Improving Access to Specialist Care

JCC Showcase February 24, 2016

Dr. Ken Gin, MD, Division Head, Cardiology, VGH, Clinical Professor, UBC

Dr. Joy Russell, MD, Vancouver Division of Family Practice

Moe Baloo, DC, MHA, Providence Health Care

Shared Care Cardiology-Family Medicine Working Group

Purpose: To improve collaboration, cooperation, and communication between Cardiologists and Family Physicians

Objectives:

• Streamline the cardiac patient journey

• Improve the Cardiology-FP Referral Process (including timely acknowledgment and triage)

• Clarify SP-FP roles, responsibilities, and expectations

• Improve Consultation and Follow-up

• Enhance Cardiology-FP relationships

Priority-Setting Exercise:

From our discussions so far, what are your biggest priorities?

Priority 1 - Referral Process • Triaging • Avoiding duplication • Referral acknowledgement • Referral options

Priority 2 - Roles and Responsibilities

• Clarity around co-management • Who is responsible for what? • Whose patient is this?

Priority 3 - Consultation and Follow-up

• Consultation letter • Clarity is provided and questions are answered • Trust that bi-directional follow-up will occur

Priority 1 - Referral Process

• Overarching goal is to improve communication and coordination around cardiology referrals:

• In particular:

o Acknowledgement of receipt of the referral within 7 days or less

o Triage referrals based on risk

o Provide specialist appointments within 1-3 weeks

o Speed up consult letter with a target of 72 hours

o Implement a common referral form, first within Vancouver, then across VCH

Why Those Particular Goals?

Survey Results of FP’s Reporting Challenges with Referral Process

Source: Marla Steinberg, Ph.D., June, 2015

Common Referral Form • Key elements include options

to refer directly to a specific cardiologist or outpatient clinic at VGH, SPH, LGH, and RH

• Currently, each clinic (~30) uses its own referral form

• Referral Acknowledgment is embedded and a SP or clinic fax-back is requested within 72 hours (3 business days)

CARDIOLOGY REFERRAL

REFERRING PROVIDER:

GP NP ED Specialist (specify)

Name:

MSP #:

Address:

Phone:

Fax:

Date:

PATIENT INFORMATION

Name:

PHN: Male

DOB: (dd/mmm/yy) Female

Address: Transgender

City: Province:

Postal code: Email:

Home phone #

Cell:

Work:

Language(s) spoken:

~If this patient does not speak English, please ask them to bring an interpreter~

Outpatient Inpatient – site:

REFER TO: Specific Cardiologist: ____________________ OR Specialty Clinic (See page 3 for clinic information)

SEVERITY OF SYMPTOMS: Severe Moderate Mild Asymptomatic

URGENCY:

If unsure of urgency, call the RACE line at 604-696-2131

Emergent (Immediate to 24 hours) Call Cardiology or send to ED

Urgent (within 2 weeks) Reason:

Semi-Urgent (within 4 weeks)

Elective (an attempt will be made to see patient within 12 weeks)

Has this patient been seen by a Cardiologist before? No Yes

Name: Date: Is this a Re-referral? No Yes

REASON FOR REFERRAL:

Please include recent relevant medical history, See attached: Consult notes Medication list medication records, investigations and lab results. Lab results Allergies/Drug Intolerances

PREVIOUS

INVESTIGATIONS:

Done Date Attached Not Done Comments

Chest x-ray

ECG

Exercise tolerance test

Holter Monitor

Cardiac Echo

Coronary angiogram

Cardiac CT/MRI

MIBI test

Other Cardiac tests

This referral will be triaged by cardiology staff. For prompt booking, please ensure all sections are fully completed.

ACKNOWLEDGEMENT OF REFERRAL (to be completed within 72 hours)

Our office will make an appointment with your patient within the next (days or weeks)

Your patient is booked to see a specialist on: Date: Time:

We will notify your patient of the above appointment Please notify your patient of the above appointment

We require the following additional information before we can book an appointment for this patient:

Common Referral Form

• The form also serves as an education piece for family physicians, NP’s, and other specialists by providing a concise description of services provided at each clinic

Referral Form Evaluation Summary

• 72 referrals were faxed between January 1 – March 31, 2015

• 75% were acknowledged

• Average time to acknowledgement was 5 days (range 0 to 26 days)

42% were within 72 hours

• Average time to appointment was 34 days

• 82% of the referrals went to a specific cardiologist

• 18% went to a VGH or SPH cardiology ambulatory clinic

Evaluation Summary (Based on pre- and post survey questions)

• All FP’s reported an increased knowledge of

cardiology services in Vancouver

• 38% of SPs said that referrals contained more complete information compared to 6% prior to the form

• Overall, 67% of FPs and 62% of SPs said the referral process had improved when using the form

Nice to get acknowledgment back in a timely

manner (GP)

It feels better that it’s actually

received and triaged (GP)

Challenges & Next Steps

• How do we ensure continued support from five distinct tertiary sites?

• How do we ensure patient care is kept ‘closer to home’?

• How can we improve the process for both the referring physician and receiving specialist? (EMR integration, etc.)

• How do we know if we’ve truly improved timely access to specialist care?

Thank you.

Questions?