Strategies to Increase Access and Reduce Demand for Specialty Care

Transcription

1 Strategies to Increase Access and Reduce Demand for Specialty Care CPCA Annual Conference Community Clinics and Health Centers: Transforming the Future of Health Care October 6-7, 2011 Vision The Specialty Care Access Initiative is a partnership between the Council of Community Clinics and the San Diego County Medical Society Foundation to reduce the demand for and increase access to specialty care for community clinic patients. Vision: All uninsured and underinsured patients in San Diego County will have timely and appropriate access to specialty care. This will require a collaboration of: - Community clinics and health centers -Private specialty care providers - Hospitals and health care systems - County of San Diego - Other safety net providers Purpose Identify barriers to specialty care access and demand Establish solutions to increase specialty care access and reduce demand Distribute knowledge about barriers and solutions Create an advocacy strategy for needed change 1

2 Current Barriers Long duration of time between the primary care appointment and specialist appointment Lack of transportation Expensive cost Intimidation in seeing a physician outside of community clinic Potential language barriers Priority Areas DR. PENGO Dermatology Rheumatology Pain management Endocrinology Neurology Gastroenterology Orthopedics Strategies Coordinate econsults between primary care physicians (PCPs) and specialists by phone, or videoconference to determine whether a patient needs to be referred Provide education for PCPs on specialty care topics including procedures, Lunch and Learn sessions, and on-line education via internet or videoconferencing Partner with Project Access San Diego to link uninsured clinic patients with volunteer physicians Place volunteer or paid specialists in clinics to provide specialty services Develop referral guidelines to help PCPs determine if a referral is needed, diagnostics to be completed prior to the referral, and documentation to be included with the referral Standardize data collection and reporting with integration to clinic information systems 2

3 Strategy # 1 econsultsd is funded by Kaiser Permanente and Blue Shield of California Foundation Launched January 18, 2011 in San Diego Modeled after successful implementation in San Francisco, Orange and Los Angeles counties Sample results from UCSF: 41% of visits with an endocrinologist were not necessary after an econsult Need for streamlined systems to prepare for healthcare reform econsultsd allows a community clinic PCP to articulate a clinical question to a volunteer specialist regarding patient care and receive a timely response. Secure, HIPAA compliant website Allows for asynchronous, -type communication between a community clinic PCP and a volunteer specialist Communication takes the form of a virtual curbside consultation Patient is not involved in the communication, strictly between PCP and specialist Goals: Increase timely communication between PCPs and specialists Decrease number of referrals to specialists Improve pre-visit work-up for those patients who are referred to specialists 3

4 How it Works Community Clinic PCP has question(s) regarding a specific patient s care PCP logs on to econsultsd, poses a question to a specialist, attaches relevant medical information econsultsd volunteer specialist logs on and answers question or recommends that patient be referred to a specialist for face to face visit PCP and specialist have a web-based dialogue pertaining to the question PCP provides follow-up care to patient or sends patient to a specialist if necessary Who is Involved? Community Clinic Primary Care Physician Initiates the question Provide ongoing care to the patient Allows them to have timely access to a curbside consultations in a variety of specialties econsultsd volunteer specialist Provides consultation as a volunteer (Phase 2 may include payment structure) SDCMSF will be recruiting volunteers, targeting big groups Allows them to give back to the community in small, manageable way without commitment of taking a new patient Patient econsult takes place without the patient s involvement Patient receives accessible, timely care without needing a specialty visit If specialty visit is required, all pre-work is complete Successes # of community clinics 12 # of primary care physicians 85 # of mid-levels and medical staff 39 # specialist volunteers 10 # specialties

5 Challenges Usage has been lower than expected (24 econsults during pilot Working on strategies to remind clinics that resource is available Next Steps Additional training for providers and staff Create single sign-on and/or alerts in clinic EMRs to remind providers Integrate with payors (County, health plans) Add physician networking feature Strategy # 2 Provider Education Goal is to increase PCP capacity to perform minor procedures at the community clinic Reduces face to face visits with specialists 5

6 Opthalmology Emergencies March 16, CMOs in attendance Dr. Mihir Parikh, opthalmologist and Project Access volunteer, was instructor Goal: To educate PCPs on common eye emergencies and effective treatments Dermatology Webinars March 31 and April 14, providers have viewed to date Recorded and available online for providers Lecture given by Dr. Kempiak from UCSD Goal: To educate PCPs on clinical indications of dermatological conditions and appropriate treatments Dermatology Webinars 6

7 Joint Injection Workshop April 15, PCPs in attendance 5 orthopaedic surgeons from Kaiser as instructors Goal: Used cadavers to increase PCP confidence in performing joint injections on shoulders and knees Joint Injection Workshop Training evaluations indicate that 78% of PCPs feel very comfortable or completely comfortable performing knee and shoulder injections after this training. Dermatology Minor Surgery Workshop July 31, PCPs in attendance 6 instructors, including 5 P.A.s from Kaiser, Dr. Schultz, CMO of Neighborhood Healthcare, and Dr. Walter Nahm, a dermatologist and Project Access volunteer Goal: To educate PCPs on how to perform shave and punch biopsies and suturing 7

8 Dermatology Minor Surgery Workshop Strategy # 2 Provider Education Successes Average # of joint injections after training 12 per provider Average # of dermatology minor procedures after training 3 per provider Challenges - Lack of time - Decreased PCP confidence after 1 training - Clinic staff not trained on procedure set-up - Complex patients Next Steps - Host refresher courses - Host workshops with clinic staff Strategy # 3 Project Access San Diego Project Access San Diego (PASD) links low-income, uninsured community clinic patients with specialty physicians, hospitals, surgery centers, and ancillary service providers who donate their time and expertise to provide specialty care for this population at no cost Launched July 2009 Eligibility Guidelines: - Adult resident of San Diego County - Must live under 350% of the Federal Poverty Level - Must not qualify for public assistance like Medi-Cal or County Medical Services - Must be referred by a community clinic 8

9 Strategy # 3 Project Access San Diego 2,100 specialty care consultations 900 patients served 12 lives saved $3.3 Million in donated healthcare services 565 physician volunteers 9 hospitals and 14 surgery centers About the October 23, 2010 Super Saturday Patients Served: 35 uninsured San Diego Residents Surgery Types: 20 surgeries, 15 colorectal screenings Value of Donated Services: $495,236 in Donated Care to PASD Patients 9

10 About the March 26, 2011 Super Saturday Patients Served: 36 uninsured San Diego Residents Surgery Types: 15 surgeries, 21 colorectal screenings Value of Donated Services: $173,462 in Donated Care to PASD Patients Patient Stories I didn t know what to do. My options are limited because of my financial situation. I can t thank you enough for considering me for a free laparoscopy inguinal hernia repair surgery; it s like winning the lottery. Strategy # 4 - Standardize Referral Process Convene roundtables Develop referral guidelines Standardize data definitions Referral Volume Denials Wait Time No Show Convene Referral Coordinator Meetings 10

11 Referral Challenges Issue Failure to include pertinent clinical information with the referral Lack of fields in referral tracking systems Failure to review referral data Failure to close the loop Solution Provided referral staff with guidelines that included documents to send with referral Added appointment date and no show status fields Referral data reviewed and discussed at meetings Track consult report Successes Referral Volume Identify high volume specialty referrals Administrative tool to support staffing Wait Time Identified regional differences Best practice sharing Referral Coordinator meeting Standardization allowed for comparisons Contact Information Christy Rosenberg, Executive Director, Council of Community Clinics - Phone: crosenberg@ccc-sd.org Barbara Mandel, Executive Director, San Diego County Medical Society Foundation - Phone: Barbara.Mandel@SDCMS.org Jim Schultz, CMO, Council of Community Clinics, Project Access, Neighborhood Healthcare - Pager: jims@nhcare.org Lauren Banfe, Resource Development Director, San Diego County Medical Society Foundation - Phone: Lauren.Banfe@SDCMS.org Lynne Farrell, Quality Manager, Council of Community Clinics - Phone: lfarrell@ccc-sd.org 11