Won’t You Be My Neighbor? Marjie Harbrecht, MD Chief Executive Officer 400-526707 1
U.S. Health Care • Great Skills • Great Science • Poor Integration / Coordination • Fragmented - Silos • Misaligned Incentives • Culture
PCPs - Raise Your Hand if these issues are common in your practice 1. You don’t know the specialist you’re referring patients to 2. Specialists say they don’t get needed information 3. Patients complain specialist didn’t know why s/he was there 4. Tests you’ve already performed are duplicated 5. You don’t hear back from a specialist after a consultation 6. A referral doesn’t answer your question 7. Your patient doesn’t come back to see you after a consultation or is referred to another specialist 8. You are unaware that your patient was seen in the ER/ Hospital.
Specialists - Raise your hand if these have occurred in your practice: 1. You don’t know the provider that referred the patient 2. You aren’t clear what question you’re supposed to be answering. 3. The patient doesn’t know why s/he was there. 4. You don’t get sufficient information with the referral – (i.e., pertinent history, workup done, etc) 5. You can’t access results from tests already performed. 6. You don’t get follow up on a patient you were concerned about.
You’re Not Alone! • PCPs report sending information 70% of time; specialists report receiving it 35% of the time 1 and 68% of specialists reported receiving no information from pcp prior to referral visits • Specialists report sending a report 81% of the time; PCPs report receiving it 62% of the time 1 • 28% of primary care and 43% of specialists are dissatisfied with the information they receive from each other (Gandi et. al. J Gen. Int. Med. 2000) 1 O’Malley, A.S., Reschovsky, J.D. (2011) Referral and consultation communication between primary care and specialist physicians: finding common ground. Arch Intern Med, 171 (1), 56-65.
Patient Reports for Poor Coordination Nearly Half Report Failures to Coordinate Care Percent U.S. adults reported in past two years: Specialist did not receive basic medical 13 information from primary care doctor Primary care doctor did not receive a 15 report back from a specialist Test results/medical records were not 19 available at the time of appointment Doctors failed to provide important 21 medical information to other doctors or nurses you think should have it No one contacted you about test results, 25 or you had to call repeatedly to get results 47 Any of the above 0 20 40 60 Source: Commonwealth Fund Survey of Public Views of the U.S. Health Care System, 2008.
Why Make Care Coordination A Priority? • Patients and families hate that we can’t make this work. • Multiple care plans - conflicting information • Poor hand-offs lead to delays/confusion - patient safety issues • Enormous waste from unnecessary referrals and duplicate testing • It will make all of our work more effective • Everyone will be happier! Source: Ed Wagner, MD – MacColl Institute
As The Environment Swirls Around Us…
Push for Integration • Market Consolidation • Hospitals buying physicians • Large physician groups forming • Integrated systems growing • Regardless of where you end up, this work needs to be done! 10
Fear – Skepticism - Old Baggage? • How will this effect my income? • Is this managed care in drag? • Is this a plan to decrease referrals? • Will I get dumped on with all the hard patients? • “Things are just fine the way they are….”
Déjà vu… All Over Again? • What’s different from Managed Care days? • Practice and community redesign • No-one taught us how before • Gatekeeper to Gateway • Better tools (Technology) to coordinate care • Patient sophistication and engagement • Aligning incentives for ALL to work together • Quality + Affordability + Experience • Realization that no one can do this alone! 12
When Teams Don’t Work Well… 13
U.S. Men's Basketball Falls Flat on World Stage By David DuPree, USA TODAY August 15, 2004 ATHENS- “This is the Olympics, and the U.S. men's basketball team was rocked, shocked, humiliated and exposed on sports biggest stage Sunday as Puerto Rico, a Commonwealth of 4 million residents, pulled off the upset of all Olympic upsets with a 92-73 drubbing of the Americans.” Most SKILLED players in the world - What went wrong?? GREAT PLAYERS vs. GREAT TEAM
Individual Choice VS Team Efficiency
Team Work??
When Teams Work Well… 17
The Achievements Of An Organization Are The Results Of The Combined Efforts Of Each Individual -- Vince Lombardi
20
Some Reasons Why This Ain’t Easy • The typical primary care physician has 229 other physicians working in 117 practices with which care must be coordinated. Pham et. al Ann Int Med. 2009 • In the Medicare population, the average beneficiary sees seven different physicians and fills upwards of 20 prescriptions per year Partnership for Solutions, Johns Hopkins Univ. 2002
Culture - It’s Misaligned No Just Not Incentives Systems Important Sorry, I’m not No time paid to do this!
Ideal State • Shared “community” vision • Shared data – timely, actionable, in usable format • All patient information available at point of care • List of those needing services - for outreach • Aggregated across community to identify target areas for improvement and monitor progress • Shared Care Plans • Everyone that touches patient on the same page… including the patient/family 23
Integrated Community Care (Accountable Care Organizations) Provided Courtesy of Premier Healthcare Alliance 24
Ultimately, working together to assist patients in achieving the highest level of health they can, preventing problems BEFORE they occur! 25
First Step: Create A Shared Vision 27
The Discussion • Mutual respect of what each brings to the table • Recognition of the value of role differentiation • Appreciation of primary care as foundation (“quarterback”) • Specialty skill sets as important and complimentary • Acknowledgement of a flawed system • Longing for more “professionalism” • Better communication, consideration, cooperation and integration • Always return to: Patient Centered Care
Identify Pain Points – Work Toward Solutions and Common Goals Solutions • Many misconceptions & wrong assumptions • PCP thought it best to make the appt for patient but specialist knew that was associated with high No Show rate. • Specialist thought they were helping by referring on to another….. • Beware of the powerful lure of status quo
PCMH-Neighbor Model - Framework
Patient-Centered Medical Home (PCMH) An approach to providing high-quality, safe, continuous, coordinated, comprehensive care, with a partnership between patients and their personal health care team… (“The Quarterback”) 31
“Won’t You Be My Neighbor?” Medical Neighbor (PCMH-N) A clinician that collaborates with a PCMH or another medical neighbor to participate in the care team to enhance bi-directional communication and collaboration on behalf of the patient. Integrated Co-located Referral based 32
Key Elements Patient-Centered extension of team care (team members working for what is best for the patient) • Access – appropriate and timely consultations • Coordination • Define roles - clarify who’s doing what? • Clear Communication • Define expectations • Ensure effective flow of information - pre/post referral • Ensure ALL understand, including patients/caregivers Keep fluid (dynamic) to adapt to changes in patient or disease status 33
Otherwise Stated: A framework so that patients neither fall through the cracks nor get duplicated services Safe – Effective – Efficient
Coordination Gaps With and Without Medical Homes in Past 2 Years Percent* 100 Medical home No medical home 80 59 57 60 54 53 51 49 49 42 42 41 41 36 40 33 33 32 32 31 30 30 25 20 20 15 0 AUS CAN FR GER NETH NZ NOR SWE SWIZ UK US Test results/records not available at time of appointment, doctors ordered test that had already been done, providers failed to share important information with each other, specialist did not have information about medical history, and/or regular doctor not informed about specialist care. Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries. 35
Examples of Agreements/Checklists American College of Physicians (ACP) Carol Greenlee MD FACP FACE Neil Kirschner, PhD www.acponline.org Systems of Care Workbook Scott Hammond, MD 36
Models for Establishing Agreements/Compacts • One-on-one • System-wide “adoption” (all players) • Unilateral approach • Medical Center / Specialty Practice (“this is how we agree to work with those who refer to our center/practice”)
NCQA’s Specialty Practice Recognition 2013 Release date: March 2013 Applications accepted: June 2013 NCQA’s Specialty Practice Recognition 2013 ~ Draft Standards ~ 38 October 2012
Prepared Patient Patient aware of and in agreement with referral with appropriate expectations
Patient Wallet Card 40
Can This Really Happen? 41
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