Redesigning Specialty Care in Community Clinics: C A L I FOR N I A H EALTH C ARE A California Case Study F OU NDATION Introduction (LAC+USC) Medical Center, with the goal of California’s more than 700 community-based, improving clinic patients’ access to specialty care. primary care clinics comprise the backbone of the state’s health care safety net, annually serving more CDSN’s Provider Practice Redesign had several than 2.8 million primarily low-income, minority, aspects, which were implemented primarily for Issue Brief and immigrant patients.1 For patients who depend care of its rheumatology and cardiology patients: on these safety-net services, however, lack of timely ◾◾ Consensus Care Guidelines, collaboratively access to specialty care is a significant and growing developed by the network’s PCPs and the challenge that can contribute to poorer health specialists, and implemented throughout the outcomes.2 Problems with specialty care access for primary care clinics; these patients arise from a combination of factors: a dearth of specialists at the clinics themselves; ◾◾ “Specialty Champions,” PCPs given the clinics’ lack of specialty diagnostic tools specialized training in a particular field by and equipment; primary care providers’ (PCP) specialists to whom they referred patients; difficulties in obtaining specialist consultations; ◾◾ Phone consultations between Specialty absence of clear lines of communication between Champions and specialists to determine PCPs and specialists; and extensive wait times whether a referral was necessary and to assist for patients to obtain specialty appointments and with some specialty care at the clinics; and diagnostic services at other sites. ◾◾ Community Grand Rounds, monthly In 2007, as part an effort to advance the larger meetings at which PCPs, specialists, and goal of integrated community care in the safety administrative and medical leadership net, the California HealthCare Foundation discussed respective and common challenges (CHCF) funded COPE Health Solutions (COPE) to providing specialty care access. to initiate local strategies for improving access to specialty services for safety-net clinic patients. These redesign efforts were supplemented Soon thereafter, the Camino de Salud (Road to by grants from other funders to support the Health) Network (CDSN) of private and public establishment of a mobile echocardiogram service, health care providers in downtown and East Los a cardiac stress treadmill at one clinic location, an Angeles joined COPE, with additional grant funds endoscopy suite at another, and two optometry and resources from the QueensCare Foundation units at a local community clinic. and the LA Care Health Plan, to develop the Provider Practice Redesign project.3 This project Results of the redesign were encouraging. Overall, was to shift how CDSN PCPs interacted with referrals were more appropriate, and a significant public county hospital specialists at the Los number of rheumatology and cardiology patients Angeles County/University of Southern California were able to be managed at the primary care A pril 2010 sites. These changes were congruent with reports from to the ED for specialty services results in much higher the clinics’ PCPs of their expanded experience, and of costs without improved health outcomes.5 increased confidence in diagnosing and managing these patients themselves. A shrinking budget and a growing population of uninsured patients combine to overwhelm the medical This issue brief reports on the nature and process of center’s already limited resources. Poor communication the CDSN redesign and on the project’s impact on and coordination, and the lack of a comfortable overall specialty care access for the network’s patients. The brief working relationship, between the hospital and the also discusses some of the challenges encountered and community clinics have exacerbated the problem, lessons learned from implementation of the redesign, reducing both entities’ ability to efficiently and and how this experience might benefit other safety-net appropriately manage patient care. One element of this communities as they grapple with their own specialty care dynamic is revealed by specialists at the LAC+USC access problems. Medical Center expressing frustration over the volume of cases they believe can and should be handled at the The State of Specialty Care in Downtown/ primary care level instead of being referred to them. East Los Angeles CDSN serves the safety-net community within the service Clinic Response to Specialty Care Patients area of the LAC+USC Medical Center. This is a densely PCPs in CDSN identify a number of serious challenges populated area of downtown and East Los Angeles that is in providing specialty care for their patients. First, home to over 3 million residents — more than 23 percent they lack standardized guidelines for care and referral of whom are uninsured and lack access to a regular source processes; such guidelines could provide confidence of care.4 Even for patients who are able to access primary for both PCPs and specialists that the referrals being care through local safety-net clinics, however, limited and made are appropriate. Further, PCPs report difficulty delayed access to specialty consultations, diagnostics, and accessing specialist consultations that might confirm or treatments frequently worsen disease severity and lead to obviate the need for a referral. In addition to poor lines compromised health outcomes. of communication between PCPs and specialists, there is a lack of coordination between them once patients are Specialty Care at Hospitals referred. Finally, PCPs report extremely long wait times LAC+USC Medical Center serves as the anchor hospital in accessing specialty care services for their patients, system for CDSN. As one of the largest teaching hospitals often preventing patients from receiving the appropriate in the country, and one of the busiest public hospitals standard of care. These problems exist in the context west of the Mississippi, LAC+USC Medical Center has of the clinics’ difficulties in managing complex disease significant difficulty meeting the community demand for processes at the primary care level due to poor financial its specialty care services. Currently, wait times for some incentives and lack of accessible diagnostic resources. specialty areas average six months or more. Safety-net patients who are unable to obtain a timely specialty care Many of these challenges stem largely from a structural appointment are often referred to a hospital emergency disconnect between the community clinics and the department (ED) instead. This pattern leads to ED county medical system. While their patient populations overcrowding and places patients in the care of emergency frequently overlap, each system exists in a service silo physicians who are not equipped to serve as PCPs or to that fails to properly and efficiently communicate monitor specialty referrals. Additionally, referring patients with the other. This environment contributes to an 2  |  California HealthCare Foundation inefficient overall safety-net health system wherein care is had limited opportunities to interact. Community Grand delivered episodically, making it much more difficult for Rounds were also open to and regularly attended by both community clinics to focus their energies on preventative administrative and medical leadership from LAC+USC care and chronic care management. Medical Center, enabling medical center leaders to heighten their understanding of community clinics. Framework for Decentralizing Specialty Care and Diagnostics During these meetings, primary and specialty care Based on the challenges and needs described above, physicians learned about each other’s respective challenges CDSN providers and COPE jointly conceptualized the and the ways in which they might collaborate to Provider Practice Redesign project. With LAC+USC improve specialty care access. For clinic providers, these Medical Center serving as the anchor hospital system, monthly meetings also served as education opportunities the project was implemented across CDSN’s community concerning specialty care. At certain meetings, clinic organizations under the rubric “the right care, at the Continuing Medical Education (CME) sessions, approved right place, at the right time.” by the Los Angeles County Department of Health Services, were facilitated by LAC+USC Healthcare The project sought to improve the rate of appropriate Network specialists. referrals from primary care community clinics to specialty care through a combination of jointly (between primary Consensus Care Guidelines. Clinic PCPs and hospital care and specialist physicians) developed specialty care specialty physicians collaborated to develop Consensus diagnosis guidelines and enhanced training of some of the Care Guidelines, which not only served as the basis for clinics’ PCPs. The project also sought to improve access referral decision-making but also fostered trust between to and use of diagnostic services through decentralization the two physician groups on which to build future of these services under the newly developed guidelines. If clinical collaboration, including consultations and patient successful, it was hoped that this project could be used as co-management. These guidelines were disease-specific, a model for other providers in under-served communities delineating different acuity levels for care in community throughout California and the United States. clinic and hospital settings and defining the referral protocol. Accurately differentiating patients’ levels of Based on CDSN provider input regarding feasibility acuity helped limit specialty referrals to the most severe of implementation and anticipated impact on care, cases, thereby reducing the number of referrals that rheumatology, cardiology, and ophthalmology were wound up being rejected or deferred. All guidelines selected to be the project’s central focus. The project used developed through this project were anchored by national the following four interrelated strategies to systematically specialty care guidelines, with key adjustments made to enhance access to specialty care for CDSN patients in the reflect the specific specialty care and diagnostic capacities chosen specialty areas. of the project’s hospital and clinic partners. Community Grand Rounds. Monthly Community Mini-Fellowships. Following the creation of the Grand Rounds meetings provided a forum for hospital Consensus Care Guidelines, participating community specialists and community clinic providers to discuss clinic providers were given the opportunity to train with challenges relating to specialty care access and to build hospital specialists in order to gain the clinical experience professional relationships. Prior to implementation of and confidence needed to properly implement the these meetings, clinic providers and hospital specialists guidelines. Participating community clinic organizations Redesigning Specialty Care in Community Clinics: A California Case Study  |  3 were asked to designate one PCP per targeted specialty Project Impact and Challenges Regarding to be a Specialty Champion. These Champions attended Specialty Access “mini-fellowship” training sessions, which consisted of The Provider Practice Redesign project produced two half-days at LAC+USC Medical Center during which immediate, positive qualitative and quantitative results the PCPs shadowed a designated specialist. These sessions among almost all of its community clinic participants. exposed the PCPs to a breadth of cases at a given specialty The project also revealed a number of challenges in clinic and showed them how patients were managed implementing such a collaborative effort across system there. The sessions focused on expanding the Champions’ and practice boundaries, the lessons of which can be scope of practice and improving their ability to manage useful to those seeking to establish analogous projects in common conditions at the primary care home, based on other safety-net provider environments. the Consensus Care Guidelines. Impact on Specialty Care Feedback from PCPs who participated in mini-fellowship During the course of the two-year implementation sessions revealed a wide range of experiences. The period for the Provider Practice Redesign project, majority of providers indicated that the most valuable participating PCPs reported a decided increase in their aspect of the sessions was the opportunity for clinical confidence in managing patients at the primary relationship-building with specialty care providers. care home, in part due to telephone consultation support Some PCPs, however, reported an incomplete level of from the specialists. In the case of rheumatoid arthritis, engagement by the specialists during the sessions. Based for example, CDSN providers noted an increased ability on this feedback, COPE is continuing to work with to treat patients in their clinics through the use of LAC+USC Medical Center specialists and the PCPs inexpensive medications which previously had not been to refine the mini-fellowship sessions. This process will available in their formularies but which were added as include the creation of a formalized curriculum for each a result of their consultations with the hospital-based rotation and will offer up to ten CME credits per session. specialists. The project’s clinic providers also reported significant increases in diagnostic capacities for cardiology Phone Consultations. Upon completion of the and ophthalmology. mini-fellowship sessions, each Specialty Champion began phone consultations with the session specialist. On Based on self-reported information provided on a average, phone consultations took place bi-weekly. Phone monthly basis (from mid-2007 to September 2009), consultations decreased over time for rheumatology Specialty Champions across the participating clinics were Champions but remained constant for cardiology able to manage 78 percent of all patients screened at the Champions. Participating providers were originally clinics for cardiology (with the other 22 percent referred assigned a specific phone consultation time-slot. However, for specialty care), and 60 percent of patients screened many PCPs reported challenges in reaching the specialists for rheumatology. Without training and telephone at the designated time or finding another mutually consultations with the specialists, Champions might have agreeable time to discuss cases. As a result, the project is instead referred many of those patients to specialty care. currently evaluating secure electronic consult (“e-consult”) Additionally, it is likely due to the increased frequency and other health information exchange systems that and quality of communications with the specialists that might supplement and facilitate these phone consultations Champions made a higher proportion of appropriate and other information-sharing (e.g., laboratory and specialty care referrals, in part based on agreements diagnostic results) between specialists and PCPs. reached during consultations. Preliminary results from 4  |  California HealthCare Foundation an independent project evaluation indicate that data Stakeholder Understanding and Engagement on this issue are underreported, with time constraints Is Key having prevented participating PCPs from regularly and The defining characteristic of the Provider Practice Redesign project was its collaborative nature, requiring accurately reporting on the work they dedicated to the joint participation and cooperation by hospital specialists project.6 This suggests that the Provider Practice Redesign and community clinic PCPs. Each provider group entered may have resulted in an even higher percentage of the project with preconceived notions about the other’s specialty care patients being cared for within the clinics challenges, competency, and scope of care. For the initiative to succeed, each “side” had to develop a or being appropriately referred to specialty care. better understanding of and comfort level with the other’s work. One way to accomplish this was to have Providers Determine Guidelines and providers and administrators from both groups jointly Community Grand Rounds engage in the planning and delivery of care efforts. For During the early months of the Provider Practice the redefining of specialty care protocols in particular, it was determined that efforts to engage leadership Redesign implementation, COPE set the agenda for the should extend to the clerical and line staff levels. Indeed, monthly Community Grand Rounds meetings, selecting engagement of the referral coordinators at CDSN the specialties to focus on and the lecture topics to be proved critical in the Provider Practice Redesign project’s discussed. During these early months, however, it turned diagnostic expansion efforts. out that providers did not become engaged in the process to the extent necessary to drive adoption of new methods and guidelines and for other related changes in behavior. Formal Process for Information Dissemination To remedy this lack of engagement, in subsequent The collaborative nature of the Provider Practice Redesign months providers were given the responsibility of setting project required that a large amount of information be priorities for the group meetings, including selecting the distributed to providers in different organizations. In specialties of focus, while COPE changed its role in the most cases, medical directors were tasked with informing meetings to that of facilitator. As an added incentive, their staff about the new Consensus Care Guidelines and Community Grand Rounds were restructured to allow referral protocols, but without a structured process for providers to receive CME credits for participation. this dissemination. As a result, adoption of Consensus Care Guidelines varied among PCPs who were not directly involved in the Provider Practice Redesign process. One lesson learned from this experience was that in order to ensure consistent understanding, sense of Added Clinic Technical Capacity Also Reduced Referrals As part of the implementation of the Provider Practice Redesign, COPE and CDSN launched a mobile echocardiogram service in December 2007, with funding from the Larry King Cardiac Foundation and the Ahmanson Foundation. To date, the mobile echocardiogram service has provided over 900 diagnostic tests to uninsured patients.7 Additional funds from LA Care Health Plan helped provide two optometry units at a CDSN partner clinic. A cardiac stress treadmill and an endoscopy suite were added at two other clinics. All of these services were designed to provide local access to specialty care for uninsured patients at CDSN community clinic sites. The availability of these resources helped to relieve pressure on the overwhelmed outpatient diagnostic resources at LAC+USC Medical Center. For example, an analysis of results from the echocardiogram service found that only 22 percent of all patients tested had abnormal results. Consequently, a large majority of patients were managed by the cardiology Champion in the primary care setting rather than being referred for specialist care. Redesigning Specialty Care in Community Clinics: A California Case Study  |  5 ownership, and adherence to new protocols and processes, The hospital specialists, too, have been required to it is crucial to establish mechanisms through which all put in extra time under the project. To provide further PCPs at participating clinics are drawn into the project. support for participating specialists, changes were made Such techniques might include: discussing the new to the Management Services Operational Agreement model at clinic provider meetings; incorporating project between Los Angeles County and the USC Keck School guidelines into intranet Web pages or electronic medical of Medicine (Keck). Under this new agreement, time is record systems; and creating monthly provider newsletters specifically budgeted for specialist phone consultations that update providers on the practice redesign process. and chart reviews with PCPs. Additionally, CDSN is currently in discussions with Keck’s Specialty Division Responding to Added PCP Time chairs of rheumatology, cardiology, and gastroenterology Commitments about engaging specialty fellows in the Provider Practice The Provider Practice Redesign changes in referral Redesign project. Participation by specialty fellows would practices resulted in more PCP visits and the need for not only increase the clinics’ capacities for phone and additional related administrative time. The most active electronic consults, but would also provide a valuable Specialty Champions consistently reported the need for learning opportunity for the specialists by giving them as many as four hours a week in added administrative the chance to interact with PCPs in the community and time, including phone consults, chart reviews for other thereby to gain a better understanding of the challenges providers, clinical documentation, and data tracking. they face. The lack of financial reimbursement for such added time creates a disincentive for providers to fully participate in the project. Financial Incentives Must Support Clinic Specialty Care In order to substantially improve providers’ ability In order to encourage Specialty Champions to continue and willingness to manage patients at a primary care being active participants, the Provider Practice Redesign level, a realignment of financial incentives is needed. project secured new funds through Kaiser Permanente’s Such a realignment would allocate funds to offset and reward the additional time providers would spend Specialty Care Initiative to reimburse CDSN clinics with each patient managing specialty care needs, as for time their Specialty Champions spend caring for well as time allocated to collaborative network and patients under the project.8 Also, CDSN partner clinics quality improvement efforts, such as Community Grand incorporated “Champion codes” into the encounter forms Rounds. Realigning incentives in this way could also help their providers use daily. These forms track patient visits, ensure that primary care-level providers comply with guidelines and meet performance standards relating to chart reviews, phone consults, and referrals made by PCPs patient specialty care processes. in their capacity as Champion. The partner clinics submit a monthly report of these activities to COPE, which then allocates grant funds according to the number of patients seen by each Champion. This added funding has helped Streamlining Data Collection Methods enable Champions to apply the specialty knowledge and Tools acquired through mini-fellowship training, while the Data tracking posed a technical challenge in tracking system has eased the administrative burden of implementing the Provider Practice Redesign project. data collection. With limited administrative time, participating providers found it difficult to self-report on the clinical time and work they devoted to the project. As 6  |  California HealthCare Foundation discussed above, providers were not compensated for Conclusion the additional administrative efforts that resulted from Access to specialty care, especially for the poor and their participation, which in turn contributed to an underserved, is an issue of critical importance. As the underreporting of data. To address this issue, the project population ages and demand for specialty resources has developed a data tracking system that can increase continues to climb, it is important to expand primary care data collection efficiency through the special Champion resources and to reserve specialty resources for patients encounter codes described above. By incorporating with complex or rare disorders. Coupling payment data tracking into the clinics’ existing processes, and reform with improvements in and expansion of the by regularly auditing records, this system provides an scope of primary care, as well as in the efficiency of the efficient and reliable method of receiving and analyzing specialty referral process, represents an effective model for outcomes data, while reducing the administrative work improving patient access to specialty care. required of providers in the project. Other Systems Adopt a Similar Model About the Authors Drawing on the experience of the CDSN Provider COPE Health Solutions (COPE), based in Los Angeles, Practice Redesign project, and funded by a specialty California, works with hospitals, clinics, and health care care grant through the Kaiser Community Benefit organizations across the country to develop integrated health program, Harbor UCLA Medical Center and a number care delivery networks and to train and grow the health care of community clinics in Long Beach and in West Los Angeles and the South Bay have adapted the Provider workforce needed to support these networks. COPE provides Practice Redesign framework. This project includes services through three major service lines: Clinical Integration implementation of a more rigorous referral screening Solutions, Health Workforce Solutions, and Business process through Specialty Champions, which could Solutions. result in a decrease in avoidable specialty referrals. To date, the project has begun to be implemented in Sarita A. Mohanty, M.D., M.P.H., is medical director for cardiology, with rheumatology to follow soon. COPE. Her work for COPE involves helping to improve In Central California, the Kern Medical Center Health access to quality care for safety-net populations by developing Plan (KMC plan), funded by the California 1115 State and implementing comprehensive and sustainable programs. Medicaid Waiver and the Kaiser Specialty Care Initiative, Dr. Mohanty is also a clinical assistant professor of medicine has also adapted the Provider Practice Redesign at the University of Southern California’s Keck School of model to improve specialty care access. Because Kern Medicine. County’s PCP capacity differs significantly from urban Los Angeles County’s, the KMC plan has tailored the Ana Alvarez is a senior project manager for COPE. In this model to better reflect the region’s resources, including capacity, Ms. Alvarez is responsible for operations at the a heavier reliance on the participation of physician Camino de Salud (Healthy Road) Network, an integrated assistants and nurse practitioners, using specialty care delivery system composed of hospital and community clinic protocols. Participation by these providers is structured organizations. by guidelines and practice protocols and supported by training sessions designed specifically for these Jodie Pham is a project manager for COPE. Ms. Pham practitioners. primarily supports COPE’s work around policy analysis, grant development, and strategic planning. Redesigning Specialty Care in Community Clinics: A California Case Study  |  7 About the F o u n d at i o n 7.To ensure long-term financial sustainability of the mobile The California HealthCare Foundation is an independent echocardiogram service, COPE entered into a contract philanthropy committed to improving the way health care with Healthcare LA IPA, the major independent physician is delivered and financed in California. By promoting association for CDSN clinics. This has permitted billing innovations in care and broader access to information, our for these diagnostic services when provided to managed goal is to ensure that all Californians can get the care they Medi-Cal and managed Medicare CDSN patients. need, when they need it, at a price they can afford. For more Revenue thus generated is used to help offset service costs information, visit www.chcf.org. for the uninsured. 8.The Kaiser Permanente-CHCF Specialty Care Initiative Endnotes is a multi-year effort funded by the Kaiser Permanente 1.The California Endowment. December 2004. “The Health Community Benefit Programs and the California Care Safety Net: Challenged Like Never Before, Needed HealthCare Foundation. It focuses on expanding access More than Ever.” Health in Brief  3 (3). to specialty care in the safety net. The initiative has funded 21 provider coalitions throughout California. 2.In a 2004 survey of Federally Qualified Health Centers, Additional funding from the Kaiser Permanente Southern 85 percent of respondents reported that their patients Region Community Benefit Program went to support the “often” or “always” had difficulty obtaining needed LAC+USC Medical Center-CDSN coalition. specialty care. Felt-Lisk, S. and M. McHugh. The Uninsured: Examining Access to Specialty Care for California’s Uninsured. California HealthCare Foundation, May 2004, www.chcf.org. See also Patrick, G. and J. Hickner. Four Models Bring Specialty Services to the Safety Net: Enhancing Scope of Practice and Referral Efficiency. California HealthCare Foundation, July 2009, www.chcf.org. 3.Formerly known as the Specialty Care Access Project. 4.Los Angeles County Department of Public Health, Office of Health Assessment and Epidemiology. Key Indicators of Health by Service Planning Area, 2007. 5.Forrest, C.B. and B. Starfield. 1996. “The Effect of First-Contact Care with Primary Care Clinicians on Ambulatory Health Expenditures.” Journal of Family Practice 43 (1); 40 – 8. 6.Cousineau, M.R., and K. R. Partlow. Impact of the Specialty Care Access Project on Serving Uninsured Patients. Center for Community Health Studies, University of Southern California, 2010. 8  |  California HealthCare Foundation