Coordinating Referrals Effectively (Text Version)

Slide Presentation from the AHRQ 2010 Annual Conference

On September 27, 2010, Carol VanDeusen Lukas made this presentation at the 2010 Annual Conference. Select to access the PowerPoint® presentation (200 KB). Free PowerPoint® Viewer (Plugin Software Help).


Slide 1

Coordinating Referrals Effectively

Coordinating Referrals Effectively → CORE

Carol VanDeusen Lukas, EdD
Boston University Safety Net ACTION Partnership

Funded by AHRQ ACTION under contract HHSA2902006000012 TO6

September 27, 2010

Slide 2

CORE team

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

Slide 3

Project aim: To improve referral processes between Primary & Specialty care

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)

Slide 4

Clinical redesign process

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

Slide 5

Why redesign?

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

Slide 6

Intended benefits

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

Slide 7

Redesigned system: primary care standard elements

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

Slide 8

Redesigned system: specialist standard elements

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

Slide 9

Redesigned system: building it into practice

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

Slide 10

Developing the implementation process

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

Slide 11

Implementation process with users

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

Slide 12

Progress after trial implementation: primary care

Progress after trial implementation: primary care

Image: A table shows the following data:

 CSHCSBCHSBMC ACC
 n%n%n%
% used CORE form329100%155100%4723.7%
# referrals audited119 72 29 
% use of CORE standards      
patient contact #5445.3%6387.5%1862.1%
PCP name;4033.6%6995.8%29100.0%
pager #2016.8%2129.2%310.3%
appointment needed by date4134.4%2636.1%1551.7%
diagnosis/reason for referral11697.4%7097.2%29100.0%
question asked119.2%3548.6%1655.2%
labs included86.7%00.0%NANA
patient handout printed75.8%34.2%00.0%

Slide 13

Progress after trial implementation: specialty care

Progress after trial implementation: specialty care

Image: A table shows the following data:

 OB/GYN;GI;
 n%n%
# reports audited15 10 
% CORE table completed213%330%
% use of CORE standards    
referral receipt acknowledged853%880%
referring provider acknowledged747%10100%
diagnosis provided;1493%10100%
question answered125%4100%
care plan stated15100%10100%
patient follow-up plan indicated747%770%
PCP follow-up plan indicated17%330%
specialist follow-up plan indicated533%550%
note signed by specialist within 2 weeks1493%10100%
note available in logician at health center213%00%

Slide 14

Implementation challenges . . . a work in progress

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

Slide 15

Overlapping development & implementation with e-Referrals

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

Slide 16

Working in a larger hospital system

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

Slide 17

Difficult organizational environment

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

Slide 18

Provider resistance

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

Slide 19

Role of project team in implementation

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

Slide 20

Continuing steps

Continuing steps

  • Feedback to providers and referral staff
  • Feedback from providers and referral staff
  • Brief clinical and administrative leaders
  • Develop system for ongoing monitoring

Slide 21

On reflection . . .

On reflection...

  • Clinical redesign team membership
  • Life goes on in the organizations
  • Iteration, adaptation and continued discovery
Current as of December 2010
Internet Citation: Coordinating Referrals Effectively (Text Version): Slide Presentation from the AHRQ 2010 Annual Conference. December 2010. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/events/conference/2010/vandeusen-lukas/index.html