Continuity of Care Implementing Compacts: A small practice journey

Transcription

1 Continuity of Care Implementing Compacts: A small practice journey R. Scott Hammond, MD Chair, CAFP PCMH Task Force Medical Director, SOC-PCMH Grant, Colorado Associate Clinical Professor, Dept. of Family Medicine UCHSC Westminster Medical Clinic, Westminster, Colorado --PCMH Level 3

2 Continuity of Care Paradigm

3 Continuity of Care Informational continuity Every provider caring for patient has access to accurate information about patient s previous care. Relational or interpersonal continuity On-going relationship between the patient and the clinicians chosen by the patient as his/her usual source of care. Geographic continuity Delivery of care in multiple locations by a team of clinicians chosen by and known to the patient.

4 Systems Of Care-PCMH Grant, Planning Phase Colorado Research and Development Systems of Care Poll (700 responses/10,725 physicians) Focus groups SOC-PCMH Summit Action Plan Implementation Phase Outreach, Promotion, Education of the PCMH and Medical Neighborhood Evaluation Phase

5 Colorado Systems of Care Poll -10/09 PCP Specialty Aware of PCMH Very familiar/somewhat 80% 38% Concept of PCMH Extremely/Very important 72% 76% Definitely/probably will become PCMH after reading description 56% Willing to meet with PCP 79% Communication satisfaction with facilities Total/very satisfied Staff finds other office cooperative - Always/regularly Receives necessary information -- Always/regularly PCP included in care by specialist 36% 15% 21% 40% 54% 51% 36% Specialist care plan supported/followed by PCP 70%

6 Colorado SOC-PCMH Summit and Action Plan Summit Practice constraints and loss of personal relationships impede effective hand-offs and clinical communication Both PCPs and specialists wish to improve this relationship. Action Plan Focus on improving physician culture and communication Engage specialty societies, focus groups Develop Primary care-specialty care compact to standardize communication and expectations. Develop informational continuity with medical facilities. Pilot standards

7 Geographic continuity Primary Care Specialty Care Compact Research Working models (Kaiser, QHN) Literature (Chen, Forrest, JHU, COPIC) ACP, TransforMed, NCQA Development of Working Model 4 PCPs ( 3 PCMH FPs, 1 IM) 4 specialists (Cardiology, Oncology, Surgery, Endocrinology) Testing

8 Primary Care-Specialty Care Compact Purpose and Principles Definitions Types of Care Transition Service Agreement Transition of Care Access Care Management Medical Collaboration Patient communication Transition of Care Records (PCP and Specialist)

9 Primary Care-Specialty Care Compact Types of Care Transition Pre-consultation exchange Formal consultation Co-management (Referral) With Shared management With Principle Care Complete transfer of care (Specialty Medical Home Network) Emergency Care

10 Service Agreement Transition of Care Transition of Care Mutual Agreement Maintain accurate and up-to-date clinical record. Agree to standardized demographic and clinical information format such as the Continuity of Care Record [CCR] or Continuity of Care Document [CCD] Ensure safe and timely transfer of care of a prepared patient Expectations Primary Care Specialty Care PCP maintains complete and up-to-date clinical record including demographics. Transfers information as outlined in Patient Transition Record. Orders appropriate studies that would facilitate the specialty visit. Informs patient of need, purpose (specific question), expectations and goals of the specialty visit Provides patient with specialist contact information and expected timeframe for appointment. Determines and/or confirms insurance eligibility Provides single source referral contact person When needed, be ready to communicate with the PCP prior to the appointment to assist in the preparation of patient. Communicates appropriate pre-referral workup to PCP, as needed. Additional agreements/edits:

11 Service Agreement PCP Patient Transition Record 1. Practice details PCP, PCMH level, contact numbers (regular, emergency) 2. Patient demographics -- Patient name, identifying and contact information, insurance information, PCP designation and contact information. 3. Diagnosis -- ICD-9 code 4. Query/Request a clear clinical reason for patient transfer and anticipated goals of care and interventions. 5. Clinical Data Problem list Medical and surgical history Current medication Immunizations Allergy/contraindication list Care plan Relevant notes Pertinent labs and diagnostics tests Patient cognitive status Caregiver status Advanced directives List of other providers 6. Type of transition of care. 7. Visit status -- routine, urgent, emergent (specify time frame). 8. Follow-up request

12 Geographic continuity Hospitals CO PCMH Pilot: Hospital Subgroup committee Patient Identifier information wallet card PCMH ID Patient education and educational materials from health plans Bidirectional communication Care Coordination Form (hospital to PCP) ED Referral Form (PCP to hospital)

13 Geographic continuity Hospitals Care coordinator job description and communication policy List of facilities and contact personnel Informational continuity Daily census of admits, discharges, updates (hospitals, hospitalists, IPA) Post hospital transition (discharge care plan) ED/in-hospital medical information transfer

14 Patient Admission Friday, July 24, 2009 Patient presents to hospital SELF REFERRAL Patient presents to hospital FROM OFFICE Clinic: Medication notes faxed to hospital from PCP Hospital: to inform PCP office fax, phone, ? Clinic: Care Coordinator to fax medical info Emergency Room Admission to Floor Hospital: to notify of Admission to Hospitalist Hospital: to provide updates regarding patient progress Hospital: ER Notes faxed to Providers office Discharged Home Hospital: Case Manager to notify PCP office and proved care plan Discharged to Skilled Nursing Facility Discharged to Long Term Care SNF: to notify PCP -? Change PCP Appointment with PCP/Specialist Discharged to Home SNF: to notify and send discharge to PCP Color Key: Hospital Action Green Clinic Action Blue SNF Action Red Page 1

15 Geographic continuity -- WMC Referrals Specialist Report Card (adapted from Clinix) Preferred Specialist List PCMH Patient Referral Form (Specialist Rx) Specialty Compact

16 It can get dirty but change can be good

17 WMC Team