Post on 25-Jun-2020
The National TelehealthWebinar Series
June 15, 2017
Presented byThe National Consortium ofTelehealth Resource Centers
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Moving Knowledge, Not Patients: Re-Thinking the Way Primary Care and Specialists Work Together for Improved Quality, Value, and Patient Experience
Daren Anderson, MD - VP/Chief Quality Officer,
Community Health Center, Inc.
Associate Professor of Medicine, Quinnipiac University, Director, Weitzman Institute
Libby Sagara - Health IT and Management Consultant, BluePath Health
Moving Knowledge, Not Patients Re-thinking the way primary care and specialists work
together
Daren Anderson, MDDirector, Weitzman Institute
The National Telehealth Webinar SeriesJune 15 , 2017
Dermatology eConsult
Consultation: 3 months old with severe scalp seborrhea and symmetrically bright red eczematoid cheeks that she scratches, protected by gloves, and generalized body atopy. refer to be seen for management of severe apparent eczema/atopy.
13127250
Community Health Center, Inc.
Transforming Primary Care at the Community Health Center
A research and innovation center supporting practice transformation for Safety Net Practices across the country
Dermatologist Response
Diagnosis: seborrheic dermatitis and atopic dermatitis.
Recommendation:
Scalp: Dermasmoothe FS oil at bedtime under occlusion over night, wash off in the morning, daily for 3 days then 2-3x/week as needed.
Rest of body: Hydrocortisone cream 2.5% BID to all affected area with wet dressing: warm water bath, pat skin dry gently, apply HC 2.5% to affected area, then put on wet warm cotton pajama or towel over, wrap baby with warm dry blankets over, leave it on for 30-45mintutes, then take off wet wraps, apply moisturizer cream (Aveeno, CeraVe, Vanicream, etc.) all over. Start wet wraps daily for 3-5 days, when skin improving, use medicated cream BID while decrease wet wraps to 1-2 x/week as needed.-----------------------------------------------------------------------------------------------------------------------------------
13127250
• 10/19/2016 09:29 AM To: Orthopedist
• 32 yo male w/ ACL tear approx 4 years ago treated w/ steroid injections, and several rounds of PT, but never fully improved. XR shows tricompartmentalarthritis. Pt perseverative on getting an MRI now and deeply concerned about need for surgical consult. Reluctant to re-engage with PT until after orthopedic consult. Please review XR and consult on appropriate next steps for imaging and/or therapies. Thank you!
• 10/19/2016 11:13 AM Orthopedist To: 32 year old gentleman with a left knee deficient ACl. It is well known that with the lost of an ACl 4 years ago this candidate may not be suitable for surgical reconstruction. We know well that loosing an ACL will create rotational instsbility specially on the lateral aspect of the knee joint. It is now too late to have any ACL reconstruction. Arthroscopic debridement can be helpful for a while but will not remove the instability.
• There is not really a need to have a MRI since it is well known that there is a deficient ACL knee and it is expected that early DJD will set up but if there is any mechanical locking MRI can be usefull to check further meniscal injury. Otherwise Quad and Hamstring rehabilitation remain the key for improving knee fucntion.
• Good Luck
Orthopedic eConsult
Target population• Primary Care Providers:
PhysiciansNurse Practitioners/PAs
• Providers EXCLUDED from the study:Pediatric OnlyPart-time
Study Design • Prospective, randomized controlled intervention trial• Blocked randomization• One-year intervention• Clinical, demographic, and utilization data for patients - at
baseline, during the intervention, and for six months after the intervention. Pre/post providers’ perceptions
CHC-UCONN Cardiology eConsult Trial
eConsults
Clinical End Points
Intervention Control
TotalN=229
Traditional Pathway N=109
eConsults PathwayN=120
N=361
no. (%) no. (%)
Death from any Cause 0 0 0 1 (0.3)
Death from Cardiovascular Causes 0 0 0 0
Myocardial Infarction 0 0 0 0
Coronary Artery Bypass Surgery 0 0 0 0
Catheterization with Stenting or Angioplasty 3 (1.3) 1 (0.9) 2 (1.7) 2 (0.6)
Diagnostic Catheterization 1 (0.4) 1 (0.9) 0 6 (1.7)
ED Visits with Possible Cardiac Symptoms* 4 (1.7) 3 (2.8) 1 (0.8) 21 (5.8)
Hospitalization for Arrhythmia 2 (0.9) 2 (1.8) 0 5 (1.4)
Hospitalization for Atypical Chest Pain 6 (2.6) 4 (3.7) 2 (1.7) 10 (2.8)
Hospitalization for Syncope or Near Syncope 0 0 0 4 (1.1)
Hospitalization for Congestive Heart Failure 2 (0.9) 1 (0.9) 1 (0.8) 0
* p= 0.02 for ED Visits with Possible Cardiac Symptom. No other end points were statistically different.
Key lesson: eConsults Achieve theQuadruple Aim
1. Improved outcomes
2. Reduced Cost
3. Satisfied clinicians
4. More convenient for patients
Specialty Care: Reducing costs/Improving Access
• Providing a High Value Referral Network and Process
– Link primary care providers with specialists electronically
– Reduce the cost of care and expand scope of primary care
– Reduce utilization of expensive specialty care, testing, procedures
– Evidence-proven short term savings
• Reduce Variation in Treatment Patterns, Improve Assessment, Diagnosis and Care Coordination
– Enhance complex care management
– Increase scope of practice for primary care
– Improve integration of physical and behavioral health Increase access to care for medically underserved members
• Improve Member Experience
– Reduced need for face to face visits
– Increase continuity with primary care/PCMH
CeCN
Provider EHR
eFax
DirectMessaging
Secureemail
?remote access
21
CeCN Specialty Network Offerings
Cardiology Rheumatology
Dermatology Pediatric Cardiology
Endocrinology Pediatric Endocrinology
Gastroenterology Pediatric Pulmonary
Nephrology Orthopedics
Neurology Pain Management/Medicine
Adult Psychiatry Child Psychiatry
Adult Behavioral Health Child Behavioral Health
Addiction Medicine Urology
Ophthalmology Retinal Screening
Infectious Disease Travel Medicine
Complex Primary Care
Coming Soon
Transgender care Pediatric neuropsychiatry
Pediatric Neurology ENT
One year referral rates for approximately 54,000 members
1 Year
Adult
Referrals
1 Year
Adult
eConsults
No F2F
Needed
F2F
Needed
%F2F
Avoided
Total
Consult
Reductio
n
Cardiology 1062 316 288 28 91% 27%
Dermatology 1956 834 636 198 76% 33%
Endocrinology 820 360 316 44 88% 39%
Gastroenterology 2312 320 142 178 44% 6%
Infectious Disease 106 44 30 14 68% 28%
Nephrology 374 148 92 56 62% 25%
Neurology 1252 392 358 34 91% 29%
Orthopedics 2340 654 440 214 67% 19%
Pain Medicine 952 56 56 0 100% 6%
Total 11174 3124 2358 766 75% 21%
Weitzman ECHO Learning Community
Using ECHO totackle “Hot Spots”
Weitzman ECHO/eConsult Learning Network
◎ 207 practices
◎ 591 ECHO sessions
◎ 2,115 case presentations
◎ Primary care providers from 25 states
Center for Connected Health Policy (CCHP)E-Consult Workgroup Introduction for NTRC
June 15, 2017
BluePath Health Inc.; Client Proprietary and Business Confidential 27
CCHP and BluePath Health work to facilitate the E-Consult Workgroup and support complementary efforts across the state
• Facilitate annual CCHP E-Consult Workshops to further reimbursement discussions among DHCS, MCPs and DPHs
• Work to obtain approval for e-consult CPT codes based on time spent (published in 2014 by California Academy of Family Physicians)
• Work with MCP stakeholders within pilot regions to discuss potential reimbursement of specialist e-consults
• With BSCF pilots and MCPs, share incentive plans to engage PCPs at CHCs/FQHCs
• Emphasize e-consult successes in addressing specialty care timely access requirements following Covered California expansion
eConsult Definition and Incentives Engagement and Collaboration
DHCS and DMHC DPHs CHCs/FQHCs
• Provide opportunities for BSCF pilot DPHs to share best practices in implementing e-consult to optimize Waiver programs and reporting, aligning measures with BSCF pilot requirements
• Facilitate collaboration and participation in CAPH educational events (e.g. PRIME webinars)
• Facilitate FQHCs, BH/MH and social services in pilot regions in pursuing GPP programs, utilizing e-consult as appropriate to meet program goals
• Seek opportunities to engage FQHCs in waiver programs which value alternative (specialty care) touches and avoidable utilization of high-cost health care services
• Follow progress in FQHC APM pilots planned for 2018 to determine how e-consult programs can be incorporated
MCPs
BluePath Health Inc.; Client Proprietary and Business Confidential 28
California’s reimbursement for store and forward telehealth services
BluePath Health Inc.; Client Proprietary and Business Confidential 29
Organizations participating in CCHP E-Consult WorkgroupOrganization Name
AARP Julie Bates
Alameda Health System Evan Seevak
Blue Shield of California Foundation Rachel Wick
California Department of Health Care Services Neal Kohatsu
California Health & Wellness/Health Net Greg Buchert
California Health Care Foundation Chris Perrone
California Medical Association Lishaun Francis
California Primary Care Association Mike Witte
California State Rural Health Association Christine Martin
CAPH/Safety Net Institute David Lown
Central California Alliance for Health Elizabeth Murphy
The Children’s Partnership Liliana Velazquez
Colorado State Medicaid JD Belshe
Community Health Center Network Ella Schwartz
Community Health Partnership of Santa Clara County Paul Nguyen
Covered California Allie Mangiaracino
Inland Empire Health Plan Matthew Wray
Kaiser Permanente, CO Ted Palen
LA County Department of Health Services Hal Yee
LA County Department of Health Services Paul Giboney
Local Health Plans of California Caroline Davis
Open Door Community Health Center Bill Hunter
Partnership Health Plan Lyle Smith
San Joaquin Medical Center Jeff Slater
San Mateo Medical Center Carolyn Senger
UC Davis Medical Center Tom Nesbitt
UCSF/Zuckerberg SF General Delphine Tuot
UCSF/Zuckerberg SF General Nwando Olayiwola
Valley Medical Center Kenneth Soda
Weitzman Institute, CHC Inc, CT Kevin Massey
BluePath Health Inc.; Client Proprietary and Business Confidential 30
Workgroup FindingsFrom Statewide Electronic Consult Program Efforts
BluePath Health Inc.; Client Proprietary and Business Confidential 31
Key Tenets of Electronic Consult
E-consult directly impacts patient and provider satisfaction. E-consult related surveys report overwhelming improved satisfaction from both patients and providers.
E-consult is the standard of care. E-consult in no longer in pilot stage. There is a significant experience base that has demonstrated lasting results.
E-consult improves access to specialty care and network adequacy. E-consults optimize face-to-face visits and satisfy specialty access standards. Improved access is demonstrated through:
• Decreased wait times for specialty care
• Decreased repeat appointments
• Decreased no shows
E-consult promotes health homes and builds PCP capacity. Over time, E-consult is shown to expand the ability of the PCP to care for the patient, keeping him/her within the health home.
E-consult is not an electronic referral. E-consult is separate and distinct from an electronic referral. The two processes should not be subject to the same regulatory requirements.
BluePath Health Inc.; Client Proprietary and Business Confidential 32
A standard definition has been accepted for electronic consultation
An electronic consultation is an asynchronous dialogue initiated by a physician or other qualified health care professional seeking a specialist consultant's expert opinion without a face-to-face patient encounter with the consultant.
To capture the service rendered, the specialist will report a code for interprofessional consultation (e.g. 99446). Electronic consults provided by consultative physicians include written report to the patient's treating/requesting physician/qualified health care professional.
(Approved by CA E-Consult Workgroup 2016)
BluePath Health Inc.; Client Proprietary and Business Confidential 33
E-consult programs across California are supporting the safety net
Program Lead Description
Community Health Center Network (CHCN) and Alameda Health System
AHS using EHR to support internal e-consults, partnering with Community Health Center Network (FQHC) who also utilizes a remote specialist network
Community Health Partnership of Santa Clara County
Participating in e-consult exchange with Valley Medical Center serving over 10 specialties
California Health & Wellness
Incorporating e-consult as part of telehealth pilot in 3 counties with selected high demand specialties
Central California Alliance for Health
Beginning pilot with selected PCPs and specialists in Santa Cruz, Monterey and Merced counties
LA Care Health Plan
Following MMC/county MOU, beginning eManagement program for MH/BH (on top of e-consult platform)
Los Angeles Department of Health Services
Los Angeles County CHCs and FQHCs partner with Health Care LA IPA specialists
PartnershipHealth Plan
Partnering with FQHCs with 6 specialties across Humboldt and Marin counties, rolling out in additional counties across the state
USCF/ZuckerbergSF General
eReferral program results in approximately 20% of requests adequately cared for by PCP, and 50% drop in wait time for specialty clinics
Early Pilot/Planning:• Contra Costa RMC• Inland Empire Health Plan• Kern Health System• San Joaquin General• San Mateo Medical Center• Ventura County
BluePath Health Inc.; Client Proprietary and Business Confidential 34
A standard set of CPT codes exists for e-consult
Program Finding Supporting Data
The standard set of e-consult CPT codes mustbe considered by State Medicaid programs
• Referring and consulting clinicians participating in e-consults will use approved CPT codes specific to interprofessional consultation.
• These codes should be incorporated into the list of approved codes for DHCS specialist reimbursement.
*JAM, Effective January 1, 2014
BluePath Health Inc.; Client Proprietary and Business Confidential 35
E-consults are being reimbursed at actuarially-sound rates
Program Finding Supporting Data
MCPs are paying specialists actuarially-sound rates for e-consult which must be acknowledged in Medicaid rate setting
• Pilot programs have demonstrated successes with e-consult, and will report more data over longer periods of time to show eConsult sustainability.
• Reimbursement would require the use of CMS/Medicaid-accepted CPT codes for interprofessional consultation with codes and rates tied to time spent per encounter.
• When fee-for-service rates apply, they are based on a percent of the provider’s face to face hourly Medicare rate, adjusted for electronic consults of up to >10, 10-15, 15-20 and >20 minutes.
Improving Access to Chronic Pain Services Through eConsultation: A Cross-Sectional Study of the Champlain BASE eConsult ServiceClare Liddy MD, MSc, CCFP,FCFPCatherine Smyth MD, MSc, FRCPC
BluePath Health Inc.; Client Proprietary and Business Confidential 36
E-consult supports efforts toward timely access
Program Finding Supporting Data
E-consult supports MCPs in efforts to meet timely access requirements
• Providers are working to meet timely access requirements through use of alternative specialty care touches (e.g. electronic consult) as part of the referral process.
• PCPs can complete eConsults with specialists “within fifteen business days of the request for appointment…” through participating in electronic consultations in which a standard response time of a specialist is 7 calendar days.
Olayiwola, J, Anderson, D et alElectronic Consultations to Improve the Primary Care-Specialty Care Interface for Cardiology in the Medically UnderservedAnn Fam Med 2016;14:133-140. doi: 10.1370/afm.1869.
BluePath Health Inc.; Client Proprietary and Business Confidential 37
E-consult supports network adequacy efforts
Program Finding Supporting Data
E-consult allows plans to expandtheir networks of specialists to support network adequacy efforts
• MCPs contract with local specialists who respond to E-Consults as a first step to a referral request. The e-consult may provide the PCP with the advice needed to treat the patient. If a face-to-face visit with the specialist is needed, it will be scheduled according to the patient’s needs.
• In geographical areas where specialists do not exist (within 10 miles or 30 minutes of the member) or do not accept Medicaid patients, the MCP may contract with a remote network of licensed specialists who can offer e-consults when appropriate to address the network adequacy requirement, avoiding unnecessary travel for the member.
• E-consults are used as part of the process of specialty care -- not just as an alternative used when providers have “exhausted all other reasonable options”.
BluePath Health Inc.; Client Proprietary and Business Confidential 38
Gaps exist in financial support for electronic consult programs
Stakeholder Source of Support Current Gaps
FQHC
• GPP
• County Specialty Care Budgets
• WPC
• APM
• APM and WPC pilots are limited. Program will not scale to support additional FQHCs until 2018.
• Incentive payments to PCPs are taken out of the clinic’s PPS rate during reconciliation
ManagedCare Plan
• DHCS
• DMHC
• Contracts do not acknowledge the use of electronic consults as a means of delivering specialty care
• eConsult is not considered a solution to network adequacy and timely access requirements
County
• GPP
• County Specialty Care Budgets
• GPP is a potential funding source for uninsured, yet specialist must be reimbursed at (minimum) Medicare rates
• Works with partners (e.g. LADHS working with CA DSH, community and university providers)
District and Public Hospital
• GPP
• County Specialty Care Budgets
• PRIME payments made based on mid-year and annual reporting of metric target achievement: referral reply turnaround rate, specialty care touches, receipt of specialist report
• GPP incents DPHs to provide non-traditional/technology based services to increase primary and preventive services
BluePath Health Inc.; Client Proprietary and Business Confidential 39
Next Steps
Activate leadership from consumer and payer associations demonstrating support for a potential solution to access to specialty care
Create case studies from mature e-consult programs that are now demonstrating cost savings through avoided unnecessary visits, travel, ED visits, duplicate tests and labs
Obtain examples of e-consult program cost savings from across the country
Share examples at October 2017 CCHP E-Consult Workshop in Sacramento
The National Telehealth Webinar Series
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Telehealth Topic: Chronic Disease Remote Patient Monitoring Project Presenters: Kim Schwartz and Becky Lundgren – Central Oregon Telehealth Network
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