Exploring Ideas for Improving Care Coordination

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Exploring Ideas for Improving Care Coordination

• Eric A. Coleman, MD, MPH
• Associate Professor
• Divisions of Geriatric Medicine and
• Health Care Policy and Research
• University of Colorado Health Sciences Center

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4 Key Areas for Change

• Develop systems to notify patients of test
  results
• Develop processes for better communication
  between primary and specialty care
• Medication reconciliation
• Coordination outside of office hours

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Lab Result Management
Where no news is not necessarily good news
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Burden of Test Result Management

• Per week, full-time PCP needs to review
• 360 chemistry results (SMA7 7)
• 460 hematology results
• 12 pathology reports
• 40 radiology reports

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Physician Perspective

• 43 of physicians surveyed report being satisfied
  with the way they manage test results
• 83 report experiencing a delay in reviewing lab
  results with potential to adversely affect care
• Implications for
• Efficiency
• Safety
• Risk management

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The Black Hole??

• 25 of physicians routinely inform patients of
  normal lab results
• 67 of physicians routinely inform patients of
  abnormal lab results
• 24 had a reliable system for identifying
  patients overdue for f/u labs

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What Can We Learn from the Literature?

• 33 of abnormal TSH values do not receive timely
  follow-up
• 36 of abnormal pap smear are lost to follow-up
• 25 malpractice claims due to failures in
  follow-up

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Lab Management3 Main Steps

• Retrieve and review results
• Communicate and interpret results to patients
• Incorporate findings into care plan

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Break It DownTest Results

• Protocol for normal results, no action required
• Protocol for normal results, action required
• Protocol for abnormal results no action required
• Protocol for abnormal results action required
• Protocol for abnormal results urgent action
  required
• Protocol for detecting when test not obtained

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Communication Strategies

• Pre-formatted letters for sharing results with
  patients on paper
• Portal to EMR to allow patients to view once MD
  as released
• Phone calls for abnormal results
• E-Visits for abnormal results (with appropriate
  time compensation)

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Lab Tracking Tools

• Paper Forms
• EHRS/EMR
• Patient Portal/web access (after MD releases)
• MS Access
• MS Outlook

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Using MS Outlook to Track Labs

• Most clinics already have the software
• Low cost approach
• free self-guided tutorial
• However, all tracking systems require up front
  time
• Track a test from the time it was ordered to the
  time that the results are given to the patient
  using built-in features
• Will provide reminders or warnings when a task is
  overdue or a test has not returned
• Can also generate mailing labels to mail results
  to patients

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Improving the Referral Process
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Communication Breakdown

• Lack of clarity over reason for referral
• Disruption in continuity of care
• Delayed diagnosis
• Unnecessary/duplicative testing
• Dissatisfaction by all parties

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Generalist/Specialist Communication

• Specialists report receiving information 32 of
  the time
• Generalist report getting referral letter 55-80
  of the time
• Patients are a silent partner who may
  self-refer

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Two to Tango

• 63 of PCPs dissatisfied
• 35 of Specialists dissatisfied
• Room for improvement on both ends

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Improving the Referral Experience

• Redesign flow of information
• Referral agreements between IPA and Practice
• for how communication will occur
• Clearly stated referral questions and answers
• Friendlier consultant letter format
• State preferred method of communication

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Referral Agreements

• Service requested
• Evaluation
• Evaluation and initial management
• Evaluation and ongoing management
• Procedure
• Second opinion
• Other

• Reason for referral
• Preferred communication
• Fax
• Email
• Voicemail
• Mail
• Other

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Care Coordination Out of the Office
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Develop a Flow Chart or How To Guide for Clinic

• How do I get an appointment?
• How do I get my labs?
• How do get I care from specialists?
• How do I get care after hours?

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After Hours

• Flow diagramcare seeking after hours
• Answering machine that says go to ED not
  acceptable
• Dont have too solve problem 100--call back in a
  few hours to see how they are doing
• Initiate first steps of therapy (UTI,
  hyperglycemia)
• Malpractice concernsneed documentation

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Out of HoursTelephone Charting
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Move to Action!

• What is the status quo in your clinic?
• What advice would your patients give us?
• What have you tried?
• What went well?
• What did you learn?
• What will be your next PDSA?
• What tools or resources will you need?

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Medication Reconciliation
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Medication ReconciliationWhat Are We Looking For?

• Create a single list
• Identify discrepancies (incompatible regimens)
• Drug/Diseasepertinent positives and negatives
• Drug/Drugmost common, most serious

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Engaging the Patient

• Encourage patient to bring all medications or
  list to every encounter
• Provide with a dedicated tote bag
• Keygt must positively reinforce behavior
• Initial MA or RN review

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Scripting Patient Care

• Coach or give permission to speak up
• Every time a prescriber takes out a prescription
  pad, ask would you like to see my medicine list
  or will this new medication interfere with my
  current meds?

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Personal Health Record
Reason Side Effects _____________
_________________ ______________________________ _
_____________________________ ____________________
__________ ______________________________ ________
______________________ ___________________________
___ ______________________________ _______________
_______________ ______________________________ __
____________________________
My Medications are Medication
Dose ______________________________ ______________
________________ ______________________________ __
____________________________ _____________________
_________ ______________________________ _________
_____________________ ____________________________
__ ______________________________ ________________
______________ Allergies _____________________
Remember to take this Record with you to all of
your doctor visits