Increasing Scope of Primary Care


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  • -- take out wait times. Jennifer will just say them
  • 1115.This section 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.
    1915b, This section provides the Secretary authority to grant waivers that allow states to implement managed care delivery systems, or otherwise limit individuals' choice of provider under Medicaid.
    1915c. This section provides the Secretary authority to waive Medicaid provisions in order to allow long-term care services to be delivered in community settings. This program is the Medicaid alternative to providing comprehensive long-term services in institutional settings.
  • Explain what the coverage initiative is
  • Mention PPR being done in LA and being replicated in Kern
  • Increasing Scope of Primary Care

    1. 1. Jennifer Abraham MD, FACP Medical Director, Kern Medical Center Health Plan 1 10/26/2009 PROVIDER PRACTICE REDESIGN USING A MULTI-FACETED STRATEGY
    2. 2. 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 long 2 10/26/2009
    3. 3. Cause Of Mortality Mortality 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 3 10/26/2009
    4. 4. 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 4
    5. 5. 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 5
    6. 6. 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 6 10/26/2009
    7. 7. 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 Fellowships Strategy 7 10/26/2009
    8. 8. Provider Practice Redesign 8  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 care 10/26/2009
    9. 9. 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 9 10/26/2009
    10. 10. 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 10 10/26/2009
    11. 11. 10/26/200911
    12. 12. 12 10/26/2009
    13. 13. Champion Process 13  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 consultations 10/26/2009
    14. 14. Reimbursements 14  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
    15. 15. Methods of Consultation 15 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
    16. 16. 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 16 10/26/2009
    17. 17. 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 17 10/26/2009
    18. 18. Implementing PPR in LA vs Kern 10/26/2009 18  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
    19. 19. Conclusion 19  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
    20. 20. Questions? 10/26/2009 20