Continuity of Care Making connections: A small practice journey

1. Continuity of CareMaking connections: A small practice journey R. Scott Hammond, MD Chair, CAFP PCMH Task Force Medical Director, SOC-PCMH Initiative, Colorado Associate Clinical Professor, Dept. of Family Medicine UCHSC Westminster Medical Clinic, Westminster, Colorado --PCMH Level 3 shammond@evcohs.com

2. PCMH Awareness in Colorado

3. Coordination of Care in Colorado

4. Care CoordinationChallenge • The typical primary care physician has 229 other physicians working in 117 practices with which care must be coordinated. Pham et. al Ann Int Med. 2009 • In the Medicare population, the average beneficiary sees seven different physicians and fills upwards of 20 prescriptions per year Partnership for Solutions, Johns Hopkins Univ. 2002

5. Continuity of Care Paradigm

6. Making Connections • Care coordinator job description and protocol consistent with available resources. • External care coordination • Hospital and skilled nursing facilities • Specialists • Internal care coordination • High-acuity patients • Post-hospital • Multi-morbid diseases • Frequent ED utilization

7. Continuity of CareHospitals • Database • List of facilities and contact personnel • Informational continuity • Daily census of admits, discharges, updates (hospitals, hospitalists, IPA) • ED/in-hospital medical information transfer • Care Coordination • Post hospital transition (discharge care plan) • List of ED patients over the past year

9. Patient: ______________________________________PCP ______________________Date:_____________ Diagnosis:______________________________________________________________ Discharge Date: ____________  Discharge Summary received  Laboratory/Diagnostic test received  Requested Date: __________  Test _______________________ Patient contacted: Date______________ Appointment: Date:_________________ Referral requested: Date: ____________

10. Continuity of CareHospitals • 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)

11. PCMH ID Wallet Card

12. Continuity of CarePCMH-NSpecialists • Define, develop and vet a PCP-Specialty Compact • Outreach • Preferred Specialist List • Implement • PCP Transition Record • PCMH-N Patient Referral Rx • Accountability • PCP/Specialist Report Card

13. Colorado SOC-PCMH InitiativePrimary Care-Specialty Care Compact • Purpose and Principles • Definitions • Types of Care Transition • Service Agreement • Transition of Care • Access • Collaborative Care Management • Patient Communication • Transition of Care Records (PCP and Specialist)

14. Colorado SOC-PCMH InitiativePrimary Care-Specialty Care Compact • Types of Care Transition • Pre-consultation exchange • Formal consultation • Co-management (Referral) • With Shared management • With Principle Care of the disease • With Principle Care of the patient • Complete transfer of care (Specialty Medical Home Network) • Emergency Care

15. Service Agreement– Transition of Care Additional agreements/edits: _____________________________________________________________ ____________________________________________________________________________________

16. 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

18. PCMH Patient Referral Rx Patient name: Gloria Date: 2/19/10 Appointment: within 1 week Specialist: Dr. Heart_ Test/Procedure: may do heart ultrasound or monitor Reason for Referral/Consultation:determine medications needed to control your heart rate and whether you need a pacemaker_____________________ ______________________________________________________________ Alternatives:watchful waiting______________________________________ Non-urgent referrals take about 4-5 days to process. You will be notified through the Patient Portal. If you do not have Internet, we will call you or mail your confirmation. Do not go or make an appointment for the visit/test until you have received your referral confirmation and insurance approval. If for some reason, you do not make or keep your appointment, please let us know so that we may cancel the referral and assist you in other ways.

19. Comments Points 5 2.5 0 -5

20. Points 10 5 0 -5Comments

21. SOC/PCMH Action Plan

22. It can get dirty but change can be good

23. WMC Team