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Reducing Care Fragmentation 1

Reducing Care Fragmentation

A TOOLKIT FOR COORDINATING CARE

Contents I. Introduction 1 MS. G: A Case Study in Fragmented Care…………………………………………….1

II. The Care Coordination Model 4 Care Coordination Model……………………………………………………………………5

MS. H: A Case Study in Coordinated Care……………………………………………5

III. Change Package and Tools 8 Key Change / Activities Table……………………………………………………………..9

Accountability…………………………………………………………………………………..10

#1 KEY CHANGE: Decide as a primary care clinic to improve care coordination………………………………………………………..10

#2 KEY CHANGE: Develop a referral/transition tracking system………10

Patient Support…………………………………………………………………………………12

#3 KEY CHANGE: Organize the practice team to support patients and families during referrals and transitions……………………12

Relationships and Agreements………………………………………………………….14

#4 KEY CHANGE: Identify, develop and maintain relationships with key specialist groups, hospitals and community agencies………14

#5 KEY CHANGE: Develop agreements with these key groups and agencies……………………………………………………………………………….14

Connectivity………………………………………………………………………………………16

#6 KEY CHANGE: Develop and implement an information transfer system…………………………………………………………………………….16

IV. Case Studies 18 FAMILY CARE NETWORK: Developing Agreements between Primary Care and Specialty Groups………………………………………………………..18

GENESYS HEALTH SYSTEM: Developing Linkages with Community Resources……………………………………………………………………..20

HUMBOLDT COUNTY: Tracking Referrals through an Electronic Referral System…………………………………………………………………………………21

SAN FRANCISCO GENERAL HOSPITAL: Connectivity through Electronic Referral…………………………………………………………………………….23

OKLAHOMA SCHOOL OF COMMUNITY MEDICINE: Developing and Implementing an Electronic Consultation Platform…………………….26

V. Tools and Resources 28

Reducing Care Fragmentation: A Toolkit for Coordinating Care, is supported by The Commonwealth Fund, a

national, private foundation based in New York City that supports independent research on health care issues and

makes grants to improve health care practice and policy. The view presented here are those of the authors, and not

necessarily those of The Commonwealth Fund, its directors, offcers, or staff.

I. Introduction

Ms. G: A CASE STUDY IN FRAGMENTED CARE

Ms. G is a 58-year-old grandmother with a 15-year history of Type 2 diabetes complicated by elevated blood pressure and recurrent episodes of major depression. Ms. G has a

BMI of 37 and has struggled with weight control since young adulthood. On a recent visit to her primary care doctor for progressive fatigue and other depressive symptoms, she was found to have an HbA1c of 9.7%, a blood pressure of 190/106 and PHQ-9 score suggesting major depression despite taking an SSRI. Her PCP postponed adjusting her hypoglycemic and anti-hypertensive drug doses until her depression was under better control, and referred her to the mental health center to review and update her depression treatment. Ms. G had diffculty getting an appointment at the center, and fnally saw a psychiatrist she had never seen before. At the mental health center, her blood pressure was 220/124 and Ms. G complained of headache, as well as fatigue. The psychiatrist, who had received no information about Ms. G before seeing her, became alarmed about her blood pressure and headache, and sent her to the ER. The ER physician told Ms. G that her BP medicine was inadequate and that she needed new, more powerful medications. She was given prescriptions for two new anti- hypertensive medications, but it wasn’t clear to her what she was supposed to do with her current BP drugs or which doctor she should call. So she took them all.

One week later, Ms. G had a syncopal episode on arising from the commode. 911 was called and she was taken to the nearest hospital where she was found to have neurological defcits and admitted with a possible stroke. With adjustment of her medications in the hospital, her BP stabilized and the neurological defcits cleared, and she was sent home with an appointment at the mental health center to have her worsening depression managed. Once home, she became increasingly depressed, forgetful and dysfunctional. She didn’t have the energy to get herself to the mental health center. She became increasingly non- adherent with her medications and was found bedridden and hemi-paretic three weeks later by her daughter who became concerned when her phone calls went unanswered. She was readmitted to the hospital with a completed stroke.

Her PCP was dismayed to hear about Ms. G’s course from her daughter. He was unaware of any of the events that followed her last visit with him, and Ms. G’s daughter was stunned and angered by his ignorance.

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Care coordination, a core function of the patient-centered medical home (PCMH), has been defned as “the deliberate organization of patient care activities between two or more participants involved in a patient’s care to facilitate the appropriate delivery of health care services.”1

Though medical care is error-prone even when care is delivered by a single provider, the opportunities for serious mishaps escalate when multiple providers are involved. The case of Ms. G illustrates the perils of fragmented care involving multiple clinicians who are not effectively communicating and sharing information. Care coordination is a set of activities that is needed to minimize the dangers of fragmentation. Those activities include assuring that all providers involved in a patient’s care share important clinical information and have clear, shared expectations about their roles in care. They also include efforts to keep patients and families informed, and to optimize their experience through transitions.

American health care has many features that contribute to fragmentation of care: independent practices, limited use of electronic records and physician payment that doesn’t reward efforts to coordinate care. More recent developments, such as health plan physician networks and the separation of primary care from hospital care, have tended to erode personal relationships between primary care physicians (PCPs) and their specialist consultants and the institutions where patients get care. As a consequence, consultants frequently complain about the poor quality of information sent by referring clinicians and the inappropriateness of many referrals 2, 3, while primary care physicians often receive no information back from consultants, and are not notifed when their patients are seen in an emergency room (ER) or admitted to the hospital.3, 4 These failures in communication and care coordination—typically referred to as fragmentation— can have devastating consequences for patients, as with Ms. G.

Why is care coordination so difcult?

1. Accountability for the process is shared, which contributes to ambiguity as to who is responsible for making it work well.

2. Many PCPs no longer have the personal relationships with consultants and hospitals that make communication easier.

3. The added time and efort required to achieve an efective referral/consultation or transition is generally not reimbursed.

4. Most primary care practices do not have the dedicated personnel or information infrastructure to coordinate care efectively.

A slowly growing body of literature and reports from innovative practices and care systems are beginning to clarify the elements associated with more effective care coordination and more successful referrals and transitions.5

One of the primary goals of care coordination efforts is a high-quality referral or transition. A referral occurs when a patient requires additional, specialized care by a medical consultant or community agency, and a transition is when a patient’s overall care is being transferred between institutions, such as from the hospital back to primary care. What constitutes high quality? In our view, all patient referrals and transitions should meet the six Institute of Medicine 6 aims of high-quality health care. From this perspective, referrals and transitions should be:

� Timely: Patients receive needed transitions and consultative services without unnecessary delays.

� Safe: Referrals and transitions are planned and managed to prevent harm to patients from medical or administrative errors.

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� Efective: Referrals and transitions are based on scientifc knowledge, and executed well to maximize their beneft.

� Patient-centered: Referrals and transitions are responsive to patient and family needs and preferences.

� Efcient: Referrals and transitions are limited to those that are likely to beneft patients, and avoid unnecessary duplication of services.

� Equitable: The availability and quality of referrals and transitions does not vary by the personal characteristics of patients.

The IOM aims appropriately defne high-quality health care from a patient’s perspective. But, transitions and referrals should also meet the needs and expectations of the involved providers to be fully successful. A patient may have a very satisfying encounter with a specialist, but if the PCP fails to send relevant information or the specialist fails to communicate with the referring provider, care for that patient or others with similar problems may well suffer.

1. McDonald KM, Sundaram V, Bravata DM, et al. Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies, Volume 7—Care Coordination. Rockville, MD: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services; June 2007.

2. Cummins RO, Smith RW, Inui TS. Communication failure in primary care. Failure of consultants to provide follow-up information. JAMA. Apr 25 1980;243(16):1650-1652.

3. Gandhi TK, Sittig DF, Franklin M, Sussman AJ, Fairchild DG, Bates DW. Communication breakdown in the outpatient referral process. J Gen Intern Med. Sep 2000;15(9):626-631.

4. Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW. Defcits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA. Feb 28 2007;297(8):831-841.

5. O’Malley AS, Tynan A, Cohen GR, Kemper N, Davis MM. Coordination of care by primary care practices: strategies, lessons and implications. Res Briefs. Apr 2009(12):1-16.

6. Committee on Quality of Health Care in America, Institute of Medicine, “Crossing The Quality Chasm: A New Health System for the 21st Century”, Washington DC: National Academy Press; (2001). http://www.nap.edu/openbook.php?isbn=0309072808

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II. The Care Coordination Model

Unlike other aspects of medical care, there has been relatively little rigorous research to direct eforts to improve care coordination.

However, many innovative health care organizations have recognized the dangers of poorly coordinated care and have implemented interventions to improve it. The recommendations in this toolkit derive from both the scientifc literature, when available, and the best ideas from the feld. We have assembled the best evidence in a Care Coordination Model (Figure 1). The goal of care coordination is high-quality referrals and transitions that meet the six IOM aims for high-quality health care, and assure that all involved providers, institutions and patients have the information and resources they need to optimize a patient’s care. The Model looks at care coordination from the perspective of a PCMH. It considers the major external providers and organizations with which a PCMH must interact—medical specialists, community service agencies, and hospital and emergency facilities—and summarizes the elements that appear to contribute to successful referrals and transitions. Those elements include:

� Assuming accountability

� Providing patient support

� Building relationships and agreements among providers (including community agencies) that lead to shared expectations for communication and care

� Developing connectivity via electronic or other information pathways that encourage timely and efective information fow between providers (including community agencies)

The Care Coordination Model (Figure 1) is shown on the following page.

–

CARE COORDINATION MODEL7 (FIGURE 1)

Community Agencies

Hospitals & ERs

Medical Specialists

PATIENT CENTERED MEDICAL HOME

Accountability

Patient Support

Relationships & Agreements

Connectivity

The MacColl Institute for Healthcare Innovation, Group Health Cooperative © 010

• Involved providers receive the information they need when they need it

Practice knows the status of all referrals/ transitions involving its panel

Patients report receiving help in coordinating care

•

•

High-quality referrals & transitions for providers & patients

Ms. H illustrates what care would look like if it were coordinated in accord with the Care Coordination Model.

Ms. H: A CASE STUDY IN COORDINATED CARE

Ms. H, Ms. G’s sister, is a 55-year-old grandmother with a 12-year history of Type 2 diabetes complicated by elevated blood pressure and recurrent episodes of major

depression. Ms. H has a BMI of 36 and has struggled with weight control since young adulthood. At a check-back visit she was found to have an HbA1c of 8.9%, a blood pressure of 148/88 and PHQ-9 score suggesting minor depression. Her PCP postponed adjusting her hypoglycemic and anti- hypertensive drug doses until her depression was under better control, and referred her to the mental health center to review and update her depression treatment.

Ms. H’s doctor had previously met with the clinical director of the mental health center. The clinical director suggested that one particular psychiatrist, Dr. P, work with referrals

,

from her practice. Dr. P was shown how to log in to and use the practice’s Web-based e-referral system.

Ms. H’s doctor recommended that she not leave the offce without making an appointment with Dr. P. The receptionist/referral coordinator worked with Ms. H and the appointment clerk at the mental health center to set up an appointment that week. Ms. H missed her appointment because one of her grandchildren was ill. The e-referral system noted her missed appointment, and the referral coordinator called Ms. H to set up another appointment.

When Ms. H saw Dr. P, he had her clinical information in front of him. He adjusted her depression medication, but also found that her blood pressure was elevated. Ms. H also complained of headache and fatigue. Dr. P became alarmed about her blood pressure and headache, and arranged for her to be seen that afternoon by her PCP, who adjusted her anti-hypertensive medications. The receptionist/referral coordinator suggested that Ms. H have her BP checked by the EMTs at the neighborhood fre station every other day, which she did. Ms. H slowly began to feel less depressed and her BP slowly came down to target levels with one more medication adjustment.

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ACCOUNTABILITY

Since care coordination, by defnition, involves multiple providers and sources of services, who among those providers is accountable for assuring that “the deliberate organization of patient care activities” takes place? Obviously, all providers must collaborate, but establishing the conditions and infrastructure for assuring quality referrals and transitions is a core responsibility of the PCMH. All primary care offces currently devote some time and energy to managing referrals. Back offces often contain stacks of charts with “yellow sticky notes” indicating the need for a referral or additional information requested by a consultant or health insurance company. In contrast, practices that assume responsibility and make an effort to coordinate care try to develop the relationships, infrastructure and processes that support successful referrals and transitions. Referrals are more likely to be successful if referring providers and consultants understand each other’s expectations and preferences, and referring practices have the staff and information infrastructure to help patients and their information get where they need to go. Patients and their families can help ensure effective and effcient referrals if they are adequately informed and supported to play an active role.

The accountability for assuring quality transitions rests primarily with the discharging institution and providers (e.g., hospitals and hospitalists, ERs and emergency physicians). But, transitions may also go in the opposite direction as when the PCMH arranges a hospitalization, or one of their patients needs nursing home care. Because of the critical importance of reducing ER and hospital care, PCMHs must try to work with area hospitals and ERs to increase the likelihood that they will receive timely, useful information when their patients are admitted and discharged. Hospitals vary considerably in their efforts to identify and contact PCPs, but many have responded positively when asked to share admission and discharge information.

An important component of assuming accountability is having the ability to track referrals and transitions to assure their successful completion. Referral tracking is made easier if there is an information system that records important landmarks in the referral process (e.g., referral appointment made, patient information received, appointment completed, consultation note returned).

Tracking referrals means developing a paper or electronic database that records all referrals made and key landmarks toward their successful completion. Whether paper or electronic, a useful referral tracking system will include: patient name, patient ID number, diagnosis, brief reason for referral, consultant name, insurance status, referral request status (sent, received), appointment date (if made), required pre-appointment tests, appointment completion, consultation note received, post-consultation care (e.g., consultant follow-up visits, specialist-to-specialist referral, return to primary care). E-referral systems generally facilitate referral tracking. To track transitions, the PCMH will have to regularly receive timely information about its patients’ admissions and discharges from hospitals, emergency rooms, and other institutions. Transition tracking should in most cases include early PCMH contact with the recently hospitalized patient and/or patients’ family, as some evidence suggests that early post- discharge follow-up prevents readmission.

PATIENT SUPPORT

Referrals and transitions challenge patients and families. They raise questions that need to be answered, generate appointments that need to be made, and produce logistical challenges and anxiety that need to be addressed. Practices that dedicate staff time to meeting these patient needs are more likely to have successful referrals and transitions. These care coordination patient support functions are sometimes confused or confated with clinical functions such as care management, because in some practices a nurse or other care manager provides support functions in addition to her clinical care management responsibilities (i.e., clinical assessment and follow-up, self-management support, or medication management). While care managers generally focus on a small, very sick subset of a practice population, almost, if not all, referrals and transitions within the PCMH would beneft from some degree of active coordination. We urge that patient support for care coordination be considered separately from clinical care management, although care managers do and should provide care coordination support for their high-risk patient panels. In many practices, patient support is provided by a referral coordinator who:

� Identifes and attempts to resolve any logistical or fnancial barriers to completing a referral

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� Helps get timely appointments

� Assures the transfer of clinical information

� Tracks progress and assists patients encountering difculties

Patient support is especially critical for coordinating the care of children with ongoing behavioral and/or physical problems. The special requirements of care coordination for these children have been well described by Antonelli, McAllister, and colleagues. 7, 8

RELATIONSHIPS AND AGREEMENTS

Referrals and transitions work best when all parties— patients, primary care providers, and consultants—agree on the purpose and importance of the referral, and the roles that each will play in providing care. As close, personal relationships between PCPs and specialists or hospital staff have become less and less common9, PCMHs would be wise to initiate conversations with their key specialist consultants or hospitals to discuss each other’s preferences and expectations. The sorts of issues and expectations that might be considered in such conversations include:

� Types of patients referred—many specialists have developed criteria for the patients they prefer to see

� Information provided at time of referral

� Notifcation of the PCMH of ER visits and hospitalizations

� Testing to be completed prior to referral—if PCP’s complete a specialist’s preferred laboratory testing prior to the referral, it increases the value of the consultation and reduces possible duplicate testing

� Availability for “curbside consults”

� Consultation report content and timeliness

� Post-consultation care expectations—need discussion to prevent unhappiness among providers because expectations weren’t met (e.g., specialist assumes care when PCP only wanted advice, or specialist returns patient and advice when PCP wanted to transfer care)

� Post-ER or hospitalization care expectations

� Specialist-to-specialist referrals—many PCP’s do not want specialists to refer their patients to other specialists without frst consulting with the PCP.

These conversations can result in agreements that can be codifed in writing or programmed into electronic referral systems. Such agreements seem to be critical to reducing unnecessary referrals, avoiding duplicated assessments, and assuring optimal post-referral or post-hospital care. Building relationships takes time and effective leadership to open necessary communication channels, but rewards practices with quality referral experiences over time.

CONNECTIVITY

A critical predictor of a successful referral or transition is assuring that the involved providers have the information they need to optimize care and a trustworthy way of communicating. On the one hand, PCPs need to be sure that consultants know the reason for a referral and have the necessary information to provide optimal service. On the other hand, consultants must provide information back to the PCP that addresses her questions and concerns. And providers should keep patients informed and confdent that all the providers involved are communicating with each other. The presence of an electronic referral (e-referral) system can help assure that this critical information fow occurs in a timely way. E-referral systems can incorporate agreed upon guidelines for referrals and transitions that prevent unnecessary ones and assure that consultants and PCPs get the information they need. These goals can also be accomplished with pencil and paper approaches to structuring and standardizing referral requests and consultation notes, and using FAX machines or telephone calls to communicate. Assuring effective connections between providers should be discussed as part of an agreement.

7. Antonelli RC, McAllister JW, Popp J. Making Care Coordination a Critical Component of the Pediatric Health System: A Multidisciplinary Framework The Commonwealth Fund; May 2009.

8. McAllister JW, Presler E, Turchi RM, Antonelli RC. Achieving effective care coordination in the medical home. Pediatr Ann. Sep 2009;38(9):491-497.

9. Pham HH, O’Malley AS, Bach PB, Saiontz-Martinez C, Schrag D. Primary care physicians’ links to other physicians through Medicare patients: the scope of care coordination. Ann Intern Med. Feb 17 2009;150(4):236-242.

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III. Change Package and Tools

Practices wanting to improve the coordination of their care should consider making changes to practice systems and processes consistent with the four elements described above—accountability, patient support, relationships and agreements, and connectivity.

These four represent high-level “change concepts,” which the Institute for Healthcare Improvement defnes as “general ideas…that can be adapted to make specifc changes that lead to improvement in many processes and clinical areas” and in aggregate, make up the “change package” for better care coordination. But, to be useful, suggested changes to a practice must be more specifc. The following table identifes the six key changes in the Care Coordination Model, as they apply to each change concept, and the specifc activities involved in making the key change. Related tools and resources that might be of help are located in the Tools and Resources section (section V) of this document, on page 28. The key changes are described more fully in the text that follows the table.

Table starts on the following page.

ACCOUNTABILITY

Key Changes Activities

#1 Decide as a primary care clinic to improve care coordination.

Develop a quality improvement (QI) plan to implement changes and measure progress.

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