Primary Care and Specialty Care

Transcription

1 Challenges in Referral Communication between VHA Primary Care and Specialty Care Jessica Zuchowski PhD, MPH VHA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy Academy Health Annual Research Meeting June 9, 2014

2 Background More primary care visits result in referrals to specialty care, patients are receiving care from multiple providers Care coordination is important Primary-specialty relationship: quality of communication is foundational Known communication facilitators in US healthcare: Integrated delivery system Shared electronic medical record (EMR)

3 Background (continued) Veterans Health Administration (VHA) is a large integrated system 8 million veterans 800 care delivery sites nationally VHA has used an EMR since the 1990 s A complete record of care delivered by all VHA providers Multiple authors, shared across all VHA sites Still persistent variation in the quality of primaryspecialty care communication in VHA

4 Objectives To characterize communication challenges perceived by primary care team members and leaders in VHA To assess variations in ease of primaryspecialty communication as reported by VHA primary care providers (PCPs)

5 Setting Study based in VHA clinics across one regional network: Southern California i and Southern Nevada 2010: VHA initiated iti t primary care transformation in the form of a Patient Centered Medical Home (PCMH) Primary Care-Mental Health integration Mental Health services integrated into primary care clinics Goal: enhance care coordination through the integration of primary and specialty care

6 Study Design: Mixed Methods Qualitative: Semi-structured interviews with primary care team members and leaders characterizing primary-specialty communication challenges Quantitative: Web-based cross-sectional survey measuring PCP-reported ease of communication with specialists Data collected in 2 separate, concurrent aspects of a larger project studying the implementation of the PCMH

7 Qualitative Data Collection Semi-structured interviews with VHA PCPs, primary care nurses, clinical and regional leaders, and other key stakeholders within the regional network Participants were identified by job title and role in PCMH implementation

8 Qualitative Analysis Keyword Review: Systematic manual review to identify interviews i that t contained any of four separate truncated keywords: special, refer, consult consult, mental Relevance Analysis: Identified interviews reviewed in their entirety; relevant sections analyzed for emergent themes that appeared in the data repeatedly; checked by a second analyst Synthesis: Results synthesized by comparing/contrasting key findings related to primary-specialty i communication

9 Qualitative Results: Sample 97 total interviews Keyword Review: 95 interviews contained 1 or more of f4k keywords Relevance Analysis: 41 interviews contained content relevant to primary-specialty communication Analytic sample: 41 interviews

10 Qualitative Results EMR represents primary way in which PCPs communicate with specialists PCP: There s no direct communication most of the time [with specialties]. It s by the consult [in the EMR]. It s what you write. To be perfectly honest, it is specialty-dependent. Some specialties are better than others.

11 Qualitative Results (continued) Interviewees reported common problems communicating with specialists via the EMR platform Difficulty communicating requests for appointments within a certain timeframe RN: Sometimes they [the patients] have to be seen sooner and they give me an appointment [through the EMR]. [I think] oh, that s way too long. Frequent rejection of referral requests RN: Every time I make a consult then it was denied. I said, Well why was that denied? So now I have to go back and find out why my consult was denied because we didn t go through three steps first. PCP: There's so many barriers to consulting some specialists and it s a hassle. A good example is a PSA that s elevated. You have to do all this [for the consult] and then order a different PSA because they want it. But it s obvious it s too elevated. If it s 40 or 50, there s no reason to do another one.

12 Qualitative Results (continued) Interviewees reported strategies to work-around the EMR challenges Telephone and contact with specialists with whom the PCPs had pre-existing relationships PCP: I put in a [EMR] consult but there s this kind of lack of trust, between primary care and specialty clinic. So I actually made it a point to stay late and wrote a summary and ed the department head, who I happen to know, and that way I made sure he [the patient] got an appointment. MH Provider: Some PCPs we worked really closely with, people that we had almost like personal relationships where somebody could call and say, I know who I m calling and I have a question, and dthat tseemed dto work really well, versus other PCPs who are kind of out of that loop and were having to go through the [EMR] consult service.

13 Qualitative Results (continued) EMR-based referral innovation: e-consults PCP: E-consults tend to be very responsive right away because we don t need to see the patient. That is helpful. l So, if you have a question you don t think the patient needs to be seen, if you have a question, you do the e-consult, he [the specialist] responds right away.

14 Quantitative Methods: Survey Sample and Data Source Web-based based cross-sectional sectional survey measuring PCP- reported ease of communication with specialists Sampling frame: all VHA PCPs from the regional network Item: How easy it is for you to communicate with the following types of health services providers? List of 18 specialties grouped into 4 categories Medical, Surgical, Population, Other 3pt. Scale: Not At All/Somewhat/Very Easy

15 Quantitative Analysis Dichotomized the response options into very easy or somewhat easy versus not at all easy Tabulated descriptive summary statistics of percentages of very/somewhat easy communication for each specialist type Survey non-response addressed through calculation l and application of non-responder weights based on job title and site

16 Quantitative Results Of the 356 PCPs invited, 191(54%) participated in the survey and responded to our questions of interest

17 PCPs indicating very/somewhat easy communication i (%) Medical subspecialists Surgical specialists Cardiothoracic Population specialists Geriatrics Women s health HIV/AIDS Other Specialists Neurology Mental/Behavioral l

18 PCPs indicating very/somewhat easy communication i (%) Medical subspecialists Surgical specialists Cardiothoracic Population specialists Geriatrics Women s health HIV/AIDS Other Specialists Neurology Mental/Behavioral l

19 PCPs indicating very/somewhat easy communication i (%) Medical subspecialists Surgical specialists Cardiothoracic Population specialists Geriatrics Women s health HIV/AIDS Other Specialists Neurology Mental/Behavioral l

20 PCPs indicating very/somewhat easy communication i (%) Medical subspecialists Surgical specialists Cardiothoracic Population specialists Geriatrics Women s health HIV/AIDS Other Specialists Neurology Mental/Behavioral l

21 Discussion Poor primary-specialty communication is a persistent problem that varies by specialty May be explained by primary care s pre-existing connections with some specialties Population specialties Mental health integration Hypothesis: When PCPs and specialists have more opportunities for contact, t they build faceto-face familiarity that facilitates communication

22 Limitations The regional scope of the study is confined to one regional network and may not be generalizable to other VHA networks or settings outside VHA An earlier national survey of VHA primary care directors found similar rates of frequent primary- specialty interface problems This study is primarily from the perspective of PCPs and does not consider the specialist side of the communication dyad Additional studies are needed with specialists

23 Implications EMRs can be improved to facilitate optimal PCP-specialist communication Accommodate special cases/exceptions Reduce rejection of referral requests Minimize need for EMR work-arounds As VHA develops e next generation e of EMR,,there e are plans to incorporate features that will facilitate bidirectional provider-to-provider communication Our findings reinforce importance of these features Highlight the need for other integrated health systems to prioritize these features

24 Implications (continued) Some elements of direct provider-to-provider interface may always be necessary Collaborative nature of referral communication Highly case-specific nature of knowledge E-consults: a virtual mechanism for hallway conversations Building relationships between PCPs and specialists may also facilitate referral communication

25 Acknowledgements Data collected under the Veterans Assessment and Improvement Laboratory (VAIL) VAIL PI Dr. Lisa Rubenstein VAIL Evaluation Lead Dr. Elizabeth Yano VAIL (XVA ) is funded by VA Primary Care Services The opinions expressed in this presentation are those of p p p the author and do not necessarily reflect the views of the Department of Veterans Affairs.

26 Danielle E. Rose, PhD, MPH 1 Alison B. Hamilton, PhD, MPH 1, 2 Susan E. Stockdale, PhD 1, 2 Lisa S. Meredith, PhD 1, 3 Elizabeth M. Yano, PhD, MSPH 1, 4 Lisa V. Rubenstein, MD, MSPH, FACP1, 3, 5 Kristina M. Cordasco, MD, MPH, MSHS 1, 5 ¹VHA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, Sepulveda, CA 2 Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at UCLA, Los Angeles, CA 3 RAND Corporation, Santa Monica, CA 4 UCLA Fielding School of Public Health, Los Angeles, CA 5 Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA jessica.zuchowski@va.gov