increasing scope of primary care
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Jennifer Abraham MD, FACP
Medical Director, Kern Medical Center Health Plan
10/26/2009
PROVIDER PRACTICE REDESIGN USING A MULTI-FACETED STRATEGY
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Specialty Care Challenges in Kern
3rd largest county in US spanning over 8,000 square miles Widely dispersed population of ~800,000 Lack of specialty care providers who see uninsured and
under-insured patients Kern Medical Center is the only county hospital in Kern
County For many specialties, KMC is the sole provider in the county
of specialty services for unfunded and underfunded patients Neighboring county was also using some of Kern’s specialty
clinics on a contractual basis. Wait times to be seen in some specialty clinics were
unacceptably long10/26/2009
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Cause Of MortalityMortality Rate per 100,000 population
Rank out 58 Counties in California
All Cancers 183.3 47
Heart Disease 232.4 58
Stroke 51.3 47
Diabetes 34.2 56
Chronic Lower Respiratory Disease 69.6 55
Chronic Liver Disease and Cirrhosis
15.4 49
Influenza/Pneumonia 28.4 57
Alzheimer’s Disease 37.4 56
Kern County Selected Health Outcomes
Source: 2009 County Health Status Profiles, California Department of Public Health
10/26/2009
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Coverage Initiative
A five-year section 1115 Medicaid Demonstration
Approved 9/1/05 for 3-year implementation Section 1115 Research & Demonstration
Projects: Provides the Secretary of Health and Human Services broad authority to approve projects that test policy innovations likely to further the objectives of the Medicaid program.
The Demonstration provides $180 million in federal funds
10/26/2009
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Coverage Initiative Goals
Expand the number of Californians who have health care coverage
Strengthen and build upon the local health care safety net system
Improve access to high quality health care and health outcomes for individuals
Create efficiencies in the delivery of health services that could lead to savings in health care costs
Provide grounds for long-term sustainability of the programs funded under the Coverage Initiative
10/26/2009
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Background on Kern Medical Center Health Plan (KMCHP)
The Coverage Initiative Program in Kern County Manage care of 5,000 patients Community clinics contract with KMC to provide
primary care for KMCHP patients Components of KMCHP:
Primary care home assignment Intensive care management for frequent hospital users Provider Practice Redesign: expanding the scope of
Primary care providers Information sharing between community clinics and
KMC 10/26/2009
Provider Practice Redesign
Objectives
Allow specialists to focus on most severe cases
Expand Access to Specialty Care Services
Decrease denied and deferred referrals
Build consensus about guidelines for delivery of care
Consensus Care
Guidelines
Information
Exchange
Community Grand
Rounds
Phone/ Chart
Consults
Mini Fellowship
s
Strategy
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10/26/2009
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Provider Practice Redesign
Model originally implemented for the LAC+USC Camino de Salud Network in LA in 2007
Model started with Rheumatology and later expanded to Cardiology
Outcomes: 444 patients screened by the Cardiology and
Rheumatology Champions 2/3 of patients managed in their primary care
home rather than being referred to specialty care10/26/2009
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Creating Guidelines
Targeted specialties chosen by analyzing referral center data for specialties with highest referrals and longest wait times: Cardiology Endocrinology Orthopedics Neurology Rheumatology
Primary care providers and specialists attend “Grand Rounds Meetings” to discuss specific challenges within those specialties
Guidelines created by pulling together evidence-based guidelines and data from published resources
Guidelines are reviewed by all providers and modified to meet needs of specialist and limitations of safety net clinics
10/26/2009
Guidelines
Guidelines are disease-specific Delineate management roles for primary care provider
vs. champion vs. specialist dependent on acuity Outlines diagnostics needed before consult Allows for more management within the primary care
setting Allows referrals to be appropriate and more focused
on most severe cases Reduces number of denied and deferred specialty
referrals
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Champion Process13
Mini-fellowships: Community clinic providers complete curriculum and undergo training under specialist working at KMC
Mini-fellowship Curriculum Incentives to complete curriculum
Pre- and Post- tests 10 CME credits
Reading Materials Increased reimbursement through KMC
Lecture by the specialist and clinic shadow day(s)
Access to specialists for phone consults & chart reviews
Process:
Mini-Fellowship
Curriculum & Training
PCP becomes a Champion with clinical
confidence to adhere to guidelines
Champion can manage higher acuity patients
by having access to
specialist for chart reviews
and phone consultations10/26/2009
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Reimbursements
Specialty Care Champions can bill for a higher reimbursement through the KMCHP to compensate for increased time and management
Specialists can bill for a phone consultation and patient review
Billing Codes: Outpatient Consultation Code: 99241-99245 Phone consultation Code: 99358
10/26/2009
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Methods of Consultation
Advantages Disadvantages
Telephone Calls
•Easy to implement•Less security concerns
•Both parties need to be available at the same time
E-Referral System
•Secure system•Referrals and consults can be sent over the same system
•Requires a system that has the appropriate capabilities•May require significant investment
E-mail •Almost everybody has email•Can respond at own convenience
•Security problems •Requires implementing encryption method
Pager •Can reach providers even if they are not by their phones
•PCPs may find it inconvenient because call back can be delayed
Fax •Easy to implement•Doesn’t require anybody to learn a new program
•Faxes can get lost or be difficult to read•Would need a secure fax site
10/26/2009
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Expectations of the Champion
Expectation of the Champion Method of Monitoring
Stronger understanding of managing and treating patients for specific disease
Pre- and post test scores
Adherence to referral guidelines Regular chart audits
Documentation of all Champion visits Champion codes required for higher reimbursement
Gradually be able to manage increasingly complex patients
Number of referrals over time to the specialist
10/26/2009
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Information Sharing
E-referral system Updating, training, and expansion to more clinics
Challenge in primary care providers sending patients to KMC and receiving: Specialty consult notes Lab or radiology results ordered by the specialist
Expanding KMC records viewing systems to the community clinics Will improve coordination of care and require less reliance on
faxing of results and consult notes Decreases duplication of labs and other services Improve patient safety and point of service quality of care
10/26/2009
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Implementing PPR in LA vs Kern
10/26/2009
More clinics and providers in the CDSN service area Specialty departments in LA vs 0.1 providers at KMC In Kern, some rural clinics are 2-3 hours from county
hospital and are staffed only with NP/PA’s most days Adaptations in the Model for Kern County
Guideline development without champion Clinic referral guidelines that are problem-based to
decrease misdirected referrals Webinar use for Grand Rounds Travel to clinic sites
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Conclusion
Provider practice redesign Increasing scope of primary care physicians Improving compensation to primary care physicians Developing guidelines for referral to clinics Expanding e-referral use Evaluation measures
Improve access to specialists Decrease wait times
Improving communication between specialists and primary care Improving information exchange
Decrease duplication of services Decrease overall cost of care
10/26/2009
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Questions?
10/26/2009
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