Coordinating care
in medical practices
p
Ann S. O’Malley, MD, MPH
Interventions to improve coordination
Academy Health
June 29, 2010
How are we using the term
“Coordination of Care?”
I
Integration
i off care across allll off a person’s:
’
 Conditions & health needs
 Providers & settings
 Family & caregivers
 Community services, e.g. home health
2
Study 1: How are practices trying to
coordinate care?
Background: Calls to improve coordination, but little guidance
Goal: Identify practices
practices’ challenges,
challenges strategies & facilitators
“Bottom up approach”
R
Respondents:
d t 62 clinicians
li i i
ffrom 36 PC & S
Spec practices
ti
& TL
1. Notices on ACP, AAFP listservs
2 Referrals from thought leaders (TL)
2.
We asked about coordination strategies:




Within the primary care practice
Between PC & other specialists/services
Between outpatient & inpatient settings (Transitions)
With community based services (few examples)
3
Study
y 1: Challenges
g to Coordination
 Lack of payment for coordination=“No Time”
• Opportunityy costs for resources spent = lost revenue
• “Culture of non-communication & non-ownership”
 Insufficient staff to help with coordination tasks
 Disruptions in continuity of care with PCP
• Patient self-referrals and spec-spec cross-referrals
• Changes
g in plan provider networks, insurance
 Health plan provider networks
• Inconsistent with PCP-spec.
p
trusted working
g relationships
p
• Administrative burden
4
Study 1: How Practices Promote
Coordination of Care for Patients
 Commitment
C
to continuity with PCP/Team
C /
 Enlist patient/family in coordination
 Trusted
us ed working
o
g relationships
e a o s ps be
between
ee PC
C & Spec
 Increase efficiency to make time for coordination
 Standardize particular coordination processes
 One size may not fit all
 Leadership, culture, and aligned $$ incentives
5
Study
y 2: Current EMRs & Coordination
Goal:
Examine whether & how ambulatory care practices
use commercial EMRs to support coordination tasks
Respondents:
• 60 providers
id
ffrom 26 practices
ti
iin 12 CTS (Community
(C
it
Tracking Site) markets & national thought leaders
• Practices with commercial EMR for > 2 years
• Smaller-Medium size practices emphasized
6
Study
y 2: Key
y Findings
g
 EMRs facilitate coordination within a practice via
ed ate data access, instant
sta t messaging
essag g
immediate
 EMRs less able to support coordination between
practices & settings due to inadequate data
standards poor interoperability,
standards,
interoperability low penetration
 Office work-flow changes necessary to maximize
EMRs’ potential to support coordination (à la AHRQ)
7
Study
y 2: Key
y Findings
g ((continued))
 “Work-arounds”
common (See JGIM article)**
e.g. problem lists, performance reporting, referral tracking
 Redundant, unorganized printouts challenge end-
user trying
t i to
t identify
id tif critical
iti l info
i f for
f coordination
di ti
 EMRs do not capture dynamic coordination process
 FFS encourages EMR documentation for billing
 Need standardized data that can be “pushed back” to
medical home from other providers to pop
pop. EMR
8
What do findings imply for HITECH’s
support of coordination of care?
Need systematic
y
structures, tools & processes
p
for
info. creation, transfer, receipt & recognition by
the sending
g & receiving
g clinicians.
Measures off “M
M
“Meaningful
i f l HIT U
Use”” could
ld include
i l d
items that support, track and confirm completion of
coordination
di ti tasks.
t k
9
Can findings help inform PPACA
implementation around coordination?
Strategies described have potential to improve
coordination if aligned with payment incentives/supports
PPACA:
Better align payment with coordination goals:
 PC Payment boosts
 Public and private sector demonstrations & grants
- Med Homes-Support for coordination as described
- ACOs-Align incentives to create mechanisms for
PC/specialists/hospitals/community services to coordinate
- State level grants for teams/coordination
Increase PC workforce-Can’t coordinate care without providers
10
Thanks to
Funders: CMWF & HCFO
Collaborators:
Joy Grossman, Hoangmai H. Pham,
Genna Cohen,
Cohen Nicole Kemper,
Kemper Matthew Davis
R
Respondents:
d t Clinicians
Cli i i
and
d thought
th
ht leaders
l d
11
Additional information
www.hschange.org
EMR Coordination Study in JGIM can be found at:
http://www.hschange.org/CONTENT/1104/OMalley.pdf
Editorial: http://www.hschange.org/CONTENT/1104/Bates.pdf
Coordination Research Brief can be found at:
http://www.hschange.org/CONTENT/1058/1058.pdf
aomalley@hschange.org
12
End of Academy
y Health Presentation
 Extra slides follow with more details
 Links to full articles listed: slide 12
13
Study
y 1: Strategies
g
Within PC practice
p
 Emphasis
E h i on continuity
ti it with
ith specific
ifi clinician
li i i
 Care coordinators (Med Asst to RN-SW)
RN SW)
 PC Teams, Pods
 Role definition and training of all team members
 Restricting panel size
 Practices contract services they cannot provide
 Systems for phone triage & direct physician access
 Specialized programs for high risk patients
14
Study
y 1: Facilitators Within PC Practice
 Involve
I
l patient/family
ti t/f il iin coordination
di ti
• Medications, Self-management, ID self- & cross-referrals
 Care
C
Plans
Pl
 Standardization of particular processes
ex. How lab results reported to patients
 Planned care visits w pre
pre-visit
visit prep & post-visit
post visit f/u
 Huddles (à la IHI, Health Partners, Bodenheimer, C. Sinsky, Wagner)
 Complexity
C
l i screener prior
i to initial
i i i l visit
i i (Pediatric)
(P di i )
 HIT
15
Study 1: Strategies & Facilitators
between PCP & Specialists
Strategies:
 Limiting referral network to “trusted” relationships
 Shared
Sh d Care
C
Pl
Plans-patient
ti t heavily
h
il involved
i
l d
 Referral Tracking Systems
 PCP-Specialist Service Agreements
 E
E-referrals
referrals (see Hal Yee’s
Yee s work)
(see Antonelli’s work)
Facilitators:
Well constructed referral/consultation notes
Real-time communication between providers
Enlist patient in information transfer
Shared EMR
16
Study
y 1: Strategies
g
& Facilitators-Transitions
 Link & Share Care Plan with ED*
 PCP-Hospitalist communication
 Care Transitions Program
(à la Coleman et al; Naylor et al)
Facilitated by:
 S
Shared
a ed financial
a c a incentives
ce
es & staff
sa
17