Paving the Path toward Improved Specialty Access What it looks like Paul Giboney, MD Director, Specialty Care and PRIME Program Los Angeles County Department of Health Services
Where We Were - 2011 Very large, very fragmented health care system: - Long wait times for specialty services Many specialties 6-12 month wait times Elective Gallbladder and Hernia cases > 18 months - Lack of coordinated care among County facilities and with Community Providers - High no-show rates to specialty clinics - Large variations in practice and referral criteria
Disruptive Innovations Specialty Primary Care (SPC) Workgroups Expected Practices / Clinical Care Library econsult Central Scheduling
Disruptive Innovation - Workgroups Specialty Primary Care (SPC) Workgroups Collaboration across facilities and disciplines Triple Aim Equity/Reduced variability Workgroups for each major specialty area include: Specialists from each facility that offers the service Primary care Providers - Empowered to Make System-wide Decisions -
Disruptive Innovation -Expected Practices* Developed in our SPC Workgroups through consensus (and often, debate) Better define clinical services that can be equitably offered to our entire population of care: Colon Cancer Screening, Cataract Surgery, Breast Cancer Screening Reduce unnecessary lab/radiology testing Rheumatology EPs Clarity/Consensus around Common Problems Insulin use in Diabetes, Management of Positive PPDs, Carpal Tunnel, Infertility, Hematuria, Heart Failure and dozens of others! To date: 160 Expected Practices have been downloaded over 25,000 times from the DHS Clinical Care Library (2,000 times each month) *JAMA, May, 2016 Development and Implementation of Expected Practices to Reduce Inappropriate Variations in Clinical Practice
DHS Clinical Care Library Expected Practices
Disruptive Innovation econsult Not a referral but a discussion between primary care doctors and specialists: A referral might result Advice, no visit needed Advice to complete workup and then have visit Urgent or routine appointment econsult HIPAA secure, web-based clinical conversation portal with ability to refer those needing appointments to a scheduling desk.
The DHS econsult Network Submitting Sites 4 Medical Centers 2 Multi-specialty Ambulatory Care Centers 19 DHS Health Centers 190 Community Partner (My Health LA) sites 14 Department of Public Health Clinics 4 Juvenile Courts Health Services Clinics 9 Sheriff s Department (Medical Services Bureau) clinics 22 Department of Mental Health clinics. 4,500+ Providers have submitted at least one econsult econsult Specialty Care 65 Specialty Services 550 econsult reviewers located at 10 different DHS facilities These locations can be envisioned together as a Patient Centered Medical Neighborhood
Access to Specialty Care econsult provides access t0 specialty care in multiple ways - Rapid access to specialty expertise - Ability for specialists to expedite cases needing more rapid specialty attention and to designate specific face to face visit instructions based on clinical need. - Ability for PCPs to deliver specialty care in the Medical Home - Reduction in wait times for routine face to face specialty care visits (because we are using specialist time more efficiently)
Responsiveness DHS currently responds to 17,000+ econsult requests every month. Our median response time* to the initial econsult request is: 24 hours! *Health Affairs, March 2017 Los Angeles Safety-Net Program econsult system was rapidly adopted and decreased wait times to see specialists.
Disposition of econsults* 25% of econsults are resolved without the need for a specialty visit. The more the PCP and Specialist discussed the case on econsult (back and forth dialogue), the more likely they met the patient s needs without a face to face specialty visit. *Health Affairs, March 2017 Los Angeles Safety-Net Program econsult system was rapidly adopted and decreased wait times to see specialists.
Disruptive Innovation Centralized Scheduling Previously scheduling done at each individual clinic or facility Hundreds of scheduling units High variability in process and access Patient Centered Specialty Scheduling For patients identified through econsult 10,000/month (250,000 to date) Central unit has ability to schedule anywhere in the system (via EHR) Precision Scheduling timeframe* according to recommendations from econsult reviewer Expedited within weeks Designated timeframe a month or more out *Based on the collaborative conversation of PCP and specialist and the unique needs of a particular patient. Can flex schedule patients to other facilities in the system with more capacity or specialized services.
What it looks like when we use all the tools. Case Study General Surgery Pre- 2015 experience elective patients with hernia and gallstones waiting more than 18 months April, 2015 SPC Workgroup identifies specific challenges in surgical access: One facility with significant backlogs (>1,000) of elective patients who had seen the surgeon, but didn t have a date for surgery yet. Another facility with over 800 elective patients who had been econsulted, recommended for a surgery visit, but who had not been scheduled for the visit. More than 80% of elective patients waiting were for cholecystectomy or hernia. (Impacted facilities were doing a good job with urgent/severe surgical access)
What it looks like General Surgery applying the tools Actions taken by the workgroup April, 2015 Identified 4 locations in our system with capacity to take on additional cases (2 hospitals and 2 ambulatory surgery centers) Routed econsult requests directly to the surgeons with capacity (routed 80% of all general surgery volume away from two impacted facilities to allow them to catch up with backlogs) This required surgeons at the receiving facilities to more than double their econsult reviews and increase volume in clinics Centralized Scheduling was able to easily book surgery appointments at the newly recommended facilities.
What it looks like General Surgery May August, 2015 Published standard forms and Expected Practices to ensure Gallbladder and Hernia patients arrived to their first surgery visit ready to be fully evaluated and scheduled for OR (used econsult to verify compliance) April Dec, 2015 For patients already seen by the surgeon, also re-routed some to facilities with capacity. Monthly Monitored volume transfers and progress on backlog reduction on workgroup calls.
What it looks like General Surgery improved access 1,000 900 800 700 600 500 400 300 200 100 DHS General Surgery Requests - Jan '16 Feb Mar Apr May June July Aug Sept Oct Nov Dec Jan '17 Feb Mar Scheduling Backlog Volume of econsults
What it looks like General Surgery Today: All facilities are scheduling to OR within 2 months of surgery visit (many in less than 4 weeks of surgery visit) Thousands of patients needing surgery routed to facilities with capacity Some of the econsult re-routing continues as OR capacity at previously impacted facilities is limited in the face of the demand. Some of the re-routing has been stopped and the facility now at steady state
Impact on other specialty backlogs
What it looks like Primary Care Primary Care Quick access to specialty expertise Connected to larger system of care (reduced isolation) Opportunity to enhance clinical capability (econsult CME ) Reduced wait times Improved scheduling process Ability to see status of request/scheduling - improved care coordination Time investment in submitting econsult More conditions managed in Medical Home more balls in PCP s court. Challenge in ordering specialty labs or diagnostics. Co-Management of complex patients Improved ability to meet patient s needs
What it looks like - Specialist Specialty Care Ability to extend expertise over a larger population of care Ability to triage Reduced wait times Reduced no shows Face to face visits are more productive - Better information - Pre-Visit Testing Completed Avoidance of inappropriate referrals Opportunity to teach/educate - PCP - Residents/Fellows Increased complexity of clinic patients. Time investing in reviewing econsult Improved ability to meet patient s needs
What it looks like - Patient Patient - Reduced wait times for specialty care - Less travel - Fewer days off work - Medical Home usually more culturally attuned - PCP more capable / empowered - Care better coordinated - transitions of care better managed, process more transparent - Specialist more informed when sees patient - Fewer specialty visits required to develop treatment plan - Timeliness recommendations customized to unique patient needs.
pgiboney@dhs.lacounty.gov