Scott Shipman, MD, MPH Director of Clinical Innovation & Primary Care Affairs, AAMC March 7, 2019

1. Project CORE:Coordinating Optimal Referral Experiences Improving Care at the Interface of Primary and Specialty Care Scott Shipman, MD, MPH Director of Clinical Innovation & Primary Care Affairs, AAMC March 7, 2019

2. Why Focus on Referrals? • Referral volumes doubled in just a decade in U.S. (‘99-’09) • Probability that a physician visit resulted in a referral increased from 4.8% to 9.3% • Number of visits resulting in a referral grew from 41 million to 105 million (Barnett 2012) • Major driver of costs in ambulatory care • High risk of fragmentation of care

3. Common Problems at the Interface of Primary Care & Specialty Care Poor communication & coordination Wide variations in care Poor access

4. Poor Communication & Coordination Referral Quality… What is Missing? • A clear clinical question ...referrals have become an administrative task • Alignment of primary care evaluation with specialist needs ...leading to risk of wasted initial visit with specialist • Longitudinal co-management agreement ...who does what over time?

5. Project CORE Goals By improving communication, coordination and culture between primary care providers and specialists, the CORE model aims to: • Improve timely access to specialty care • Improve qualityand experiencefor patients and providers • Enhance primary care comprehensiveness • Control costs of care

6. Evolution of the CORE Model Ensure sustainability, complete program evaluation AMCs averaging 1,500 eConsults/ month AAMC receives 3 year, $7M award from CMMI & together with UCSF convenes 5 AMCs to implement the CORE model Project CORE expands to 7 additional AMCs (beyond the initial CMMI project) 2019 2014 2015 2017 2016 2018 The CORE model is implemented across 15+ medical & surgical specialties across the 5 AMCs & averaging 700+ eConsults monthly Further expansion of Project CORE with a new cohort of 7 AMCs and a CORE for Kids (Pediatrics) collaborative assembled Medicare begins paying for eConsults, Further scale of model and expansion to additional AMCs > 1,500 eConsults completed/month across AMCs > 2 Million Primary Care Patients

7. The CORE Model

8. Implementing eConsults in the EMR • eConsults Overview: • Condition specific templates • Initiated by a PCP to a specialist colleague • Typically straight forward, low-acuity issues • < 3 business day response • RVU credit to PCP & specialist

9. Enhancing Primary Care Referrals • Problem-Specific Decision Support Through Templates that Include: • Pre-referral evaluation • Pre-referral conservative management • Clear clinical question • Relevant data (tests, labs) • Co-management preference

10. Technology isn’t enough…. AND Implementation Strategy Establish a culture of collaboration between PCPs and specialists to facilitate improvement and increased standardization in care delivery EMR-Based Tools Enhanced Referrals + eConsults, decision support tools built into the EMR

11. The CORE Network

12. Transforming Health Care through Project CORE 27 Academic Medical Centers across 15 States > 3,000 FM & GIM PCPs across hundreds of clinics > 2 Million Primary Care Patients > 1,500 eConsults completed/month across AMCs

13. A Growing CORE Community of AMCs University of Washington Oregon Health & Sciences University Dartmouth-Hitchcock Medical College of Wisconsin University of Wisconsin Yale University MetroHealth University of Utah Penn State University University of Michigan University of California, San Francisco University of Iowa The Ohio State University University of Virginia University of Colorado ECU Physicians Vidant Health System Wake Forest Baptist Health University of California, San Diego Greenville Health System CMMI (5) CORE2 (5) CORE3 (9) CORE for Kids (8)

14. Specialties Active in Project CORE • Pediatric – Neurology • Pediatric – Psychiatry • Pharmacy (Ambulatory) • Psychiatry • Pulmonary • Radiology (Diagnostic & Interventional) • Rheumatology • Sleep Medicine • Urology • Allergy/Immunology • Burn & Wound • Cardiology • Colorectal Surgery • Dermatology • Endocrinology • ENT • Gastroenterology • Geriatrics • Hand/Plastic Surgery • Hematology • Hepatology • HIV Medicine • Infectious Disease • Maternal Fetal Medicine • Medical Genetics • Nephrology • Neurology • Neurosurgery • Ob-Gyn • Occupational & Enviro • Oncology • Orthopedics • Pain Management • Pediatric – Allergy • Pediatric – Cardiology • Pediatric – Dermatology • Pediatric – Endocrinology • Pediatric – ENT • Pediatric – Genetics • Pediatric – GI • Pediatric – Hematology • Pediatric – Nephrology …and growing!

15. Assessing the Impact of Project CORE: Experience across 5 AMCs in CMMI-funded Pilot (2014-2017)

16. Uptake of the Model • Over 16,000 completed eConsults across 5 AMCs, with 7.5% of all specialty contact to medical specialties occurring via eConsult

17. Role of eConsults Varies by SpecialtyeConsults/(eConsults + Referrals) Each blue point represents one AMC in the CMMI cohort. The hash represents the collaborative average. Allergy & Immunology Cardiology Endocrinology Gastroenterology Hematology Infectious Disease Nephrology Neurology Pulmonology Rheumatology 5% 10% 15% 20% 25% 30% 35% 40% 45% 0% PY1-PY3 data for all CMMI AMCs live within that specialty.

18. Assessing Impact Tied to CORE Goals • Improve timely access to specialty care • Improve qualityand experiencefor patients and providers • Enhance primary care comprehensiveness • Control costs of care

19. Access to Specialty Care • Timelier access to specialty care by enabling more patients to be managed in primary care, increasing capacity in specialty clinics for new patients and higher acuity patients Timely access to specialty care improved by 5% 84% increase in new patients

20. Access to Specialty Care • Timelier access to specialty input and better communication at the point of referral helps to increase the proportion of patients seen and reduce no-shows 32% No-show rates to CORE specialties decreased by increase in referral completion 17%

21. Improve Patient Experience • eConsults lead to lower out of pocket costs and time spent accessing specialty care for those patients who can be managed in their primary care medical home For every 1,000 eConsults completed, patients saved = $45,000 Patients equally satisfied with specialist recommendations via eConsult vs. referrals by avoiding out-of-pocket medical charges, transportation costs, and missed work

22. Improve Provider Experience • eConsults and enhanced referrals enable better communication and coordination between providers leading to improved satisfaction and high uptake of the model 91% By year three, 83% of physicians reported that CORE led to better patient care of PCPs were active users of eConsults

23. Enhance Primary Care Comprehensiveness • eConsults enable timelier access to specialist input, thereby reducing referrals for those lower acuity patients that can be managed in primary care with specialty guidance 13% reduction in referral rates by PCPs

24. Control Costs of Care • eConsults lead to more efficient care and decreases in unnecessary referrals • Enhanced referrals ensure patients are better “teed up” for their initial specialty visit, thereby decreasing the number of specialty follow-up visits and downstream utilization • Templated point of care decision support can lead to fewer unnecessary referrals and reduce unnecessary or duplicate testing $8 million in estimated savings to Medicare due to more efficient specialty use.

25. “ eConsults have lessened patient wait times, reduced unnecessary referrals, and improved collaborative efforts amongst providers. Hope to see all specialties utilizing eConsults in the future. ” - AMC PCP participating in Project CORE

26. “ “I was in the process of referring [the patient] to Orthopedic clinic, however, with the Enhanced Referral, it recommended x-rays and an eConsult, which I did. This worked very well and helped prevent an unnecessary referral visit.” ” - AMC PCP experience with enhanced referrals

27. Communicating the Value Proposition of the CORE model

28. Achieving Cost Savings: eConsults at UW Health “The implementation of eConsults led to a host of benefits at UW Health. It is one of those rare programs that improves things for us at every level: improved clinical care, enhanced education between specialists and primary doctors, decreased costs of overall care for everyone while at the same time improving the work satisfaction of our clinical providers of care.” Pete Newcomer, MD, Senior Vice President, Chief Clinical Officer In the first three years of the program: ~$1.8M estimated savings for the Medicare primary care population served by UW, due to visits saved to CORE specialties post-implementation. Access to timely specialty input within 14 days of PCP referral or eConsult improved from 9.1% to 22.8% in participating specialties. >5,400 eConsults were completed, accounting for 6.2% of all specialty consultation. Widespread adoption and effectiveness of the program: 86% of primary care faculty sent an eConsult during the project period. 90% of patients who had an eConsult were managed without a follow-up specialty visit.

29. University of Washington: Addressing Access through eConsults

30. Participation in the CORE Collaborative

31. AAMC Program Support AAMC Support AMC Program Implementation Phases • 1:1 team calls • Collaborative kick-off meeting, site visit, webinars, and workgroups • Resources • 6 resource modules • Sample templates • Summary of site approaches and sample implementation resources • Data and reporting • Payer engagement • “CORE Clips” newsletter • Online CORE community and discussion board • CORE Network activities

32. Q A & THANK YOU! To learn more or to request additional information, visit www.aamc.org/projectcore or email projectcore@aamc.org Scott Shipman, MD, MPH sshipman@aamc.org Meaghan Quinn, MHSAmquinn@aamc.org

33. Impacting Care through CORE