D. wait times and overcrowding

• Enhance patient satisfaction

• Improve quality and continuity of care

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Referring Medical Facility

• Primary/Specialty Clinics

• Lower Acuity Hospitals

• Urgent Care• Free Standing E.D.• Extended Care

Facilities• NH/LTAC• ALF/SNF/Rehab

Assign BedAssign Bed

Scenario: An ill patient is seen in a referring medical facility and requires hospital admission.

Hospital

House Supervisor

Direct ADMIT

Alert

Admitting Physician

AcceptAccept

Patient

Hospital Boarding

Pass

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3

2

Direct Admit System for HospitalsDASH

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Easy Access and Entry

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Real-time Communication

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Tracking

DASHBOARD

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0 1 2 4

72

84

140

27

1221

99108

170

0

20

40

60

80

100

120

140

160

180

Before and After DASH

DASH Impact on Referrals

Case Study: DASH Implementation at a 360-Bed Hospital

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Hospital Case Study360-bed, acute care transforming rural hospital45 minutes from a major city in the SouthHas 9 acute care hospitals in a 25 mile radius with the closest one < 6 miles awayHad an occupancy rate of 75% in 2013Averaged 60 direct admit patients in 2013

Main desired outcomes • Build loyalty among high volume referrers• Streamline their admission process

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Challenges Identified During DASH Implementation

Long response times – at times reached over 10 hoursBed Unavailable: Inefficient admission process Highlight other inefficiencies in admit, discharge and

transfer Peaked in the sixth month with 23 “bed not available”

responses

Implemented direct admit unit - immediate results

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DASH Results

586

1380

592

84

115

148

0

20

40

60

80

100

120

140

160

0

200

400

600

800

1000

1200

1400

1600

2013 2014 2015

Direct Admissions

Total Admissions Avg # of admissions/mo

8:51

4:393:07

0:001:122:243:364:486:007:128:249:36

2013 2014 2015

Click to Arrival Time

Click to Arrival Time

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Results*

Increased referrals from existing

sources as much as 27 percent, earning more loyalty from those who may

typically split their referrals between multiple hospitals

Reduced phone calls required to complete a direct admission by

over 90 percent

Reduced time to generate a direct admit form to 3

minutes

Captured actual key performance metrics like bed assignment

time to increase operational efficiencies

*Actual results may vary.

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What We’ve Learned

Types of referrals

Impact of unmanaged referral processes

Referral management in the U.S. – problems and solutions

Physician referrals and engagement

Use of referral management technology

Case study

Q & A

Francisco Loya, MD, MBACEO, EmCare Hospital MedicineFrancisco.Loya@emcare.com

Mirza BaigChief Technology Officer, EmCare Hospital MedicineMirza.Baig@emcare.com

Call (855) 878-7326 or visit www.emcare.com/dash