CO ordinating R eferrals E ffectively  CORE

1. COordinatingReferrals EffectivelyCORE Carol VanDeusen Lukas, EdD Boston University Safety Net ACTION Partnership Funded by AHRQ ACTION under contract HHSA2902006000012 TO6 September 27, 2010

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

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)

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

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

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

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

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

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

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

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

12. Progress after trial implementation: primary care

13. Progress after trial implementation: specialty care

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

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

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

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

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

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

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

21. On reflection… • Clinical redesign team membership • Life goes on in the organizations • Iteration, adaptation and continued discovery