Transcript or “will this new medication interfere with my current meds?”

Exploring Ideas for Improving
Care Coordination
Eric A. Coleman, MD, MPH
Associate Professor
Divisions of Geriatric Medicine and
Health Care Policy and Research
University of Colorado Health Sciences Center
4 Key Areas for Change
1)
2)
3)
4)
Develop systems to notify patients of test results
Develop processes for better communication
between primary and specialty care
Medication reconciliation
Coordination outside of office hours
Lab Result Management
“Where no news is not
necessarily good news…”
Burden of Test Result Management
Per week, full-time PCP needs to review:
–
–
–
–
360 chemistry results (SMA7 = 7)
460 hematology results
12 pathology reports
40 radiology reports
Physician Perspective

43% of physicians surveyed report being
satisfied with the way they manage test results
 83% report experiencing a delay in reviewing
lab results with potential to adversely affect care
 Implications for:
– Efficiency
– Safety
– Risk management
The Black Hole??

25% of physicians routinely inform patients
of normal lab results
 67% of physicians routinely inform patients
of abnormal lab results
 24% had a reliable system for identifying
patients overdue for f/u labs
What Can We Learn
from the Literature?

33% of abnormal TSH values do not receive
timely follow-up
 36% of abnormal pap smear are ‘lost’ to
follow-up
 25% malpractice claims due to failures in
follow-up
Lab Management—3 Main Steps

Retrieve and review results
 Communicate and interpret results to
patients
 Incorporate findings into care plan
Break It Down—Test Results






Protocol for normal results, no action required
Protocol for normal results, action required
Protocol for abnormal results no action required
Protocol for abnormal results action required
Protocol for abnormal results urgent action
required
Protocol for detecting when test not obtained
Communication Strategies

Pre-formatted letters for sharing results with
patients on paper
 Portal to EMR to allow patients to view once
MD as released
 Phone calls for abnormal results
 E-Visits for abnormal results (with appropriate
time compensation)
Lab Tracking Tools

Paper Forms
 EHRS/EMR
 Patient Portal/web access (after MD releases)
 MS Access
 MS Outlook
Using MS Outlook to Track Labs

Most clinics already have the software
– Low cost approach;
– free self-guided tutorial
– However, all tracking systems require up front time

Track a test from the time it was ordered to the time that
the results are given to the patient using built-in features
 Will provide reminders or warnings when a task is
overdue or a test has not returned
 Can also generate mailing labels to mail results to patients
Improving the Referral Process
Communication Breakdown

Lack of clarity over reason for referral
 Disruption in continuity of care
 Delayed diagnosis
 Unnecessary/duplicative testing
 Dissatisfaction by all parties
Generalist/Specialist
Communication

Specialists report receiving information
32% of the time
 Generalist report getting referral letter 5580% of the time
 Patients are a “silent partner” who may selfrefer
Two to Tango

63% of PCPs dissatisfied
 35% of Specialists dissatisfied
 Room for improvement on both ends
Improving the Referral Experience

Redesign flow of information
 Referral agreements between IPA and Practice
for how communication will occur
 Clearly stated referral questions and answers
 Friendlier consultant letter format
 State preferred method of communication
Referral Agreements

Service requested:
– Evaluation
– Evaluation and initial
–
–
–
–
management
Evaluation and
ongoing management
Procedure
Second opinion
Other

Reason for referral
 Preferred
communication
– Fax
– Email
– Voicemail
– Mail
– Other
Care Coordination Out of the Office
Develop a Flow Chart or
‘How To Guide” for Clinic

How do I get an appointment?
 How do I get my labs?
 How do get I care from specialists?
 How do I get care after hours?
After Hours

Flow diagram—care seeking after hours
 Answering machine that says “go to ED” not
acceptable
 Don’t have too solve problem 100%--call back in a
few hours to see how they are doing
 Initiate first steps of therapy (UTI, hyperglycemia)
 Malpractice concerns—need documentation
Out of Hours—Telephone Charting
Move to Action!

What is the status quo in your clinic?
 What advice would your patients give us?
 What have you tried?
– What went well?
– What did you learn?

What will be your next PDSA?
 What tools or resources will you need?
Medication Reconciliation
Medication Reconciliation
What Are We Looking For?

Create a single list
 Identify discrepancies (incompatible regimens)
 Drug/Disease=pertinent positives and negatives
 Drug/Drug=most common, most serious
Engaging the Patient

Encourage patient to bring all medications
or list to every encounter
 Provide with a dedicated tote bag
 Key=> must positively reinforce behavior
 Initial MA or RN review
Scripting Patient Care
Coach or give permission to speak up:
– Every time a prescriber takes out a prescription pad,
ask “would you like to see my medicine list” or “will
this new medication interfere with my current meds?”
Personal Health Record
My Medications are:
Medication
Dose
Reason
Side Effects
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Allergies: _____________________
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Remember
to take this Record with you
to all of your doctor visits