iht² cmio symposium beverly hills – econsult: a model for integrated care – rob bart, cmio, los...
TRANSCRIPT
eConsult – a Model for Integrated Care
- making it easier to behave like a system
Rob Bart, MD
Chief Medical Information Officer
Los Angeles County Department of Health Services
with contributions from Paul Giboney, MD & Hal Yee, MD
Background
Background – ACA & Work force
32 million Americans newly insured
10,000 Americans turn 65 daily through 2033
MD shortage of 91,500 by 2020
Underserved populations will bear the greatest burden of workforce shortage
Background – ACA & Work force
Projected physician shortages
Background – ACA & Work force
Projected first-year enrollment growth
Los Angeles County
Population >10 million
Largest homeless population in US @ > 48,000 (2010)
10% undocumented immigrants
Los Angeles County
Los Angeles County
Los Angeles County Department of Health Services
2nd largest municipal health system US after NYHHC
US$3.5 billion budget (17% county funded)
800,000 unique patients served 2012
Volume of Services
Ambulatory - >2.6 million
Emergency - >300,000
Inpatient - ~75,000
Healthy Way LA (LIHP) – 252,379 enrolled
Los Angeles County Department of Health Services
Goals for Today
3 Responses to Specialty Care Need
The use of Workgroups to bring together a fragmented specialty care delivery system.
The use of technology (eConsult) to transform the way we understand specialty care services.
The implementation of a centralized specialty appointment scheduling system to improve customer satisfaction and reduce no shows.
The Challenge
Mario receives primary care at CP or DHS
42 year old with Ulcerative Colitis
He has a flare in his condition
His PCP would like GI specialist input for the flare
The Problem
Long wait time for GI clinic appointment
No good way for PCPs to communicate with specialists about possible consults or patients needing expedited attention
The challenge
• How does a large, historically fragmented health care system address the issues of:
• Long wait times for specialty services
– Lack of coordinated care between County and Community Providers
– High no-show rates to specialty clinics
– Large variation in care delivery processes
The “Black Hole”
350,000+ referrals to specialty care annually
Long Wait times for specialty clinic visits(2011) Gastroenterology – 162 days
Nephrology – 86 days
Podiatry – 222 days
Urology – 208 days
Cardiology – 140 days
Dermatology – 208 days
Gynecology – 109 days
Neurology – 225 days
Access to specialty care is consistently recognized as one of the top problems in the safety net.
Fragmented Care
Hal Yee, 2013
Fragmented Care
Hal Yee, 2013
Patient Centered Medical Neighborhood
Hal Yee, 2013
Principles
Effective Practice Practical “real world” improvement
Disruptive Innovation
Investment in Patient Centered Medical Neighborhood (PCPs and Specialists). Specialty Primary Care Workgroups
eConsult – in partnership with local Medicaid plan and FQHCs
Investment in Patient Centered Specialty Scheduling Reduction in process variation
Reduction in no-show rates
Improved patient experience
Specialty Primary Care Workgroups
Effective Practices
Collaboration across facilities and disciplines
Triple Aim
Equity/Reduced variability
eConsult
• HIPAA secure, web-based “clinical conversation” portal.
• Advantages
– PCP and Specialist collaboration
• Improved PCP clinical capability
• Relationship building
• Troubleshooting of system issues
– Improved responsiveness to requests for specialty assistance
– Reduction in avoidable specialty visits
– Improves effectiveness of specialty clinic visits (when they are indicated)
eConsult – Primary Care
eConsult – Primary Care
eConsult – Primary Care
eConsult – Primary Care
eConsult – Primary Care
eConsult – Primary Care
eConsult – Primary Care
eConsult – Specialty Care
eConsult – Specialty Care
eConsult – Specialty Care
Impact - eConsult
eConsult
14 Specialty Services
Cardiology, Dermatology, Diabetes, Endocrinology, Gastroenterology, Gynecology, Hematology, Hepatology, Nephrology, Neurology, Obstetrics, Ophthalmology, Podiatry, Urology
1,300+ PCPs using system
130 PCP Sites (40 DHS, 90 Community Partner)
110+ Specialty Reviewers
Average Time to Respond to Initial Request = 2.5 days
A primary measure of impact is that 100% of specialty requests are answered promptly by an expert who is able to provide assistance.
Impact - eConsult
DHS Appointment Service Center (ASC)
The old way – “Mail and Pray”
The new way - Patient Centered Specialty Scheduling For patients identified through eConsult
ASC has the ability to schedule anywhere in the system
Appointments are scheduled only after personal patient contact GOALS –
Improved patient experience
Quick scheduling turn around times
Less variation in process
Lower „no show‟ rate
More effective work, not just more efficient work
Impact - ASC
Patients Scheduled – 16,000+
Successfully Scheduled Rate – 84%
For unreached patients - phone message left, letter sent and PCP
notified via eConsult
No show rate – 13.5% (historically 35 - 40%)
Overall Impact
Community Partner Medical Director –
“eConsult has been a blessing and the providers are thoroughly enjoying the opportunity to learn new patient management strategies from the specialty providers. The best part is our patients aren‟t waiting over 6 months for consultations!”
Summary
The power of collaboration to overcome the challenges of a large and fragmented system.
The power of conversation (via eConsult) to bring specialty services into the medical home.
The power of a scheduling process that focuses on effectiveness and patient engagement.
Future – DIRECT Project
Future – DIRECT Project
