Coordinating Referrals Effectively (Text Version)

On September 27, 2010, Carol VanDeusen Lukas made this presentation at the 2010 Annual Conference. Select to access the PowerPoint® presentation (200 KB). 

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Slide 1

Coordinating Referrals Effectively → CORE

Carol VanDeusen Lukas, EdD
Boston University Safety Net ACTION Partnership

Funded by AHRQ ACTION under contract HHSA2902006000012 TO6

September 27, 2010

Slide 2

CORE team

• BUSPH/BMC central team:
  • Carol VanDeusen Lukas, EdD, BUSPH, PI
  • Mari-Lynn Drainoni, PhD, BUSPH, co-PI
  • Charles Williams, MD, BMC Family Medicine, clinical redesign lead
  • Andrea Niederhauser, MPH, BUSPH, project manager
• Clinical redesign team members:
  • Christine Odell, MD, BMC Ambulatory Care Center
  • Joseph Peppe, MD, South Boston Community Health Center
  • Stephen Tringale, MD, Codman Square Health Center
  • Ronald Iverson, MD, BMC Department of Obstetrics and Gynecology
  • Francis Farraye, MD, BMC Department of Gastroenterology
• AHRQ task order officers
  • Claire Weschler, MSEd, CHES
  • Mary Barton, MD, MPP

Slide 3

Project aim: To improve referral processes between Primary & Specialty care

• AHRQ-sponsored ACTION task order
• Using SUTTP principles
• Five clinical sites
  • Two specialty clinics:
    • Obstetrics and Gynecology (OB/GYN)
    • Gastroenterology (GI)
  • Three family medicine primary care sites:
    • Codman Square Health Center
    • South Boston Community Health Center
    • BMC Family Medicine Ambulatory Care Clinic (ACC)

Slide 4

Clinical redesign process

• Regular meetings with clinical redesign team to conduct the work of redesign
  • MDs + with periodic participation of senior referral staff
• Meetings early in process with providers & with referral staff in each site for input
• Periodic meetings to brief health center clinical leaders + HealthNet + BMC clinical leaders/administrators

Slide 5

Why redesign?

• Current referral system fragmented; varies among & between primary care sites & specialties
• Patients often unclear about reason for referral, how to make appointment, what to do after seeing specialist
• Specialists do not consistently receive clear reason for the referral or adequate information on tests already done
• Primary care physicians do not receive information about outcome of referral visit
• Referral staff cope with multiple discordant processes & lost information

Slide 6

Intended benefits

• For patients—clearer instructions & improved timeliness
• For primary care providers & specialists—consistent, complete information from the other & clear outline of follow-up care plans
• For referral staff—a standard method of processing referrals & clear outline of handling no-show appointments
• For all parties—feedback on how the system is working for ongoing process improvement

Slide 7

Redesigned system: primary care standard elements

• Patient contact number
• PCP name
• PCP pager
• Appointment needed by date
• Diagnosis
• Reason for referral/ question
• Labs included
• Patient handout printed

Slide 8

Redesigned system: specialist standard elements

• Referral receipt & provider acknowledged
• Diagnosis provided, question answered
• Follow-up plans indicated for:
  • Patient
  • Specialist
  • PCP
• Note signed by specialist within 2 weeks & available in electronic records in PCP office

Slide 9

Redesigned system: building it into practice

• CORE standard elements embedded in:
  • Referral form from PCP to specialist
  • Letter from PCP to patient
  • Consult report from specialist to PCP
• Service agreement among participating practices
• CORE user tools
  • CORE summary sheet
  • Referral guidelines
  • Desk guide

Slide 10

Developing the implementation process

• Work to fit with existing structures & systems
• Clinical redesign team members—the clinicians in the participating sites—
  • Help design the implementation process
  • Play key roles in carrying it out
• Clinical redesign team lead has ongoing relationships with sites and with organizational leaders

Slide 11

Implementation process with users

• Introduce new system at regular provider meetings
  • Clinical redesign team members are local implementation leads
  • Written materials to support presentations
• Review with administrative & referral staff
• Make adjustments based on feedback
  • Initial meetings and follow-up conversations
  • Clinical redesign lead makes technical changes
• Provide feedback after two-month trial implementation

Slide 12

Progress after trial implementation: primary care

Image: A table shows the following data:

	CSHC		SBCHS		BMC ACC
	n	%	n	%	n	%
% used CORE form	329	100%	155	100%	47	23.7%
# referrals audited	119		72		29
% use of CORE standards
patient contact #	54	45.3%	63	87.5%	18	62.1%
PCP name;	40	33.6%	69	95.8%	29	100.0%
pager #	20	16.8%	21	29.2%	3	10.3%
appointment needed by date	41	34.4%	26	36.1%	15	51.7%
diagnosis/reason for referral	116	97.4%	70	97.2%	29	100.0%
question asked	11	9.2%	35	48.6%	16	55.2%
labs included	8	6.7%	0	0.0%	NA	NA
patient handout printed	7	5.8%	3	4.2%	0	0.0%

Slide 13

Progress after trial implementation: specialty care

Image: A table shows the following data:

	OB/GYN;		GI;
	n	%	n	%
# reports audited	15		10
% CORE table completed	2	13%	3	30%
% use of CORE standards
referral receipt acknowledged	8	53%	8	80%
referring provider acknowledged	7	47%	10	100%
diagnosis provided;	14	93%	10	100%
question answered	1	25%	4	100%
care plan stated	15	100%	10	100%
patient follow-up plan indicated	7	47%	7	70%
PCP follow-up plan indicated	1	7%	3	30%
specialist follow-up plan indicated	5	33%	5	50%
note signed by specialist within 2 weeks	14	93%	10	100%
note available in logician at health center	2	13%	0	0%

Slide 14

Implementation challenges: ...a work in progress

• Influence of electronic medical records
  • Overlapping development & implementation of e-Referrals
  • Working in larger hospital system
• Difficult organizational environment
• Provider resistance

Slide 15

Overlapping development & implementation with e-Referrals

• Some success in building CORE changes into e-Referrals system
• But, CORE implementation challenged by:
  • Confusion at front-line between CORE & e-Referrals
  • E-Referrals roll out problems delay CORE
  • Some desired CORE changes could not be accommodated
  • Monitoring reports generated by e-Referrals limited

Slide 16

Working in a larger hospital system

• ACC clinic records part of larger hospital system
• Limits to possible EMR changes in ACC because all providers across hospital use same system
• CORE cannot simply replace forms
  • CORE not default, have to select from menu
• CORE referral form difficult because of limited text box capacity

Slide 17

Difficult organizational environment

• New BMC CEO
• Massachusetts health reform changes state financing at great loss to BMC
• Several reductions in force in course of project
• Restructuring in BMC ACC
• High stress levels from hiring freeze, diminished service capacity, leadership changes

Slide 18

Provider resistance

• In addition to previous challenges...
• Providers hard to get together
• Hard to convince of mutual benefits of new system
• Chose path of least resistance
  • On PCP side, patient letter not automatic

Slide 19

Role of project team in implementation

• Central project team:
  • Facilitated process, audited data, provided tools
  • Met regularly with clinical redesign leads to troubleshoot
  • After two months, full team met to address ambiguities, clarify some elements, remove others
• Clinical redesign leader provided TA, modified systems directly working closely with sites
• Clinical redesign leads provided feedback to their colleagues supported by audit data, crib sheet of why each element important & talking points

Slide 20

Continuing steps

• Feedback to providers and referral staff
• Feedback from providers and referral staff
• Brief clinical and administrative leaders
• Develop system for ongoing monitoring

Slide 21

On reflection...

• Clinical redesign team membership
• Life goes on in the organizations
• Iteration, adaptation and continued discovery