Mile High Health Alliance

Mile High Health Alliance, Specialty Care Access Working Group
National Partnership Project:
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Denver Health and Hospital Authority
America’s Essential Hospitals
National Association of Community Health Centers
Kaiser Permanente
December 4, 2014, 11:30 am – 2 pm, COPIC
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Purpose of the Meeting
Introduction of Participants
Formed in 2014 based on recommendation in
Denver’s Community Health Improvement Plan:
5-Year Access to Care Goal: By December 2018, at least
95% of Denver residents will have access to primary
medical care, including behavioral health care
Objective A3: Create a health alliance of important
stakeholder organizations in Denver, to increase access
to care, better coordinate health care services, and
decrease health care costs.
Brings together stakeholders from:
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medical care
behavioral health care – mental health and
substance abuse treatment
public health
other governmental entities
social and community services
to collaboratively address the city’s most
difficult health challenges and achieve better
health for all Denver residents.
Mission: Achieving Better Health through Collaboration
Three Initial Program Areas:
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Meeting since April 2014: Hospitals and health care systems,
safety net clinics, behavioral health providers, public health,
Colorado Access (RCCO), CORHIO, private specialty physicians
Convening support from the National Partnership Project
Background:
◦ Access to specialty care for uninsured and underinsured is a
major challenge, not solved by expansion of coverage.
◦ Sharing the burden of providing specialty care could be
managed through a referral system connecting supply and
demand for care.
◦ Studied several referral systems in other cities and states, for
e-consults and face to face visits.
1. Central hub connecting uninsured and underinsured patients to specialty care providers, with
equitable distribution of the burden of care.
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Safety net clinics refer patients to hub
Providers located in specialty care systems and private
practices
2. Hybrid to include both e-consults and face-toface referrals. E-consults whenever possible.
3. Support for patients to keep appointments –
reminders, transportation, interpretation.
4. Good communication between PCP and
specialist, retain patient in original medical
home.
5. Capacity for both physical and behavioral health
care referrals. Develop in sequence or
integrated from the start.
6. Support PCPs to practice at the top of their
scope.
7. Coordination with new developments regarding
HCPF e-consult program and CO Project ECHO.
8. Plan for the remaining uninsured.
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National Partnership of the Health Care Safety
Net
◦ America’s Essential Hospitals
◦ National Association of Community Health Centers
◦ George Washington University
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Funded by Kaiser Permanente Community
Benefit Arm
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Purpose: To support safety net providers
efforts to collaborate around the ACA
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Partnered with Denver Health since early
2014
◦ Will continue through December 2015
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Now working with Specialty Care Access
Group
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Our Support Includes:
◦ Planning Calls
◦ Technical Assistance
◦ Stakeholder Engagement
Means of improving access
• Distribute burden
• Improve efficiency
• Increase scope of care provided in medical
home
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Community
Health Center,
Inc
(Connecticut)
San Francisco
General Hospital
LA Care Health
Plan
Kaiser Pilot
(Denver)
Primary care
submits
electronic
referral
Specialist
reviews
Iterative
communication
Specialist
requests more
information
Specialist provides
guidance and PCP
manages patient
Specialists
recommends inperson visit
Figure 1: Adapted from slide in California Healthcare Foundation webinar:
“Electronic Referral and Consultation Systems (eCR),”
http://www.chcf.org/events/2014/cin-webinar-05-28-2014
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Project Access
Northwest (Seattle)
Operation Access
(San Francisco)
Doctor’s Care
(Denver)
Medical Home
submits
referral
Specialist
requests more
information
Hospital-based
practices provide
service
Referral hub:
• Reviews for
completeness
• Assigns to
volunteer provider
• Provides case
management
services
Patient care
returned to medical
home
Independent/Group
practices provide
service
Specialty Care for Underserved Populations
Kaiser Permanente’s Safety Net Specialty Care Program
December 4, 2014
Documenting the Problem
 2010 partnership with the Colorado Health Institute
 Statewide assessment of the Safety Net’s availability of specialty care
services
 57 Safety Nets representing 102 clinics
 62% response rate from medical/clinical directors and administrators
15 December 3, 2014
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© 2011 Kaiser Foundation Health Plan, Inc.
Statewide Assessment Findings
“ Just to be clear – we struggle with every single
specialty. … Every day, across all specialties, we have
patients that can’t contribute to their communities,
can’t adequately support their families, and bear a
disproportionate burden of morbidity simply based on
their inability to obtain specialty services.”
— Safety Net Medical Director
16 December 3, 2014
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© 2011 Kaiser Foundation Health Plan, Inc.
Statewide Assessment Findings
 Uninsured have the most difficult time with access
 Securing specialty care through existing relationships with
specialists and/or hospitals
 Assessment highlighted access, not demand
17 December 3, 2014
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© 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
Statewide Assessment Findings
Denver Metro Area
 Least Available
– Reproductive Endocrinology
– Transplants
– Pain Management
 More Available
– Obstetrics
– Cardiology
– Gynecology
18 December 3, 2014
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© 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
Statewide Assessment Findings
19 December 3, 2014
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© 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
Statewide Assessment Findings
Neutral Conveners
 Bring together stakeholders and form partnerships
 Engage and recruit participating providers
 Coordinate care
 Maintain neutrality
20 December 3, 2014
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© 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
Demand Study
 Participating Safety Nets
– Clinica Family Health Services
– Metro Community Provider Network
– Salud Family Health Centers
 Availability of Services
 Commonly Referrered
– Orthopedics
– Gastroenterology
– Dermatology
21 December 3, 2014
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© 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
Safety Net Specialty Care Program
 Vision
– Provide specialty care services that will have positive health outcomes
for low-income Safety Net patients
 Goals
– To strengthen existing partnerships and create new collaborations with
health care Safety Nets
– Provide opportunities for Kaiser Permanente clinicians to serve
underserved populations in a meaningful and long-lasting way
22 December 3, 2014
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© 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
Safety Net Specialty Care Program
 E-consults
– Medical consultations that are conducted electronically, using a clinical
messaging portal enabled by a third party vendor, facilitating
communication between primary care providers (in the Safety Net) and
(Kaiser Permanente) specialists
 Direct Care
– Safety Net patient face to face visits with a specialist
 Medical Education
– Opportunities for Kaiser Permanente clinicians to formally and informally
share information, new guidelines, and best practices with Safety Net
providers
23 December 3, 2014
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© 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
Safety Net Specialty Care Program
E-consults
Safety Net Specialty Care Program
Direct Care
 Mutual agreement between providers
 Uninsured adults
 Specific menu of services
E.g. Cardiology
– Echocardiograms
– Holter Monitor
– Event Monitor
– Treadmill
– Nuclear Treadmill
 Wrap around services
Safety Net Specialty Care Program
Medical Education
 Identifying topics
 Informal and formal education
– Hep C guidelines for Safety Net partner leads
– CME course: pre-op physicals
Safety Net Specialty Care Program
 Administration-Colorado Community Health Network
 Safety Nets
– Clinica Family Health Services
– Metro Community Provider Network
– Salud Family Health Centers
 Kaiser Permanente Specialties
– Allergy/Immunology
– Cardiology
– Dermatology
– Endocrinology
– Gastroenterology
– Ophthalmology
– Pulmonology
– Rheumatology
Safety Net Specialty Care Program
 552 e-consults
 78 direct care visits
 2 instances of medical education
Safety Net Specialty Care Program
Lessons Learned
 Focus on patient outcomes
 Be Nimble
 Utilization challenges
 Relationship building and neutrality
 Patience and persistence
http://www.coloradohealthinstitute.org/uploads/downloads/2010_Special
tyCare.pdf
[email protected] or 303-344-7604
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Our Mission:
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eConsult - What is it?
• An electronic consultation/referral (eConsult)
program would enable primary care and
specialist providers to quickly and easily
exchange clinical questions, messages and
share patient medical records as part of a
medical consultation process via a secure
online HIPAA-compliant telemedicine system.
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The Potential Importance of an
eConsult System:
• It is estimated that 30 percent of referrals
could be avoided if additional forms of
communication between PCPs and specialists
were available.
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eConsult Program Results
• The Doc2Doc study in Oklahoma 2007-12:
Established network of 502 providers (including 208
specialists)
 Managed more than 110,000 patient referrals and
online telemedicine consultations.
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• Benefits included
Reduced wait times for access to specialty care.
 Reductions in unnecessary specialty visits.
 Cost savings of over $130 PMPM for patients
receiving eConsults when compared to patients who
were simply referred for specialist visits.
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Providers Appreciate eConsult Systems:
• A survey of PCPs using San Francisco General
Hospital’s program showed that, “seventytwo percent of primary care providers
reported that electronic referrals improved
overall clinical care compared to prior
methods.”
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High Interest in Colorado:
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Provider Survey: Estimated proportion of referred
patients appropriate for eConsult services:
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Establishing eConsult in Colorado
• The Department is working with CORHIO:
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Working to identify an eConsult program option.
• Establishing funding Authority:
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Working with CMS to ascertain Colorado authority to
fund an eConsult Program.
• The Department hopes to pilot an eConsult
program in early-2015.
 Initiate mechanisms to reimburse providers’ eConsult
work.
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Selecting eConsult Pilot Specialty(ies)
• To pilot the eConsult system HCPF will evaluate:
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What specialty(ies) do primary care providers believe would be
most helpful?
Specialty
% PCPs Indicating Need
*From HCPF provider survey data
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Selecting Pilot Specialty(ies) - continued
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What specialty(ies) do RCCOs assess to be most needed?
o Neurology, Rheumatology, Urology, Dermatology,
Psychiatry, Endocrinology, Eccrinology.
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What insights can we gain from Medicaid client specialty usage
data?
o Analyze usage, costs, etc.
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What specialist types/groups are motivated to pilot eConsult?
o Identifying specialist types/groups that are excited and
capable of supporting a successful pilot will be critical.
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Need to Identify Right Specialty for Successful Pilot
Colorado Provider Survey Responses from Specialists:
I would be willing to dedicate the following number of hours
per week to eConsult work when necessary:
Hours Per Week
% Indicated this
Response
Number of
Responses
0 to 2
72.28
73
2 to 4
23.76
24
4 to 6
2.97
3
6 to 8
0.99
1
More than 8
0
0
Total
101
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eConsult Next Steps:
• Finalize eConsult system plans & timeline with
CORHIO.
• Stakeholder engagement efforts.
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Identify pilot specialty(ies).
Recruit primary & specialty care providers to participate.
• Establish provider reimbursement mechanisms.
• Launch Pilot & Grow eConsult Program.
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Decide in advance who at your table will:
1. Facilitate the discussion
2. Take notes for the group
3. Report back to the whole
Review and evaluate the recommendations for a new
specialty care referral hub in Denver - which includes
options for both e-consults and in-person referrals according to the following criteria:
1. Urgency of the need
2. Effectiveness of the model for both Medicaid/underinsured and uninsured
3. Ease and speed of implementation
4. Ensuring participation of specialists and specialty care
systems in Denver
5. Cost of establishing the system
6. Sustainability
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Briefly report on your group’s discussion,
adding ideas not yet presented by groups
reporting before you.
For more information or to
join the Mile High Health
Alliance and the Specialty
Care Access Group,
contact Dr. Lisa McCann,
[email protected]