Deliverable #14: Referral Protocols and Benchmarks MLK MACC PRESENTED TO LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES

Deliverable #14: Referral Protocols and Benchmarks MLK MACC PRESENTED TO LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES APRIL 30, 2008

Introduction Based on its experience with public hospitals throughout the nation, it has been a priority of Health Management Associates (HMA) from the start of the engagement with the LA County Department of Health Services (DHS) to fully understand the referral process into and out of the MLK MACC. While it is critical to have the appointments available for referrals, the steps by which patients (or their primary care givers) request and receive those appointments, the priority that certain patients are given because of their need for those appointments, the communication between specialists and referring primary care providers and the transmittal of diagnostic information and consultant reports are as important as appointment availability. This work for HMA was led by senior people with extensive clinical and administrative experience in establishing effective and efficient referral systems within large public health care systems. HMA facilitated several group meetings with the PPP clinics in SPA 6 which had generated MLK-appointed referrals in the last quarter of FY 2006-07, including: Compton Central Health Clinic, Sacred Heart Family Medical Clinics, Inc., St. John s Well Child and Family Center, Inc. University Muslim Medical Association, Inc., and Watts Healthcare Corporation. In addition, HMA interviewed and spent time with the referral team at Hubert Humphrey Comprehensive Health Center, since they are the single largest referral source into the MACC. AT MLK, HMA interviewed the former nurse manager from its Referral Center to better understand staffing and operations issues from this perspective and spent considerable time with the MLK staff responsible for the referral process. HMA had several meetings with senior staff in its Office of Ambulatory Care to better understand its responsibility to the PPPs and the initiation of the RPS referral system. Finally, HMA met with the leadership of the Office of Managed Care as well as the leadership of LAC+SC and Harbor-UCLA to discuss potential opportunities for increasing appropriate referrals into the MLK MACC. The purpose of this deliverable to gather into one place all of the notes, observations and ideas gathered over the past four months (some of which appeared in part in past deliverables) in assessing the MLK referral process and structure and to make recommendations for priority steps to be taken to assure that patients in most need to get into the MACC are able to do so. Current Referral System Issues MLK MACC Referral Center The MLK Referral Center has developed and documented referral processing protocols and systems. While most of the systems are manual and inefficient, many are functional and allow for processing a high volume of referrals. While the referral processes are clearly sub-optimal and protocols for timeliness are not met, there are resources that, if redirected, could certainly better meet the demand. Health Management Associates 2

Historically, the Referral Center has received specialty and diagnostic referrals from community clinics via fax or mail. While they have started the transition to the RPS for outside referrals, they currently use a lotus notes tracking system which has limited capability; identifying the status of a received referral is done manually. An RN case coordinator reviews for urgency and appropriateness. For closed clinics, (e.g., GI, neurosurgery, endocrinology) specialists do this manual review. A large binder of referral guidelines is used to determine appropriateness and the binder is provided to all referring health centers (although the nurse manager admits the referring health centers probably never refer to the binder.) If the referral is rejected, a letter has been sent to the patient and provider. If the referral is accepted, the appointment is scheduled and the referral center updates the tracking system. The Affinity system generates a letter to the patient to inform of the appointment; a copy of the letter is to be sent to the referring provider organization. The Referral Center calls patients with urgent referrals to inform them of their appointment. Given demand and staff limitations, the protocol is not consistently followed. The MLK Referral Center went live with the electronic RPS referral system November 7, 2007. All DHS CHCs and Public Private Partner (PPP) sites in the MLK SPA are currently connected to the system, although internal campus referrals have not yet started to utilize RPS. Since inception, the monthly RPS referral volume has risen from 633 referrals in November, to 806 in December, and 1,214 in January 2008. The top demanded clinics include Cardiology, G.I., Dermatology and ENT. Hubert Humphrey is the largest referring site into MLK specialty services, with Dollar Hide and Harbor- UCLA following. Referral Processing The MLK Referral Center has now had several months experience with RPS and has implemented the basic work flow of the system. Incoming referrals are reviewed administratively by RNs twice daily in the morning and afternoon. Each referral is examined individually on line for completeness and general appropriateness during this process. At this point the referral may be denied if inappropriate or sent back to the referring provider if additional information is needed. Alternatively, the referral may be approved or assigned to clinical review. If the RN approves the referral, it is assigned directly to a Referral Center clerk for appointing (for so-called open clinics). Referrals assigned for clinical review are assigned to a specific specialty reviewer (for so-called closed clinics). Referrals needing clinical review are printed along with any other accompanying diagnostic work up and hand delivered and dropped off for the specialist to review for acceptability. The specialist may approve, deny or send the referral back to the referring provider for additional information. The Referral Center staff will process the referrals accordingly. Health Management Associates 3

An analysis of January 2008 Pending RPS Referrals report showed that of 1214 total referrals received, 100% had been reviewed administratively by Referral Center nurses. Eighty one per cent had either been approved, cancelled or denied, and 253 or 19%, were pending processing for approval. Of the 253 still pending, 173 were in Clinical Review awaiting review by the specialist. 28 were in Requested Additional Information. 39 were Pending Submit or Saved Submit and not yet really in the Referral Center s hands. 9 were in Administrative Review Assigned. In summary, the Referral Center administratively reviewed 100% of the incoming referrals. The biggest bottleneck of referrals occurred with the clinical review process, and ideally could be streamlined by Referral Center nurses having a greater degree of triage responsibility and control. The second largest bottleneck occurred with Additional Information requested, which was mostly related to G.I. referrals. Having the specialist pre-requisites on line and clearly disseminated to referring providers could help decrease this significantly. Referrals approved for appointing may be given appointments directly by the Referral Center clerks. However, a number of specialties control their own scheduling. In these circumstances, the Referral Center must drop off approved referrals for the specialty clinics to designate appointments and pick them up later for processing completion in RPS. An analysis of the January RPS Approved Appointments report indicated that of 868 approved referrals, 215 were pending appointment scheduling. This delay in scheduling may have been due to changes in specialty clinic templates that occurred at the time, but also could reflect associated delays with local control over scheduling. With enhanced Referral Center control of appointment scheduling this may be minimized. Priority Referral Processing The Referral Center currently receives several different groups of handwritten referrals to process. Hubert H. Humphrey Comprehensive Health Center (HHHCHC) faxes priority referrals needing timely specialty appointments. The overall quality of these referrals is compromised due to illegibility, incomplete clinical and demographic documentation, inability to soundly track faxes, and inappropriateness. Referral Center nurses have been reviewing and entering them into RPS for tracking and work flow follow up. This is a cumbersome process, requiring phone follow-up to get effective data and added time for referral entry into RPS. This could be alleviated by elimination of faxes and entry of priority referrals directly into RPS by the referring site, with special designation of priority written in the reason for referral. The Referrals can be examined in the Administrative Review process when received by the Referral Center nurses and handled accordingly if appropriate. The development of guidelines for Health Management Associates 4

priority referrals by the specialist at MLK could help with improving appropriateness of the referrals and facilitate timely processing/triage by referral center nurses. MLK Campus Referrals Providers at the MLK campus are not on RPS and don t use the Referral Center for facilitating the majority referrals to specialty care. They use a variety of mechanisms to attempt to place referrals to specialty care, including direct phone calls to specialists, calls to specialty clinic staff or giving the patient clinic phone numbers or location for scheduling appointments themselves. A handwritten referral is created, which may have limited quality. Tracking the success of these referrals to the specialist is not possible manually. Often these patients are seen without the referring documentation reaching the specialist or the specialist knowing where the patient is from. Consequently the consult report is not sent back and continuity of care and communication is compromised. Identifying true demand on specialty services becomes problematic. In addition, a number of specialty services not available at MLK are regularly sought at Harbor-UCLA MACC by MLK providers. Currently handwritten referrals to Harbor are sent to the MLK Referral Center for processing. The nurses pull associated lab and diagnostic work up, enter the referrals in RPS, track them in a paper file and send copies of work done to referring providers. This is an inefficient process. Implementing RPS amongst MLK providers could address the above difficulties, and improve quality and patient care. Specialist Consult Reports The MLK Referral Center has taken ownership of getting consult reports back to referring providers for all RPS referrals. A work flow is in place that includes delivery of the printed RPS referral for all upcoming specialist appointments to each specialty clinic. The Center also simultaneously picks up consult reports that are written by the specialists daily from the specialty clinics. The Referral Center staff used to mail a copy of the result to the referring provider. Effective 2/20/08 they initiated scanning of the consults into RPS for speedier delivery to the referring site. Success of this process relies heavily on the availability of specialist documentation. Given the lack of an electronic record and variability in provider charting practices and clinic workflow, this could be problematic. Currently there is not a tracking or monitoring system in place to see how many reports are actually obtained by the Referral Center. This is necessary to evaluate the effectiveness of the current process. Given the importance of the consult report to continuity and follow up patient care, it is essential to be vigilant about developing an appropriate process. Any electronic options should be explored. Health Management Associates 5

Referral Center Staffing and Referral Volume Currently there are 2 staff RNs, 1 Supervisor RN, (1 LVN on medical leave), and 5 clerks in the Referral Center. This staff should be able to handle a significantly greater referral volume. Increased RPS referral volume should be targeted for effective community utilization of available services. Implementation of RPS on MLK campus will cause Referral Center volume to rise (perhaps double current number) quickly. Community outreach to PPPs and residents could help increase volume further. For 3000 referrals per month, 4 clerks should be able to handle scheduling and consult results management. For 5000 referral per month, 5 clerks should be sufficient. The associated Appointment Center, which is largely a Call Center, has 2 clerks who are CNAs and one supervisor who is a PFT technician. The Appointment Center staff receives calls for specialty follow up appointments and new appointments for primary care. Callers for primary care are either scheduled in Internal Medicine at MLK if there is availability, told to go to the UCC if the patient feels it is urgent, or are given contact information for Hubert Humphrey. This staff also sends a two week appointment reminder letter via mail to all patient appointments made in the system. A special printer facilitates this process. All returned/forwarded mail is processed by this staff as well. Unfortunately, there are no reports currently available on call volume or abandoned calls. This should be developed with the communications resource person at MLK as soon as possible. Call volume was reported as manageable by the local Administrator. If call volume is low, this staff may be more effectively utilized if it eventually took on more Specialty Clinic follow up calls and relieved clerks in the clinics who are charged with multiple responsibilities. Leadership of the Referral Center must be able to direct new RPS associated implementations and work flows, lead the process of enhancing the nurses role, facilitate priority referral protocol development and liaison relationships with specialists and be able to develop and utilize reports. The leadership of the Referral Center should be able to smoothly relate to the CMO, help spear head identifying and problem- solving bottlenecks and backlogs that arise with a referrals, and be able to reach out to PPPs and the community to promote the MLK MACC and the Referral Center. If budget cuts are forthcoming, the supervisor clerk in the Referral Center (unfilled) should be eliminated and staff supervised by the nurse supervisor or Appointment Center supervisor. The LVN position could be eliminated next. If volume is on the low side in the Referral Center, one clerk could be eliminated or reassigned to the Appointment Center if it is redesigned for greater volume. If a primary referral mechanism is organized longer term, this process could be managed by the supervisor of the Appointment Center. Health Management Associates 6

Hubert Humphrey CHC Referral Assessment Hubert Humphrey CHC went live on RPS in early November 2007. As of January 1, 2008 1,807 referrals had been placed. Some 975 were approved and 767 were pending. Of the pending referrals, 253 were directed to Martin Luther King and the remainder to either Harbor or LAC/USC. As HHHCHC organizationally reports to the MLK MACC, and because it is the single largest off campus referral source, it is important to understand its processes and relationship to the MACC. Referral Work Flow and Bottlenecks Humphrey created an RPS referral work flow to accommodate their providers and minimize resistance, given limitations with computer accessibility in exam rooms. Here providers write handwritten referrals for specialty services largely at either MLK (estimated 80% of referrals placed) or Harbor. Harbor is utilized as a resource if a service is not available at MLK or for CHP patients that are believed to need services from an accredited hospital. Once a referral is handwritten, it is delivered to the clinic discharge nurse. The discharge nurse enters the referral into RPS and saves it for future submission. She writes or prints the RPS referral confirmation number and attaches it to the chart. Charts are picked up daily by a Medical Records staff member. The Medical Records staff person then scans all Affinity documents thought to be necessary for each referral, such as recent progress notes, lab and diagnostics and formally submits the referral. The medical director compiled old specialty prerequisites to help enable the Medical Records staff to scan the appropriate documents. This work flow requires multiple steps prior to a referral actually being submitted and processed. This slows referral submission. In addition, scanning of many of the diagnostics is duplicative as results are in Affinity. The clinical reason for referral may be scant, as providers don t enter their own referrals and utilize the handwritten approach which has variable quality limitations. If a referral is subsequently returned from MLK asking for additional information, central Humphrey administrative staff is notified and they have to individually email providers with referral messages. These process inefficiencies could be eliminated by providers entering referrals directly into RPS. The medical leadership at Humphrey is planning to organize RPS training for their providers so that they can access their referrals in the system, obtain appointment information and get communication about any additional information required regarding their referrals. This is a good first step in involving providers with RPS and encouraging direct referral entry. Having more available computers in the clinics or exam rooms would also ultimately be cost and labor effective. Health Management Associates 7

Priority Referrals The local administration at Humphrey has vocalized the need for expeditious handling of referrals that require prompt appointment dates, such as those for masses, etc. RPS does not have a clearly identified mechanism for a specific priority referral queue within it at this time. A fax work flow has been developed with MLK as outlined above that needs revision. In addition, a separate tracking system has been implemented at Humphrey for nurses to case manage these referrals for completion. In the face of the current RPS capabilities, having the specialty clinic pre-requisites on line and readily available to providers will help prevent referral return for additional information, which is a bottleneck in process. If protocols for priority referrals were developed and distributed by the specialists it would streamline this process as well. Specialist Consult Reports A workflow with RPS referrals for receiving specialty consult reports back has been designed and implemented at Humphrey. Currently reports are received by the RPS representative in Medical Records. Mailed or scanned reports in RPS are then sorted and copied, with one copy sent to the local referring provider and the other filed in the medical record. RPS Reports Humphrey and other referring sites need to be able to monitor their outstanding or pending referrals, get reports on referral demand from their site and obtain outgoing referral patterns of their providers. Regular RPS reports should be developed and made accessible for their utilization. Overarching Systemic Issues The electronic RPS system is a significant improvement in the delivery, quality and legibility of referrals. All referrals are tracked and vital information about demand for specialty services is being generated. Further enhancements can be made in the system to rationalize access to scarce safety net services further and promote efficiencies in the process. Having more extensive referral algorithms for specialty services automated within the system at the point of referral would facilitate this. Current specialty prerequisites are largely focused on diagnostic work up. Ideally these algorithms should also address: Prioritizing referrals by acuity Health Management Associates 8

Ensuring that basic primary interventions were implemented prior to referral and providing guidelines per standards of care Directing referrals to the correct specialty clinic Eliminating inappropriate referrals before they can be entered During our assessment we found that different definitions about what Emergent and Urgent or Priority referrals were understood at different DHS sites, leading to some confusion. Clinical sites implemented the system somewhat differently and in some cases developed other tracking systems. An electronic system in the public health setting generally cannot handle true emergencies. It should, however, be able to handle prioritizing referrals of greater clinical acuity or of greater priority. A central RPS/Referral team could designate clear policies across the DHS and manage implementing an initiative for extensive specialty algorithms or rules. A mechanism for primary care referrals does not exist and could be extremely helpful for the Specialty Care Centers and perhaps the Urgent Care Centers. Particularly for patients with chronic diseases with no medical home that either repeat return to the UCC or are followed continuously by specialists to ensure care, potentially clogging specialty care. PPP Specialty Referral Issues HMA had a focused discussion with key leadership of PPPs referring into MLK MACC. Key findings from that discussion are Southside Coalition represents 7 health centers (Central City, Eisener Pediatric, South Central, St. John s, T.H.E., UMMA and Watts) with 320K annual visits; payer mix = 49% Medical, 24% PPP, 10% sliding fee, 8% free, 7% others, 1% Medicare, 1% Healthy Families; ethnic mix = 60% Latino, 35% African- American (bilingual capabilities problematic) Repeating themes of lack of trust and no effective communication between the PPPs and the County occurred throughout the meeting. South Central reports referring more referrals to LAC+USC because of the problems at MLK. There is a reluctance and trust issue on the part of both patients and providers. PPP participants feel that more purposeful communication should occur between lead providers from County and the PPPs. They feel there is no contact person at MLK for questions and that there is not the needed relationship, especially given the history at MLK. Health Management Associates 9

PPPs are not clear on services now available at MLK and were not aware that the surgeons were doing surgery at Rancho. PPPs feel there is not support from the County in addressing issues. They believe that there needs to be greater effort, particularly in South Central, which has the greatest density of uninsured. Historically, a big problem with referrals has been the inability to get consult reports back. In addition, the thresholds for referral acuity are not clear on the front end and are different at different specialty locations. Often referrals have been returned and rejected months after initial submission. In addition, diagnostic work up often has been repeated at County unnecessarily. RPS system went live at Watts Health Center 2 only recently for MLK. Watts staff did a walk through at MLK to see how RPS referrals are processed. Watts Medical Director reports that the procedures look good on paper, but time will tell. Impressed that specialist gets referral information. Sending 3 referrals per day to MLK. Expressed lack of confidence in the prioritization process in RPS. Watts Medical Director reported that patients, providers and the community trust the MLK doctors, but not the MLK system. In past, patients would have lengthy waits for appointments with last minute cancellations, etc. PPPs have heard the wait time for appointments is reduced. But also have perception that there are very few doctors left at MLK. PPPs could do more tests as part of the workup prior to specialty or diagnostic visits at MLK or other specialty sites. PPPs recommended that MLK administrators go out and tell folks what services and resources are available. There is no current formal structure for PPPs to receive referrals for Primary Care from MLK (urgent care?), but they were open to setting this up where there is capacity. The PPPs have Chronic Disease initiatives including Diabetes, Best Babies, Immunizations, Asthma and Hypertension. Health Management Associates 10

Relationship to Broader DHS Referral Operations In discussions with both the Office of Ambulatory Services and the Office of Managed Care, there were several ideas discussed to increase access to the specialty and diagnostic services at the MLK MACC by patients needing those services in SPA 6 and surrounding areas. An issue that has arisen in discussion with PPPs and the referral people at other DHS facilities with long waits for appointments is the ability of RPS to allow for patients to be referred to MLK MACC from outside of SPA 6. There appeared to be a wide-spread mis-understanding that RPS only allowed for providers in SPA 6 to refer to MLK and others to refer only to the DHS facility in their particular SPA. There, apparently, is a mechanism for choosing out of area referrals. This technical fix has not been adequately communicated to all PPPs. Further, the notion of automatically sending referrals from certain SPAs when there partner DHS facility has reached a certain wait time in a certain specialty should be explored by DHS. Discussions with the Office of Managed Care raised several key issues. Now that there is a favorable State of California opinion that will allow for DHS to have specialty contracts for insured patients (primarily Medi-Cal), and, it appears, that there is now an ability on the part of DHS to bill for professional fees separately, there is the potential for the Managed Care Office to enter into contractual relationships with MLK MACC in several areas, assuming that the MACC can meet the access and quality standards set forth in such arrangements. These opportunities include: 1) MLK taking on additional specialty care capacity for CHP patients living in SPA 6 assigned to other DHS and private providers; 2) MLK becoming a specialty care provider for Health Care LA (the safety net IPA representing PPPs throughout the County). These two strategies will need significant coordination with the Office of Managed Care. MLK MACC Referral System Benchmarks and Recommendations The benchmarks for judging the success of the referral system at MLK MACC should include: One electronic system, RPS, is utilized for all outpatient referrals to MLK Specialty clinics (with the exception of emergent, post-hospital discharge, and UCC designated slots) to facilitate improved quality, safety and identification of demand. Target volume increase of MLK RPS referrals to 3000-5000 per month based on MLK campus Go-Live and increased MACC utilization (based on 30% of annual visits as New Specialty ranging from 130,000 to 190,000 total visit estimates). Health Management Associates 11

Target MLK Referral Center processing goals as follows: a. 3-5 days to process referrals for open direct appointing clinics b. 14 days for closed clinics requiring more extensive clinic review c. 2 days to process priority referrals Increase volume of PPP referrals by 50% Monthly reports on MLK referral backlog, specialty demand and referral processing are prepared, utilized and distributed to local leadership. Target 90% of specialist consult reports are returned to referring provider within 2 weeks. The recommendations for the restructuring of the referral processes related to MLK MACC that, HMA believe, will facilitate it to meet the benchmarks outlined above are: MLK Recommendations Prioritize the completion of MLK specialty clinic pre-requisites and their placement within the RPS electronic system to enhance communication between referring providers and specialists at the point of referral. Set goal of completion of all specialty review/changes by March 10, 2008 (as soon as possible). Have pre-requisites entered into RPS by end of March (as soon as possible). Develop succinct summary of pre-requisites for all specialties for on-line chart posting and hard copy distribution by end of March, 2008 (as soon as possible). Arrange for the RPS central team to place individual pre-requisites within each specific referral submission. Recommend MLK specialists develop priority referral guidelines or protocols for those referrals that are not emergent, but need to be seen more quickly. Recommend CMO/Senior leadership designate specific Specialty Liaisons to collaborate with Referral Center nurses (especially higher demand services)for: 1.) ongoing revisions/evolution of referral guidelines; 2.) operational management of referral flow and efficiency; 3.) development of nurses as experts to help support referring providers interacting with the electronic system; 4.) utilization of nurses for clinical review of referrals to enhance efficiency. Liaisons could be designated as soon as March, 2008. Once specialty liaisons are formally designated, begin enhancement of the role of the Referral Center nurse to include: 1.) Clinical Review process of the RPS referral based on specialist guidelines; 2.) Oversee all Priority referral processing Health Management Associates 12

according to specialist protocols and input; 3.) Identify and surface referral bottlenecks to specialty and administration; 4.) Utilize RPS reports to enhance operations and efficiency; 5.) Act as phone resource for referring providers and local referral coordinators as they interact with the referral system. Promote more comprehensive direct appointment scheduling access for Referral Center staff through collaborative process between Specialty liaisons and Referral Center nurses in affected areas. Begin as soon as liaisons are formalized. Publicize specialty availability at MLK as well as the resources of the Referral Center, including RNs as provider resource to the PPPs and other local referring sites, the benefits of RPS, the specialty pre-requisites, etc. Develop tracking system in the MLK Referral Center for monitoring success/completeness in get specialist reports back from the specialty clinics to the Referral Center. Initiate an assessment audit that examines the number/per cent of reports obtained/not obtained, or requiring chart pull by Medical Records for one month. Explore the feasibility of using dictation visible in Affinity for specialist consult notes, including availability of the service to all specialties and willingness of physicians to use it. Ensure provision of the Affinity view patient results/information application across the Martin Luther King network (including Hubert Humphrey, Dollar Hide). This will reduce the cumbersome process of scanning all diagnostic work up associated with referrals and facilitate communication across sites. Utilize monthly RPS reports to evaluate internal and external bottlenecks and inefficiencies with referrals, as well as to document referral patterns, specialty demand and capacity beginning March 2008. Implement RPS for the MLK campus providers, including internal medicine, geriatrics and specialties. Discuss and develop implementation plan with key leadership, including use of pilot site, potential obstacles (PC in exam rooms), getting provider buy-in, and handling demand in the Referral Center. Identify realistic but timely target date for pilot implementation. MLK CMO and senior leadership should sanction and help facilitate this implementation. MLK CMO should collaborate with Referral Center on an ongoing basis in resolving operational bottlenecks and capacity issues that occur in specialties that are associated with referrals. HHCHC Recommendations Health Management Associates 13

The ultimate goal is to have providers at HHH enter their own referrals in RPS. May 2008 Recommend obtaining computers or tablets in exam rooms at HHH to facilitate physician efficiency and quality of care. Short term, identify if additional PCs could be made available in MD conference rooms or nurses station for providers. (mid March 2008) Short term get access to RPS for HHH providers to follow communications about their own referrals displayed in the system. (end of March 2008) Have MLK specialty pre-requisites on RPS as soon as possible and published in hard copy for distribution to HHH providers and nursing staff. Minimize scanning of almost all documents currently associated with HHH referral submission. Diagnostic and lab results are largely in Affinity system. If MDs submit their own referrals, scanning would be minimal. They can note the pre-requisites done and any results. In addition, their reason for referral can be more explicit. HHH administration should get monthly RPS reports to evaluate number and sources of referrals sent, outstanding or pending referrals and identify bottlenecks. Monthly meetings with the MLK Referral Center and RPS team should be held to enhance communication and resolve referral related issues. DHS Recommendations Discussions should be initiated between MLK MACC and the DHS Office of Managed Care to address the potential of increased specialty referrals from CHP and Health Care LA providers. The DHS Office of Ambulatory Services should, with MLK MACC, initiate an effort with PPPs to encourage referrals from appropriate non-spa 6 PPPs into MLK when the wait is too long at other DHS facilities and there is capacity at MLK. A specialty clinic entrance rule development team should be initiated DHSwide by senior DHS medical leadership in collaboration with RPS and Referral Center representatives. This is a big endeavor requiring specialty leadership buyin and planning. Special resources may need to be reviewed and tapped to examine the process. Health Management Associates 14

A central DHS Referral/RPS team should be designated to help establish policies across the County about the referral process, including definitions, requirements, etc. so that processes are similar across SPAs. RPS reports on backlog, processing time, sources of referral and specialty demand should be developed and accessible to DHS Referral Center leadership and senior administration. Longer term, a mechanism for primary care referrals should developed to facilitate medical homes especially for patients with chronic disease. Several additional RPS enhancements should be considered including: 1. Develop an enhancement that will sort, file and print all pending appointed referrals by date and specialty. This will streamline the current manual process for filing, pulling, and sorting upcoming referrals with appointments in the Referral Centers prior to referral delivery to the specialty clinic. 2. Explore development of a Consult Note Tracking feature in RPS that will note outstanding consult reports (not sent to referring provider), analyze volume/per cent returned by specialty/month, and measure length of time from patient appointment date to consult note return. Health Management Associates 15