Real-Time ReferralProgram Overview

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Primary Care – Specialty Care

Primary Care

Specialty Care

• An ideal system will provide timely specialty input, when needed.

• No more and no less

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Stakeholders: Purchasers / Payers

• Our care is too expensive for population-based and value-based payments

• Credible threats to exclude AMCs from network coverage

• The referral rate doubled between 1999 and 2009

• 1 in 3 patients is referred to a specialist each year (1 in 2 for the elderly)

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Stakeholders: The Patient

• “I have a problem today.”

• Care burden:

• Time from work

• Copayment

• Transportation

• Parking

• Child care

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Stakeholders: The PCP

• Timely access to specialty guidance

• Some questions have:

• A narrow scope

• Available data in the shared EHR

• Without the need for an exam

• Relational continuity with the patient

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Stakeholders: The Specialist

• Address lower-complexity questions efficiently

• High complexity cases improve teaching

• Reimbursement for non face-to-face work

• Improve access

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RTR Program

eReferral + eConsult = RTR Program

• eReferral: Improves quality and clinical content of referrals, optimizing utilization

• eConsult: timely input from specialists for lower complexity, data-driven questions

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Impact at 1-Year- UCSF Experience

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RTR Program

• 72 hour eConsult response expectation

• Specialist can convert to a scheduled visit for case

complexity

• 0.5 wRVU payment to Specialist

• 0.5 wRVU credit for PCP (toward productivity)

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I am referring @name@, a @age@ y/o @sex@, to Gastroenterology for direct scheduling for colonoscopy

Indication: (choose one)

My assessment that this patient is safe for an endoscopic procedure with sedation.

This patient, (please select any that apply)____ has had a recent MI or STROKE____ requires HOME OXYGEN____ is on ANTICOAGULATION therapy____ has a clinically significant CARDIAC ARRHYTHMIA ____ has a history of CHRONIC OPIATE or SUBSTANCE ABUSE____ has a history of a PSYCHIATRIC disorder to consider when planning sedation.____ has severe OSA ____ Other co-morbidity that should be considered in consultation prior to sedation

If the patient has one of the above risks, @he@ will be scheduled in the GI clinic for an evaluation prior to the procedure.

eReferral

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eConsult

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Clarify Expectations for Follow-Up

Pending specialist evaluation, I anticipate:

-CONSULTATION ONLY: Recommendations and Return to Primary Care

-CO-MANAGEMENT—PCP IS FIRST CALL: PCP maintains responsibility for day-to-day management -CO-MANAGEMENT—SPECIALIST IS FIRST CALL: Specialist assumes responsibility for management of thIs

problem.

-E-CONSULT

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Improved Access for Primary Care PopulationReferrals and eConsults per 100 Primary Care Visits

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Improved Access for Primary Care PopulationReferrals and eConsults per 100 Primary Care Visits

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Increased External Referrals

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UC- Wide Expansion

• RTR Implementation at UCSD, UCLA, UCD and UCI

– Synergistic efforts to improve access to specialty care

– Improve the total value of care for their PC populations

– Share EPIC platform

– Buy-in

• 14 specialties will be introduced over 12 months

ROI

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Primary Population of 50,000

• Improved access to specialty care has important implications not reflected in the model.

• Strengthening referral relationships• Greater access to higher complexity, external referrals to our

specialty practices• The reduction in ED use and hospitalization within 120 days of

referral (seen at UCSF)

  Year 1 (ramp up)

Year 2

Averted visits 275 1378eConsults 186 931

Gross Savings $70,695 $353,476eConsult Fee

(Medical Center / Medical Plan)

$19,893 $99,468

Net Saving $50,802 $254,008ROI  3.55:1  3.55:1

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Conclusion • Significant impact on:

• Referral rates

• Specialty care utilization

• Costs

• eConsult does not appear to induce demand

• High acceptability among PCPs and specialists

• Referral templates fundamentally improved referral

communication

• High quality, patient centered care – This is not merely

reducing cost > quality

• Timely access to specialists

• PCP relationship continuity

• Decreased complexity of care management

• Save patient out-of-pocket costs

• Train tomorrow’s physicians to deliver more flexible care

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RTRRTR