C A L I FOR N I A H EALTH C ARE F OU NDATION Specialty Care in the Safety Net: Efforts to Expand Timely Access May 2009 Specialty Care in the Safety Net: Efforts to Expand Timely Access Prepared for California HealthCare Foundation and Kaiser Permanente Community Benefit Programs by Lisa Canin and Bobbie Wunsch Pacific Health Consulting Group May 2009 About the Authors Pacific Health Consulting Group specializes in providing management consulting services to public sector health care organizations and foundations. Bobbie Wunsch is a founder and partner. Lisa Canin is a clinical psychologist who does consulting, research, evaluation, and writing in social science and health policy arenas. For more information, visit www.pachealth.org. About the Foundation The California HealthCare Foundation is an independent philanthropy committed to improving the way health care is delivered and financed in California. By promoting innovations in care and broader access to information, our goal is to ensure that all Californians can get the care they need, when they need it, at a price they can afford. For more information, visit www.chcf.org. About Kaiser Permanente As a health care provider and nonprofit health plan, Kaiser Permanente’s mission is to provide high-quality, affordable care services to 8.6 million members and the communities served, through care innovations, clinical research, health education, and community collaboration. Kaiser Permanente provides funding and support for Community Benefit programs and services through research, community-based health partnerships, and direct health coverage for low-income people and families. For more information, go to www.kp.org/newscenter. ©2009 California HealthCare Foundation Contents 2 I. Introduction Major Activities and Sources of Data 4 II. California’s Safety Net for Specialty Care Areas of Highest Need Efforts to Expand Access Challenges in Referral and Communication Processes Challenges in Data Collection 8 III. Findings and Future Directions Referral and Clinical Care Guidelines Provider Training and Expanded Scope of Practice Expanding Specialist Networks Web-Based Referrals Telemedicine 1 5 IV. Conclusions 1 7 Appendices: A: Specialty Care Coalitions and Grants B: Resources to Support Specialty Care Access I. Introduction The work focused on three areas: T imely access to specialty care is a significant and growing challenge for low-income Californians who depend on safety- the demographics of specialty care net institutions — public hospitals and community clinics and health for California’s underserved; centers — for their health care. To better understand the size and causes of the problem, as well the size and scope of access problems; as to encourage effective solutions, Kaiser Permanente Northern and and the cultivation of innovative Southern California Regions’ Community Benefit Programs partnered with the California Association of Public Hospitals (CAPH) and the strategies to improve access and California Primary Care Association (CPCA) in 2006 to examine manage demand. specialty care access for uninsured and Medi-Cal populations. Project activities included a statewide survey of safety-net providers, discussion papers, roundtable forums, and technical assistance teleconferences. Then, in 2007 Kaiser Permanente Community Benefit and the California HealthCare Foundation (CHCF) came together to fund 28 planning grants and 23 implementation grants to regional provider coalitions across California to identify local barriers to care and develop strategies to improve access. Implementation projects began in early 2009. The work has focused on three areas: the demographics of specialty care for California’s underserved; the size and scope of access problems; and the cultivation of innovative strategies to improve access and manage demand.1 The purpose of this report is to share findings from these activities with a broad audience. Major Activities and Sources of Data This report highlights findings from a series of activities that address specialty care access and the promotion of integrated community care in the safety net. The Specialty Care Access Initiative (SCAI) was established in 2006 by Kaiser Permanente Community Benefit in partnership with the California Association of Public Hospitals and Health Systems/California Health Care Safety Net Institute (CAPH/ SNI), and the California Primary Care Association (CPCA). Kaiser 1.The work focused on internal medicine sub-specialty services to adults and did not include mental health or dental care. 2 | C alifornia H ealth C are F oundation Permanente Community Benefit brought CAPH and The funders developed, and will continue to CPCA together as partners to examine the problem provide, training and technical assistance resources of specialty care access and explore promising for learning about promising practices across approaches to improving access. Building a strong California’s safety-net organizations. Included are collaborative alliance between these institutions was reports, discussion papers, roundtable forums, and an important component of the overall project. technical assistance teleconferences. These activities To provide benchmark information, the Pacific are detailed in Appendix B. Health Consulting Group conducted a specialty care survey of the state’s community clinics and health centers (CCHCs) and public hospital systems in 2007. Fifty-eight percent of California’s clinic corporations responded to the survey, as did 80 percent of the state’s public hospital systems. At the end of 2007, Kaiser Permanente Community Benefit (throughout its Northern and Southern California regions) and CHCF (for rural communities not covered by Kaiser facilities) offered local safety-net coalitions the opportunity to develop community plans to improve specialty care access. In most cases, coalitions were county-based, comprised of community health centers, public hospital systems, and other partners such as county health departments, private providers, and medical societies. In other areas, such as Los Angeles, coalitions were based on specific geographic planning areas within the county. In some rural areas regional coalition members partnered across county lines. Coalitions received planning grants and the opportunity to apply for multi-year implementation grants in 2008. A total of 28 coalitions completed planning grants and 23 coalitions received implementation grants, representing a four-year commitment of more than $20 million by the funders. A complete list of grants is included in Appendix A. Specialty Care in the Safety Net: Efforts to Expand Timely Access | 3 II. California’s Safety Net for Specialty Care Public hospitals are the largest W hile the safety net for primary care is clearly defined, the safety net for specialty care is not well understood. provider of specialty care in Safety-net primary care providers throughout California rely on California’s safety net. three principle sources for specialty care: public hospital systems, community clinics and health centers (CCHCs), and private specialists. Public hospital systems. These are the largest provider of specialty care for the safety net in California, offering a wide range of onsite services for their own primary care patients and those in the community. The vast majority of public hospital patients’ specialty care needs are met in-house. Where there are no public hospital systems, patients receive specialty care from an array of sources, including private providers, CCHCs, out-of-area specialty centers, and private hospitals. Further findings: Most referrals to public hospitals for specialty care come from providers within the public hospital systems: In-house primary care providers account for 52 percent of the total referrals, and in-house specialists provide another 12 percent. One-fifth of the referrals come from CCHCs, and 11 percent from private providers. Public hospital systems are the largest referral destination for outside specialty care for CCHCs, receiving 39 percent of their total outside referrals. All of the public hospital systems refer at least some patients to sources outside of their systems for specialty care. Community clinics and health centers. Though the level of specialty care provided by CCHCs is often limited, 61 percent of CCHCs indicated that their organizations provide at least one specialty service onsite, and more than a third offer three or more different specialties. Despite the generally limited role that CCHCs play in providing specialty care services, a few serve as major safety-net specialty care providers in their communities; this is particularly true in rural Northern California. 4 | C alifornia H ealth C are F oundation Specialty care services offered by CCHCs tend the 2004 study, 85 percent of clinic medical directors to be targeted to their own primary care patients. in California’s federally funded health clinics said Of the specialty care referrals that CCHCs receive, their patients “often” or “almost always” had trouble 82 percent come from in-house primary care accessing specialty care. Half of the surveyed medical providers. Ten percent come from primary care directors described the situation as having worsened providers at other CCHCs, and 4 percent come from over the prior two years. private providers. Only 16 percent of the CCHCs As reflected in both the 2007 statewide survey that provide onsite specialty care do so with special and the regional coalition needs assessments, funding. Almost half of those with special funding orthopedics, gastroenterology, neurology, and for specialty care are located in the Los Angeles area; dermatology were perceived as the services most this indicates that most CCHCs absorbed these difficult for safety-net patients to access. These services into their annual operating budget. specialty areas were also among the top ten most Private providers. These deliver a significant needed services identified in the 2004 Mathematica amount of specialty services for safety-net patients. study. Not surprisingly, the 2007 survey showed Survey respondents reported that 33 percent of that the longest mean wait time for CCHC all CCHC referrals for outside specialty care were patients referred out were ones identified by survey made to private providers. The lowest percentage respondents as being among the most needed and of referrals from CCHCs to private providers was most difficult to access: neurology, orthopedic reported in communities with public hospital surgery, and dermatology. For two-thirds of the types systems, such as Los Angeles County (16 percent); of specialty services referred out, CCHC patients the highest percentage was in rural Northern typically waited between one and three months to California (61 percent) and other communities see specialists. Public hospital patient referrals to without access to public or University of California neurology care outside of the public hospital system hospital systems. also had long waits (three to six months). The longest wait time of all was for dermatology services referred Areas of Highest Need out of public hospital systems for patients with The 2007 survey findings reaffirm a 2004 complex needs; the typical wait was more than six Mathematica survey commissioned by CHCF months. that found significant barriers to timely access for The survey inquired about the extent to which specialty care by Medi-Cal and uninsured patients. In primary care providers limit patient referrals due to anticipated access difficulties. Respondents estimated that approximately one-third of their primary One-third of safety-net primary care care providers “frequently” limit referrals to high- need specialty services because of perceived access providers “frequently” limit referrals to difficulties. This type of referral suppression was high-need specialty services because of more pronounced among CCHC providers than those in public hospital systems, possibly because perceived lack of access. these hospitals provide a range of specialty services in-house. Specialty Care in the Safety Net: Efforts to Expand Timely Access | 5 Furthermore, primary care providers in CCHCs disease (including HIV/AIDS), or orthopedic had difficulty accessing consultation with specialists care into their scope of practice. There was little when they needed it. The clinics reported that their evidence of expanded scope activities in other primary care providers were able to consult with a specialties. specialist less than half of the time that consultation Personal relationships were critically important was needed. Some regional differences were notable, in engaging specialists and obtaining care for with primary care providers in Los Angeles County patients and consultations with providers. reporting particularly high levels of difficulty Safety-net institutions overwhelmingly depended obtaining consultation. Primary care providers in the on providers’ personal relationships to recruit public hospital systems were somewhat less impacted; specialists. Concern was expressed about the risk survey respondents reported that these providers were of overburdening a limited number of specialists able to access consultation 50 percent to 75 percent personally known to safety-net providers. of the time. Although nearly one-third of the responding Efforts to Expand Access CCHCs had telemedicine equipment available, it Prior to new funding there were already efforts was not widely used to expand access to specialist underway to increase access to specialty care, providers in the safety net, except in isolated rural according to survey respondents. These strategies areas. included providing onsite specialty care, expanding the scope of practice for primary care providers, Challenges in Referral and building a specialty referral network, and acquiring Communication Processes the capacity to get access via telemedicine. Referral processes generally were not standardized and did not incorporate referral guidelines and Onsite specialty care, provided to some degree treatment protocols. The resulting inefficiencies by 61 percent of responding CCHCs and all the were particularly problematic in an environment of public hospital systems, reduced patient wait limited resources. They included: time, improved primary care providers’ ability to expedite service delivery, and enhanced the Inappropriate or ambiguous referrals (those frequency and ease with which primary providers without sufficient information); could access consultation. For example, while the Incomplete or insufficient work-ups better typical wait time for a majority of outside referrals addressed with more complete primary care was between three and six months, CCHC attention, resources, or training to manage patients typically waited less than four weeks for routine specialty needs in-house; onsite care. In addition, primary care providers were much more likely to receive consultation Difficulty allocating specialty appointments reports back from onsite specialists. rationally for the sickest or most complex patients; and Only 14 percent of CCHC respondents indicated that some of their primary care providers Over-reliance on one-to-one personal incorporated specialty dermatology, infectious relationships and informal processes that are 6 | C alifornia H ealth C are F oundation inefficient and do not build a reliable and Challenges in Data Collection sustainable institutionalized network of specialty In order to establish a baseline understanding of providers. specialty care access, the authors used the survey and the needs assessment component of the Few CCHCs and public hospital systems had implementation planning grants to assess the access or used written guidelines for referring patients for problems in a range of ways. For example, the survey outside specialty care. Most of the public hospital included queries regarding numbers of patients seen, systems had written referral guidelines for at least specialty visits provided, and number of patients some onsite specialty areas. referred. Furthermore, strategies for improving There were significant difficulties in capturing coordination of specialty care referrals had not been consistent, reliable, and valid information about widely adopted in safety-net practice. These strategies the level of care provided by CCHCs and public include technology enhancements, such as tracking, hospital systems and the amount of care needed electronic health records (EHRs), email, and Web- by their patients. Often, the data were incomplete, based referral, as well as offering patient support inaccurate, or missing. Only a minority of the to insure that appointments are kept and that organizations consistently tracked referrals in records are in order and present at appointments. searchable and quantifiable ways. The safety-net A significant survey finding was that 68 percent of organizations had very different processes for tracking the CCHCs and 53 percent of public hospitals used referrals and accessing data about them. Some only a manual log to track referrals, and 30 percent of kept information in patient charts or handwritten safety-net institutions did not track specialty referrals logs; some that had computer systems did not use in any formal way. Only 4 percent of the CCHCs them; and others used computer referrals, but with and 20 percent of the public hospitals reported using systems that were not searchable. Even clinics that electronic medical records, and less than 15 percent maintained computerized referrals often captured of all respondents used email to communicate with information that was inconsistent across standard specialists. fields. This meant that observations regarding need were likely to reflect qualitative impressions. The lack of a common understanding of metrics Most safety-net primary care providers created other problems. For example, “wait time” for specialty care could be defined as beginning when used manual logs to track specialty a provider identifies the need for specialty care, or referrals; 30 percent did not track when a referral clerk records and enters the need. Another measurement challenge was the difficulty referrals at all. of accounting for demand suppression — which occurs when providers do not refer patients to specialty care because they have not been successful in accessing it in the past. A related problem was measuring the impact of referral lists being closed because they were too long or full to accept referrals. Specialty Care in the Safety Net: Efforts to Expand Timely Access | 7 III. Findings and Future Directions Three broad approaches emerged: In late 2008, Kaiser Permanente C ommunity Benefit and CHCF Specialty Care Initiative grantee coalitions submitted Reduce the demand for implementation proposals describing local strategies to improve specialty care; expand the access to specialty services. Twenty-three coalitions received funding to implement the strategies. Three broad approaches emerged: supply of available services; and Reduce the demand for specialty care; expand the supply of available strengthen the coordination of care. services; and strengthen the coordination of care. The plans reflected the unique needs and capabilities of individual coalitions, as well as knowledge and opportunities that emerged through the statewide survey, discussion papers, technical briefs, roundtable forums, and regional planning processes. The goal of coalition activities is to enable systemwide change and advance the larger goal of integrated community care in the safety net. It is anticipated that future work will extend far beyond the life of the grants. More than half of the regional coalitions plan to implement one or more of five types of improvement activities, including: Development and implementation of referral and/or clinical care guidelines; Training for primary care providers, including fuller scope to incorporate specialty care activities; Expanded specialist networks; Web-based referral or consult systems; and Referral coordination improvements. In addition, a wide range of other approaches are being planned or expanded by the coalitions, including: Shared specialist or hub models to expand specialist networks; Use of mid-level providers; Internal specialty clinic redesign; Chronic disease registries; 8 | C alifornia H ealth C are F oundation Clinical care screening programs; The specialty areas most frequently focused on in Community collaborations and regional implementation plans include: partnerships; • Orthopedics (addressed in 50 percent of the coalition plans) • Gastroenterology (38 percent) Public health campaigns; and • Neurology (31 percent) • Dermatology (23 percent) Transportation services to specialty care • Cardiology (19 percent) appointments. • Endocrinology (19 percent) • Ophthalmology (15 percent) The planned improvement activities tend to • Rheumatology (15 percent) be multi-dimensional. Adoption of one approach typically involves a range of inter-connected activities. For instance: The implementation plans are not necessarily Primary care provider training to incorporate directed toward highest-need specialties. In a number some degree of specialty care or diagnostic of situations, coalitions selected specialties perceived activity into the primary care setting is almost as having the greatest opportunity for success. For always planned alongside clinical guideline example, while cardiology and ophthalmology were adoption; identified by CCHC survey respondents as two Expanded specialty care networks designed of the easiest specialty services for their patients to encourage broader participation by private to access, they are included as focus areas in a specialists are generally accompanied by number of the coalition plans. Feasibility and ease complementary strategies to simplify the of implementation, regardless of relative assessment referral process, ensure appropriate referrals, of need, was a significant factor for some coalitions. and improve provider communication (i.e., In fact, one plan characterized a component of their referral coordinators, Web-based referral activities as a “low-hanging fruit” approach, in which systems, referral guidelines); it was determined that a large impact on access and quality could be realized with minimal added cost. Web-based referral projects are frequently implemented with the use of referral guidelines; and Telemedicine, Web-based consulting technologies, shared specialists, and circuit riders are all strategies that require recruitment of specialists or expansion of specialist networks; some of the plans articulate recruitment strategies. Specialty Care in the Safety Net: Efforts to Expand Timely Access | 9 Referral and Clinical Care Guidelines Provider Training and Expanded Scope Safety-net providers see guidelines as a way to of Practice standardize and streamline specialty referral, improve Training for primary care providers, included in provider relations, and triage specialty resources 61 percent of the coalition plans, focused on general by preserving them for higher-need cases. Rather specialty training and skill development in specific than designing guidelines from scratch, a number diagnostic and treatment procedures. A range of of coalitions and safety-net providers intend to use purposes were given, including: guidelines that have already been implemented in Increasing comfort and familiarity in expanded other settings. Significant concern was expressed clinical areas in order to implement care about the extent to which guidelines incur additional guidelines effectively in specialty areas and diagnostic services and care management resources pre-referral work-ups; Enabling primary care providers to expand their scope of practice in order to directly provide Safety-net providers see guidelines as a way specialty care and diagnostics; to standardize and streamline specialty Allowing primary care providers to adopt the role referral, improve provider relations, and of specialist champion at their sites, providing internal training for and consultation with other triage specialty resources by preserving primary care providers; and them for higher-need cases. Enhancing the possibilities for co-management between specialists and primary care providers for patients with complex specialty care needs. for which there is generally no compensation. In addition, internal resources need to be allocated The plans identified a range of delivery for provider education and training to use approaches to expanded training, including: guidelines effectively. The coalitions that plan to Mini-fellowships, in which specialists provide develop guidelines through specialist/primary care intensive clinical training opportunities (often collaborative processes, sometimes referred to as alongside themselves) as well as mentoring, “consensus guidelines,” see this as an opportunity patient co-management, and access to future to create the trust needed to build future clinical consultation; collaboration — including patient co-management, consultation, and mentoring. Monthly or quarterly CME workshops, typically onsite in the primary care provider environment, focused on effective triage and delivery of specialty care; Access to Webinar classes or telemedicine consults for training purposes; and 10 | C alifornia H ealth C are F oundation Procedure-intensive training opportunities, areas and safety-net patients) that specialists are including short courses and focused procedural less interested in. Geography plays an important mini-fellowships. role. Providing primary care providers with training These approaches often focus on the most in procedures is resource intensive in terms of common procedures and conditions with high unmet time, cost, and personnel. A growing number need, such as flexible sigmoidoscopy, colposcopy, of fellowships as well as successful commercial breast cyst aspirations, facial lesions, cryotherapy, ventures offer hands-on CME specialty splinting, casting, joint injections, diabetic foot procedures training for primary care providers. care, nail/callous removal, stress testing, and office In making decisions, safety-net providers must ultrasound. weigh need, capacity, and access to cost-effective Because the scope of practice for primary care training. providers has narrowed over the past decades, there is vigorous debate within national family and internal Consideration must be given to managing medicine societies regarding the need to train and time and resource demands as well as financial certify primary care providers in a fuller range of disincentives such as reimbursement obstacles and procedural and diagnostic skills. The potential productivity pay arrangements. One viewpoint benefits include better access for patients, greater is that primary care providers can most easily continuity of care, and professional growth and train to provide procedures and diagnostics that competence-building opportunities for providers. A are more objectively assessed and amenable to discussion paper about an expanded scope of primary practice guidelines (e.g., ENT, diabetes, fractures, care practice described eight examples in safety-net and sigmoidoscopies). Further, it is argued by institutions throughout California. Major discussion some experts that the more “cognitively complex” points included the following: and time-consuming areas (e.g., neurology, psychiatry, and pain) pose too great a potential Activities most frequently identified as drain on basic primary care to recommend as a appropriate for primary care provider strategy. fuller scope include: colonoscopy, esophagogastroduodenoscopy, diagnostic ob/gyn Ongoing consulting relationships with specialists ultrasound, colposcopy, outpatient radiography, are an important support for expanded scope office orthopedics (including joint exams, of practice. Collaborative training experiences, injections, simple castings, and fracture care), including mini-fellowships and formal and informal fine-needle aspiration, skin cancer screening and mentoring relationships, all provide opportunities for biopsy, EKG interpretation, diabetes care, and the growth of consultative relationships and patient infectious disease management. co-management. Expanded scope activities that specialists do not The benefits of an expanded scope of practice want to do tend to happen naturally and with must be balanced against potential negative impacts relatively little “turf ” conflict. The same is true on primary care time and overburdening primary for locations, settings, and populations (e.g., rural care providers. Concerns include increased marginal Specialty Care in the Safety Net: Efforts to Expand Timely Access | 11 costs (diagnostics, medications, and provider time recruitment efforts to develop and publicize system dedicated to specialty care), the need for expanded improvements. liability coverage, and increased demand for specialty Expanded efforts are expected to help support services. In addition, fear was expressed about professional norms and expectations regarding increased demands of more complex, medically participation in safety-net care, which, in turn, difficult patients. helps create sufficient “critical mass.” When more Strategies for retention of primary care providers specialists are engaged to help, those who do can be included opportunities for professional growth assured that the burden will be spread so they are not such as teaching, leadership, clinical care, and overwhelmed with unmet need. procedural training activities. However, it was noted Not all of the plans intend to use newly recruited that such experiences make primary care providers specialists in the same way. Some are committed to more eligible for recruitment to specialty practices. having decentralized onsite services, although only Additionally, the role and training of mid-level four programs plan to recruit for the purpose of clinicians such as nurse practitioners and physician scheduling specialists onsite. To attain malpractice assistants was discussed as a strategy to further reduce coverage and enhanced Medi-Cal reimbursement, the burden on primary care physicians. some plans are moving toward shared specialist care through a specialty care “hub” at sites with federally Expanding Specialist Networks qualified health center (FQHC) approval. About one-third of coalitions proposed developing A discussion paper and technical brief “specialist networks” that formally engage a larger commissioned for this project address some of the network of volunteer and paid specialists to serve financial, legal, and regulatory challenges safety- safety-net patients. This differs markedly from net institutions face as they offer more specialty the historically informal personal relationships care within primary care settings. Providing onsite that characterize specialty care in many safety- care requires considerable administrative time net settings. In order to make participation more and attention to manage. Safety-net providers attractive to specialists and efficient for safety-net must attend to a complex set of federal and state primary care providers, coalition strategies typically policies and regulations that govern accepted scope include system improvements such as strengthened of practice and licensing. Additionally, there are utilization tracking, clear contractual agreements, financial implications of onsite care, including: Web-based referral systems, and implementation of Risk of increased levels of uncompensated care; consensus care guidelines. Benefits of developing more formalized referral processes include simplifying Increased auxiliary staffing and other resources, participation for specialty providers, ensuring that including space, equipment, pharmaceutical and there are clear terms of participation for them, and diagnostic needs; and reducing the burden on primary care providers Need to provide malpractice “gap” coverage for caused by having to manage multiple individual specialists who otherwise would not be covered relationships. Some providers plan to use physician (e.g., retired specialists). champions or specialty care coordinators for their 12 | C alifornia H ealth C are F oundation A January 2009 Policy Information Notice (PIN) number of patients referred, seen, closed, remaining regarding “Specialty Services and Health Centers’ open, and directly booked). Scope of Project” describes the criteria federal There are financial implications of referral agencies will use to evaluate requests from health technologies and Web-based programs. Advantages centers seeking to add specialty services. Important range from improved allocation of scarce resources, implications for staffing arrangements, malpractice reduced waste and inefficiency, improved coverage, data requirements, and compliance communication between primary care providers and reporting are outlined in these new criteria. specialists, and enhanced capacity to track and report on referral metrics. The costs are also significant: Web-Based Referrals intensive commitment of staff resources; hardware; Over 60 percent of the coalitions plan improvements software licensing, subscription, and maintenance; to their referral and consulting systems. Some implementation support; training; and maintenance. encompass full integration with EHRs and An additional obstacle is that some private specialist interoperability with other systems management offices may be unequipped to handle referrals or tools, while others focus on specific specialty areas or connect electronically to the referral system. on standardizing email protocols. A range of goals Some implementation plans proposed new were identified for these initiatives, including: or modified staff roles to help oversee improved specialty referral and case management. These varied Automation of appointment reminders; by institution with respect to terminology and Integration of guidelines; functions of personnel. Specific activities described for these staff roles include: Convenient review and triage of requests; Recruiting and maintaining relationships with Increase in legibility and completeness of referral specialty providers; and scheduling; Overseeing care coordination and planning Ability to expedite urgent referrals; (work-ups, patient education, tertiary care, Ability to track referral progress; follow-up); Capacity to store and forward diagnostic Referral coordinating and tracking; information and images; and Standardizing, streamlining, and coordinating Standardization and improvement of consultation communication between specialists and primary reports back. care providers and between patients and providers; Even implementation plans that lack guideline Developing and/or implementing referral and decision-support or provider communication guidelines and treatment protocols; mechanisms can enable the tracking of access and utilization data (e.g., referral or consult request and Managing chronic disease registry activities; utilization by specialty, reason for referral, provider, Internal quality improvement and referral review; specialist, time from initiation to appointment, Specialty Care in the Safety Net: Efforts to Expand Timely Access | 13 Patient navigation and advocacy; Though a “site fee” designed to cover the costs of telecommunication, setup, and administration of the Matching patient requests with volunteer program for some referring provider sites is provided specialists; by some payers, there is still significant confusion Staff training; among providers about whether and how to bill for telemedicine consultations. In addition, primary Appointment reminders and scheduling; and care sites have significant difficulty finding specialists IT support and review of alternative vendors for who are equipped and willing to see their patients via new systems acquisition. telemedicine, particularly if patients are uninsured or on Medi-Cal. To date, most telemedicine providers have had difficulty developing a viable business Telemedicine model, and safety-net providers have relied heavily on Telemedicine is gaining attention as a way to grant funding to support telemedicine activities. address the gap in specialty care access for both Infrastructure and broadband connectivity urban and rural patients. In the statewide survey, have also been barriers to more widespread use of nearly one-third of the CCHCs indicated they had telemedicine. The California Telehealth Network, some availability of onsite telemedicine equipment; established in 2008 under a federal grant from the however, only rural sites reported using telemedicine FCC, will provide access to subsidized, high-speed with any frequency. Half of the coalition broadband for hundreds of safety-net providers implementation plans included some telemedicine- throughout the state. This will allow them to connect to one another more easily and with the security and service-level guarantees necessary for telemedicine. Primary care sites have significant Funds available through the American Recovery and Reinvestment Act (ARRA) will also offer funding difficulty finding specialists who are opportunities for the advancement of broadband and equipped and willing to see their patients telehealth programs. via telemedicine, particularly if patients are uninsured or on Medi-Cal. related activity, often targeting ophthalmology (for retinal screenings) and dermatology. Other plans included provider continuing education and consultation for specialty care. California has been a pioneer in telemedicine policy, enacting one of the first state telemedicine laws in 1996 and expanding it in 2005. Nevertheless, reimbursement policies lag behind current practice. 14 | C alifornia H ealth C are F oundation IV. Conclusions These findings and the integrated T he project survey established a foundation for conversations about specialty care access for California’s underserved. project activities engaged safety- These findings and the integrated project activities engaged safety- net participants across the state in net participants across the state in learning from one another and developing a common understanding of the challenges they face. A learning from one another and number of overarching themes emerged from this multi-phase project: developing a common understanding While initiatives are locally designed and implemented, they of the challenges they face. share common goals and strategies across the state in their efforts to impact the demand for care, the supply of providers, and coordination of patient care; To the extent possible, the one-on-one relationships need to be transformed into institutional relationships, so they can be sustained over time and are not solely dependent on specific individuals and situations; The ability to capture accurate information about the status of specialty care and of the need for specialty care in the safety net are critical to progress; Improvement activities and systemwide changes aimed at providing more integrated and comprehensive care require multi-dimensional approaches; Planning and implementing improvement activities are resource-intensive in terms of time, funding, and individual and organizational motivation; Relationships, effective communication, and recognition of individual and partner contributions build the trust and create the foundation upon which collaborations depend; and Coalition-building — among regional safety-net partners and between professional institutions like CAPH and CPCA — is necessary for systemwide change as well as for implementation of specific strategies. Specialty Care in the Safety Net: Efforts to Expand Timely Access | 15 The funding for planning and implementation utilization rates do not necessarily imply prudence.” projects enabled most of the coalitions to move To give the data meaning, it is important to set forward with a variety of projects. The participants benchmarks for judging progress, whether it be offered general guidelines for others pursuing similar Medi-Cal or other cost savings, reduced wait times, goals: increased patient and staff satisfaction, or improved performance standards. Carefully craft the early steps, with strong vision, The findings from this project so far provide a leadership, and achievable goals; snapshot in time, but the implementation of local Begin with smaller projects or pilots to build access strategies will continue to reflect a dynamic competence and confidence; process and changing environmental conditions. In addition, the experiences of participating coalitions Establish adequate time for planning that will further highlight statewide policy opportunities includes detailed business and feasibility to address systemic barriers to specialty care access. assessments and addresses strategies for Future publications will address new lessons that sustainability; emerge as local specialty care access strategies are Recruit internal champions and identify, support, implemented and evaluated. The stage is now set and develop capable and visionary leaders; for supported implementation of projects around the state that are designed to reduce obstacles and to Attain “buy-in” from impacted staff—from increase access to specialty care for California’s safety- administrators to line staff; and net patients. Be committed to adaptation and change, which are not universally embraced within systems. Both the statewide survey and the planning grant needs assessments revealed the need to establish standardized and reliable methods for specialty care related data collection — a challenge common among safety-net institutions in many areas of patient care. Systemwide use of some common metrics and comparable data fields to capture and report on a range of variables is critical to creating an accurate clinic, regional, and statewide picture of access to care. Without valid and reliable data, it is not possible to capture and report on the status of safety- net care, establish benchmarks, assess progress, and demonstrate return-on-investment. Numbers will not, on their own, tell the whole story. As one participant stated: “High care utilization rates do not necessarily imply waste; low 16 | C alifornia H ealth C are F oundation Appendix A: Specialty Care Coalitions and Grants Pl ann i ng Imp l ementati o n Coa lit ion Lead A gency G rant G rant California HealthCare Foundation ACCEL Specialty Access Project El Dorado County Department of 4 4 Public Health Gold Country Access to Care Coalition Northern Sierra Rural Health Network 4 Improving Appropriate Access to Specialty Del Norte Clinics, Inc. 4 Care in Rural California Improving Specialty Care Access on the Humboldt Del Norte IPA / North Coast 4 4 North Coast Clinics Network Lassen Modoc Shasta Siskiyou Coalition Shasta Consortium of Community Health 4 4 Centers MCHCC Specialty Care Planning Project Merced County Health Care Consortium 4 Mendocino County Specialty Care Access Alliance for Rural Community Health 4 Project Kaiser Permanente Community Benefit Programs Northern C a li f o rni a R eg i o n Ad-hoc Specialty Care Access Committee Santa Clara Community Health Partnership 4 4 Alameda County Access to Care Collaborative Alameda County Medical Center 4 4 Community Clinic Consortium Community Clinic Consortium of Contra Costa 4 4 Fresno Healthy Communities Access Partners Fresno Healthy Communities Access Partners 4 4 Marin Specialty Access Coalition Marin County HHS 4 4 San Francisco Safety-Net Coalition San Francisco General Hospital/UCSF 4 4 San Joaquin County Specialty Access Coalition Health Plan of San Joaquin 4 4 San Mateo County SCAI San Mateo Medical Center 4 4 Solano Coalition for Better Health Solano Coalition for Better Health 4 4 Yolo County Future of the Safety Net Communicare Health Centers 4 4 Specialty Care in the Safety Net: Efforts to Expand Timely Access | 17 Pl ann i ng Imp l ementati o n Coa lit ion Lead A gency G rant G rant Kaiser Permanente Community Benefit Programs, continued S outhern C a liforn i a R eg i o n Access OC Specialty Care Work Group Access OC (Orange County) 4 Coalition of Safety-Net Access Providers Valley Care Community Consortium 4 4 (Los Angeles) Kern Medical Center Specialty Care Coalition Kern Medical Center 4 4 LAC+USC Camino de Salud Network LAC+USC Healthcare Network 4 4 Specialty Care Access Project Long Beach Community Increased Access The Children’s Clinic 4 4 Specialty Care Coalition San Bernardino Specialty Care Coalition Latino Health Collaborative 4 4 San Diego Specialty Care Access Initiative Council of Community Clinic Health Care 4 4 Network Service Planning Area (SPA) 3 Specialty Care East Valley Community Health Centers 4 4 Planning Coalition (Los Angeles) South Los Angeles Collaborative for Southside Coalition of Community 4 4 Specialty Care Access Health Centers Ventura County Safety-Net Specialty Care Ventura County Medical Center Health Care 4 4 Access Coalition Agency Westside Specialty Care Access Project Venice Family Clinic (Los Angeles) 4 4 18 | C alifornia H ealth C are F oundation Appendix B: Resources to Support Specialty Care Access Date/ F u nder / lo cati o n Organ i z er California HealthCare Foundation Publications Examining Access to Specialty Care for California’s Uninsured May 2004 CHCF www.chcf.org/specialtycare or www.chcf.org/topics/healthinsurance/index.cfm?itemID=102587 Transforming the Specialty Referral Process March 2008 CHCF www.chcf.org/specialtycare or www.chcf.org/topics/view.cfm?itemID=133607 Bridging the Care Gap: Using Technology for Patient Referrals September 2008 CHCF www.chcf.org/specialtycare or www.chcf.org/topics/view.cfm?itemID=133761 Understanding Common Reasons for Patient Referrals in Difficult-to-Access Specialties May 2009 CHCF www.chcf.org/specialtycare Telehealth Reports and Initiatives (multiple reports) Ongoing CHCF www.chcf.org/telehealth Pending specialty reports on these topics will become available in June 2009: June 2009 CHCF • Nurse practitioner and physician assistant specialty practice models • Federally qualified health centers as specialty care providers — business planning tool • Regulatory issues related to federally qualified health centers as specialty care providers • Improving specialty access through enhanced primary care scope — mini-fellowship models www.chcf.org/specialtycare Discussion Papers Fuller Scope of Practice for Primary Care Providers: A Strategy to Improve Access to February 2008 KPSC CB Specialty Care in the Safety Net by Pacific Health Consulting Group 208.176.52.104/content/Upload/AssetMgmt/Site/programs/specialtycarematerials/ roundtable3/ScopeofPracticeDiscussionPaper.pdf Weaving Webs in the Safety Net: Public Hospital Systems and Community Health Centers July 2008 KPSC CB Collaborating to Improve Specialty Care by Pacific Health Consulting Group 208.176.52.104/content/Upload/AssetMgmt/Site/programs/specialtycarematerials/ SCAIDiscPaper2Collaboration.pdf A Slippery Slope: Financing Specialty Services in California’s Safety Net by Pacific Health January 2009 KPSC CB Consulting Group www.safetynetinstitute.org/content/upload/AssetMgmt/Site/ DiscussionPap3SpecialtyCareFinancing.pdf Specialty Care in the Safety Net: Efforts to Expand Timely Access | 19 Date/ Fu n d e r / lo cati o n O rg a n i z e r Roundtable Forums www.safetynetinstitute.org/content/SpecialtyCareResources.htm Developing and Managing Effective Referral Systems July 30, 2007 KPSC CB (65 attendees) Oakland E-Health November 5, 2007 KPSC CB (70 attendees) Burbank Scope of Practice March 6, 2008 KPSC CB (70 attendees) Burlingame Protocols and Guidelines June 17, 2008 KPSC CB (90 attendees) Sacramento Workforce Strategies September 22, 2008 KPSC CB (45 attendees) San Diego Financing November 3, 2008 KPSC CB (60 attendees) Burbank Technical Assistance Teleconference Calls www.communityclinicvoice.org/webx/.eeaef98 (register to enter) Needs Assessment March 8, 2008 KPCB (participant numbers unavailable) Coalition Building April 4, 2008 KPCB (28 participants/17 coalitions) Building a Case for Sustainable Strategies May 21, 2008 KPCB (35 participants/24 coalitions) Business Case Statements June 25, 2008 KPCB (7 participants/6 coalitions) Promising Practices: Telemedicine July 15, 2008 KPCB (20 participants/14 coalitions) Promising Practices: Volunteer Model July 22, 2008 KPCB (21 participants/14 coalitions) Promising Practices: Hub Model July 22, 2008 KPCB (21 participants/14 coalitions) E-Referral Approaches October 8, 2008 KPCB (38 participants/20 coalitions) 20 | C alifornia H ealth C are F oundation C A L I FOR N I A H EALTH C ARE F OU NDATION 1438 Webster Street, Suite 400 Oakland, CA 94612 tel: 510.238.1040 fax: 510.238.1388 www.chcf.org