Using Electronic Tools for Improved

Care Coordination & Network SupportCareOregon

Jonathan Weedman, CCTP, LPC, Vice President, Population Health

Tanya Kapka, MD, MPH, Senior Medical Director, Clinical Services, CareOregon

“I have discovered in life that there are ways of getting almost anywhere you want to go, if you really want to go.”

― Langston Hughes

careoregon.org

CareOregon Strategy: Network and electronic toolseConsults on RubiconMD:

• Specialty support for primary care and improve patient/member experience and outcomes

• Reduce no-shows to specialists and increase timely access to specialist advice

Collective/PreManage:

• ED utilization reduction strategy funded upskilling and collaboratives on HIE tools in primary care network

• Alignment with key specialty behavioral health partners (MH and SUD) with flags/data sharing

• Value based payment model (inpatient, ED) cost of care metric for targeted work cost/utilization, flags/data sharing

GSI care coordination platform:

• Coordination with population health teams for complex patient management and care coordination on GSI

• Social workers embedded in network enhanced ability to support PCP and members by accessing health plan resources efficiently

Tableau dashboards:

• Regular sharing of quality metrics with clinic partners electronically and for leadership meetings and collaboratives

• Tracking specialty utilization patterns on dashboard organized by PCP site, specialty site, and/or by diagnoses

• Updated specialty dashboard for 2019 add ortho dashboard including MRI and opioid data tracking

EPIC support for network (QI and innovation team):

• Innovation team network support to clinics via partner projects and collaboratives for QI and EMR tools/workflows

careoregon.org

CareOregon Metro: Intentionally Aligning Regional Strategies, Priorities and the Quadruple Aim for Health Care Transformation

• value based alternative payment models supporting team based care

• BH integration and care coordination for BH/PH/dental needs

• Improved tools for care coordination and referrals

Enhancing Patient

Experience

• ED and hospital transitions using population segmentation models to target interventions; enhanced Regional Care Team support and coordination

• Spread of PreManage, Trauma Informed Care, enhanced care coordination

• data-informed focus on pediatrics and social complexity (OPIP collaboration)

Improving Population

Health

• specialty behavioral health coordination

• reducing waste to allow funding for higher priorities including social needs

• ED utilization reduction and improved access to evidence based high quality primary care

Reducing Costs

• optimizing team based care with staff working to top of license

• support for ongoing education and training (ECHO, MedsEd, collaboratives, TA)

• specialty support (including e-consults) and coordination for social needs

Reducing Provider Burnout

CCO 2.0 IS RIGHT AROUND THE CORNER! GOVERNOR’S PRIORITIES

1.Improve the behavioral health system

2.Increase value and pay for performance

3.Focus on social determinants of health and health equity

4.Maintain sustainable cost growth

SPECIALTY REFERRALS PROJECT

E-CONSULTS FOR PRIMARY CARE SUPPORT

GOALS: IMPROVE COST AND UTILIZATION AND QUALITY

Tanya Kapka, MD, MPH Senior Medical Director, Clinical Services

Swati Kumar, MPH Sr. Implementation Manager, RubiconMD

WHY E-CONSULTS?The Importance:• Many primary care referrals are low complexity, and do not need a face to face visit

• Access to some specialty care is limited, with potentially long delays

• Medicaid population historically has higher no show rate which strains relationships with specialists

• PCP and specialist relationships have eroded over time due to structural changes in care delivery

• Costly care in specialty settings may also include sometimes unnecessary procedures

WHY E-CONSULTS?Goals: Rebuild the medical neighborhood

• Less costly and more timely specialty advice

• Reduction in unnecessary specialty visits or procedures, particularly where access may be limited or delayed

• Support PCPs with tools to help them meet patient needs in the primary care home

• Improved ability to partner with specialists to target access for complex patients in a more coordinated way

careoregon.org

Access to specialty input

• Limitations with existing information services for complex cases

• Challenges with unclosed loops

• Limited specialty access for certain populationsAdministrative Burden

• Time burden of referring patients and managing physician networks

• Challenges coordinating care and obtaining information for specialists after referral Patient Satisfaction

• Long wait times for specialists appointments

• High out of pocket costs for services

• Inconvenience of visiting specialists including transportation and time off work Provider Satisfaction

• Lack of support and resources for primary care which prevents providers from practicing at top of their licenses

• Limited clinical knowledge sharing between primary care physicians and specialists

KEY CHALLENGES IN PRIMARY CARE

careoregon.org

−Primary care at the center of the health

care experience, that is why eConsults

empower PCPs with specialist insight to make informed decisions.

−Education. Learn something new with an

eConsult? Claim CME credit.

−Equal access to care – for any patient, no

matter who they are or where they live.

Founded in 2013, RubiconMD is an eConsult partner for primary care clinicians

careoregon.org

Of the 120 specialties & subspecialties few common cases across our top 8 specialties

Dermatology

▪ Rash diagnosis and treatment advice

▪ Management strategies for acne vulgaris

▪ Mole evaluation

▪ Plaque psoriasis treatment options

Cardiology

▪ EKG evaluation

▪ Resistant hypertension management

▪ Treatment advice of refractory hyperlipidemia

▪ Arrhythmia evaluation

Endocrinology

▪ Evaluation of hormonal abnormalities (thyroid, parathyroid, testosterone, etc.)

▪ Treatment options for patient with uncontrolled diabetes

▪ Osteoporosis management

Gastroenterology

▪ Colorectal cancer screening based on risk

▪ IBD workup and treatment advice

▪ Investigation of liver enzyme abnormalities

▪ Evaluation of fatty liver disease

Heme/Onc

▪ Acute/chronic leukemia workup

▪ Anemia investigation

▪ Incidental routine lab abnormalities analysis

▪ Anticoagulation therapy/prophylaxis recommendations

▪ Tumor workup and monitoring

Neurology

▪ New onset seizure evaluation

▪ Refractory migraine treatment and prophylaxis

▪ Peripheral neuropathy investigation

▪ Memory loss evaluation

OB/GYN

▪ Infertility workup and treatment

▪ Amenorrhea investigation

▪ Vaginal bleeding workup and diagnosis

▪ Management of pregnancy complications

Orthopedics

▪ Management options for fractures

▪ Operative indications for low back pain

▪ Knee ligament/meniscus tears treatment options

▪ Treatment advice for hip/knee arthritis

careoregon.org

THE PLATFORM

careoregon.org

careoregon.org

eCONSULT METRICS & SUCCESS

− 82% Improved Care Plan

− 67% Educational

− 30% Avoided Diagnostics

− 37% Avoided Referral

eConsult outcomes (reported by CareOregon clinicians)

All Dates

DEMAND BY SPECIALTY (PILOT SITES + EARLY SPREAD)

COST AND UTILIZATION OR QUALITY INTERVENTION?

HOW TO EVALUATE SUCCESS

• Referral more likely to appropriate specialty, in a timely manner

• Provider education, reducing the need for future referrals for other patients and includes CME to support quadruple aim goals

• Improved care plans, timeliness, and patient experience

• Better “packaging” when face to face visits are needed: diagnostic process and appropriate testing completed prior to specialty visit, reducing demand for total number of F2F visits

• Improved PCP efficacy, competence, and quality of care

careoregon.org

• Goal to have sustained ROI with phase 2 of spread (2019) while also improving patient outcomes/quality and experience of care

• Metro primary care innovation team supporting this phase of implementation in Metro area

• Quarterly data evaluation at CareOregon includes tracking of F2F visits and associated costs to track utilization data from Rubicon

• OCHIN clinics (both Rubicon pilot sites have OCHIN EPIC) opportunity for more success next phase given potential for platform integration into OCHIN EPIC

• Ongoing conversations with high quality specialty partners who are also engaged in developing better support regionally/statewide for primary care and Medicaid members

• What would be outcomes to measure going forward? Quality, utilization patterns, ROI?

e-Consult Implementation Next Steps Specialty Referrals Project

Atul Gawande on health care: from cowboys to pit crews

“Making systems work in medicine is the great task of my generation of physicians and sciences…as individualistic as we want to be, complexity requires group success. We all need to be pit crews now.”