COORDINATING REFERRALS EFFECTIVELY CORE

Carol VanDeusen Lukas, EdD

Boston University Safety Net ACTION Partnership

Funded by AHRQ ACTION under contract HHSA2902006000012 TO6

September 27, 2010

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CORE teamBUSPH/BMC central team:

Carol VanDeusen Lukas, EdD, BUSPH, PIMari-Lynn Drainoni, PhD, BUSPH, co-PICharles Williams, MD, BMC Family Medicine, clinical redesign leadAndrea Niederhauser, MPH, BUSPH, project manager

Clinical redesign team members:Christine Odell, MD, BMC Ambulatory Care CenterJoseph Peppe, MD, South Boston Community Health CenterStephen Tringale, MD, Codman Square Health CenterRonald Iverson, MD, BMC Department of Obstetrics and

GynecologyFrancis Farraye, MD, BMC Department of Gastroenterology

AHRQ task order officersClaire Weschler, MSEd, CHESMary Barton, MD, MPP

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Project aim: To improve referral processes between Primary & Specialty care

AHRQ-sponsored ACTION task orderUsing SUTTP principlesFive clinical sites

Two specialty clinics: Obstetrics and Gynecology (OB/GYN) Gastroenterology (GI)

Three family medicine primary care sites: Codman Square Health Center South Boston Community Health Center BMC Family Medicine Ambulatory Care Clinic (ACC)

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Clinical redesign process

Regular meetings with clinical redesign team to conduct the work of redesign MDs + with periodic participation of senior referral staff

Meetings early in process with providers & with referral staff in each site for input

Periodic meetings to brief health center clinical leaders + HealthNet + BMC clinical leaders/administrators

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Why redesign?Current referral system fragmented; varies among &

between primary care sites & specialties

Patients often unclear about reason for referral, how to make appointment, what to do after seeing specialist

Specialists do not consistently receive clear reason for the referral or adequate information on tests already done

Primary care physicians do not receive information about outcome of referral visit

Referral staff cope with multiple discordant processes & lost information

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Intended benefits

For patients – clearer instructions & improved timeliness

For primary care providers & specialists – consistent, complete information from the other & clear outline of follow-up care plans

For referral staff – a standard method of processing referrals & clear outline of handling no-show appointments

For all parties – feedback on how the system is working for ongoing process improvement

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Redesigned system: primary care standard elements

Patient contact number

PCP name

PCP pager

Appointment needed by date

Diagnosis

Reason for referral/ question

Labs included

Patient handout printed

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Redesigned system: specialist standard elements

Referral receipt & provider acknowledged

Diagnosis provided, question answered

Follow-up plans indicated for:PatientSpecialistPCP

Note signed by specialist within 2 weeks & available in electronic records in PCP office

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Redesigned system: building it into practice

CORE standard elements embedded in:Referral form from PCP to specialistLetter from PCP to patient Consult report from specialist to PCP

Service agreement among participating practices

CORE user toolsCORE summary sheetReferral guidelines Desk guide

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Developing the implementation process

Work to fit with existing structures & systems

Clinical redesign team members – the clinicians in the participating sites – Help design the implementation processPlay key roles in carrying it out

Clinical redesign team lead has ongoing relationships with sites and with organizational leaders

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Implementation process with users

Introduce new system at regular provider meetingsClinical redesign team members are local

implementation leadsWritten materials to support presentations

Review with administrative & referral staff

Make adjustments based on feedback Initial meetings and follow-up conversationsClinical redesign lead makes technical changes

Provide feedback after two-month trial implementation

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Progress after trial implementation: primary care  CSHC SBCHS BMC ACC

n % n % n %

% used CORE form 329 100% 155 100% 47 23.7%# referrals audited 119   72   29

% use of CORE standards

patient contact # 54 45.3% 63 87.5% 18 62.1%

PCP name 40 33.6% 69 95.8% 29 100.0%

pager # 20 16.8% 21 29.2% 3 10.3%

appointment needed by date 41 34.4% 26 36.1% 15 51.7%

diagnosis/reason for referral 116 97.4% 70 97.2% 29 100.0%

question asked 11 9.2% 35 48.6% 16 55.2%

labs included 8 6.7% 0 0.0% NA NA patient handout printed 7 5.8% 3 4.2% 0 0.0%

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Progress after trial implementation: specialty care  OB/GYN GI

n % n %# reports audited 15   10  % CORE table completed 2  13% 3 30%% use of CORE standards

referral receipt acknowledged 8 53% 8 80% referring provider acknowledged 7 47% 10 100% diagnosis provided 14 93% 10 100% question answered 1 25% 4 100% care plan stated 15 100% 10 100% patient follow-up plan indicated 7 47% 7 70% PCP follow-up plan indicated 1 7% 3 30% specialist follow-up plan indicated 5 33% 5 50% note signed by specialist within 2 weeks 14 93% 10 100% note available in logician at health center 2 13% 0 0%

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Implementation challenges: ….a work in progress

Influence of electronic medical records Overlapping development & implementation of e-

ReferralsWorking in larger hospital system

Difficult organizational environment

Provider resistance

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Overlapping development & implementation with e-Referrals

Some success in building CORE changes into e-Referrals system

But, CORE implementation challenged by:Confusion at front-line between CORE & e-ReferralsE-Referrals roll out problems delay CORESome desired CORE changes could not be

accommodatedMonitoring reports generated by e-Referrals limited

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Working in a larger hospital system

ACC clinic records part of larger hospital system

Limits to possible EMR changes in ACC because all providers across hospital use same system

CORE cannot simply replace forms CORE not default, have to select from menu

CORE referral form difficult because of limited text box capacity

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Difficult organizational environment

New BMC CEO

Massachusetts health reform changes state financing at great loss to BMC

Several reductions in force in course of project

Restructuring in BMC ACC

High stress levels from hiring freeze, diminished service capacity, leadership changes

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Provider resistance

In addition to previous challenges …

Providers hard to get together

Hard to convince of mutual benefits of new system

Chose path of least resistanceOn PCP side, patient letter not automatic

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Role of project team in implementation

Central project team:Facilitated process , audited data, provided toolsMet regularly with clinical redesign leads to

troubleshootAfter two months, full team met to address

ambiguities, clarify some elements, remove others

Clinical redesign leader provided TA, modified systems directly working closely with sites

Clinical redesign leads provided feedback to their colleagues supported by audit data, crib sheet of why each element important & talking points

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Continuing steps

Feedback to providers and referral staff

Feedback from providers and referral staff

Brief clinical and administrative leaders

Develop system for ongoing monitoring

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On reflection…

Clinical redesign team membership

Life goes on in the organizations

Iteration, adaptation and continued discovery