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Performance Objectives for Access to
Care & Referral Management: People,
Systems & Business Practices
Objectives
• Explain the significance of monitoring
access to care
• Explain the significance of monitoring the
referral process
• Name three MHS performance metrics
which will improve access to care or the
referral process
2
Session Overview
• Performance objectives & the impact on
improving access & customer satisfaction
• Optimizing the referral management process
– Performance measures that improve access are
provider schedules and appointment availability open
30 days or more
– Discussion on tactics for improvement which include
demand forecasting, template management &
appointment information systems management
• From the provider perspective review the
significance of access to care and referral
management
3
Multi-Service Market
Success Stories -
Tidewater
• Tidewater Multi-Service Market (MSM) - meet on a monthly discuss
a variety of common issues
– share current availability of clinical services/procedures
– access is in specific clinics – problems identified
– Discuss optimization opportunities within the direct care system before
utilizing network care, determine what & how MTF’s may be able to
assist
Examples:
1. About a year ago, FT Eustis needed temporary support for Internal
Med consults pending backfill of a vacancy. NMC Portsmouth took
on about 100 patients for them during the 3-4 month time until the
staffing issue resolved.
2. Navy has Yorktown clinic located outside FT Eustis. Yorktown
enrollee’s are directed to go to FT Eustis Urgent Care Center rather
than use local network resources.
4
Tidewater Success
Stories Continued
3. Langley offered to assist with Active Duty routine Ortho referrals,
opening access for higher acuity referrals at NMC Portsmouth. This
enabled balancing of Ortho referrals and avoided network referrals for
higher acuity patients to the network.
4. Langley enrollees on the Portsmouth side of tunnel, have some
flexibility for routine OB care, however NMC Portsmouth remains the
high risk center for all market referrals.
5. Langley will soon open a small feed & grow nursery to off set network
admissions.
6. Success – the details!
– Each month - MTFs review updates to a combined tiered "Capability
Report" - visible to all Tidewater MSM members as a quick reference
– Referral Management Center (RMC) staff within the market all have
contact information available for immediate response to questions,
assistance or troubleshooting.
– Monthly meetings are great peer relationship builders!
5
The NCA – Challenges
& changes with impact!
• 10 MTF’s essentially competing for the same
beneficiary population
• Business Rules defined for Referral
Management, Appointing and Enrollment
practices approved by the Access Council
MTF leadership MSMO Director
• Intent of the rules - decrease the number of
wasted appointments, improve call center
appointing ability improving access
6
The NCA – basic rules
• Prime is Prime – No MTF should see their own
prime over others for specialty care
• Eliminated MTF Book only
• Opened schedules 6 weeks in advance
• No more than 10% Provider Book only
– MTF leadership approved waiver process
• Developed a portal to monitor appointment
utilization, access to care, network leakage with
clinic drill down capability
7
NCA – Initiatives under
development
• ROFR – Central point of entry – eliminate
duplication of efforts increase access
• NCA Joint Tracking Database – in beta test – to
allow individual Referral Management Center’s
(RMC’s) to use the same tracking resource,
essentially creating one RMC in the NCA
• NCA Consult reminder system – using a module
of the Patient Appointment reminder system –
decrease the 40% gap in admin closure of
referrals
8
Significance of Monitoring
Access to Care & Referral
Management
• To improve access and patient satisfaction for the
beneficiaries who access our health care facilities within
the MHS
• To improve the referral management (RM) process
focus on people, systems, and business processes that
can all be influenced or changed is imperative
• TRICARE Prime beneficiaries are entitled to the access
to care standards for specialty care in accordance with
32 CFR 199.17 (p)(5)(ii)
• TRICARE is the nation’s largest health care plan and
how access is managed and improved is everyone’s
responsibility
9
Access To Care
Priorities
• 32 CFR 199.17 (d)(1)(a-e) assigns priority of care within
the MTF as follows:
• Active Duty Service Member (ADSM)
• Active Duty Family Member (ADFM) and Transitional
Survivors of service members who died on active-duty,
who enrolled in Prime
• Retirees, their Dependents and Survivors who are
enrolled in Prime
• ADFMs not enrolled in Prime, Transitional Survivors of
service members who died on active duty who are not
enrolled in Prime and TRICARE Reserve Select
beneficiaries
• Retirees, their Dependents, and Survivors who are not
enrolled in Prime
10
Access To Care
Performance Objectives
& Monitoring
• Meet ATC standards for Acute, Routine,
Wellness, Specialty appointment types at least
90% of the time
• TOL registration: >=20% entry level and >= 50%
advanced level (beneficiary count measured)
• TOL appointing: 10% entry level and 20%
advanced level (all appointments measured)
• Web Enable Appointments (WEA) Acute,
OPAC, PCM, Routine, Well and Established
clinic appointments: entry level 50% to advance
level 80%
11
Access To Care
Performance Objectives
& Monitoring
Improve Template & Appointment Management:
– Provider schedules (primary/specialty) reflect at least
30 days out (all appointment types measured 10%
gap)
– Decrease Primary Care “MTF Book Only”
appointment rate: entry level <10% and advanced
level <5% (PC/MC appointment types measured)
– Decrease the primary care “unused/unbooked”
appointment rate <5% (all appointment types)
– Decrease the primary care “No Show” rate <5% (all
appointment types)
12
Access To Care
Performance Objectives
& Monitoring
Improve Template and Appointment
Management (cont):
– Decrease NED discrepancies .05% of total enrolled
beneficiary population. Implement Open Access
appointing (Acute & OPAC) appointment types
measured)
– Centralized appointing all appointing for primary and
specialty care (measurable by implementing)
– Establish a single telephone number for all
appointing (measurable by implementing)
13
Tactics to Improve
Specialty Care Appointing
• Establish procedures to appoint AD members with initial
specialty care appointment prior to leaving the MTF
• Establish procedures to appoint all enrolled
beneficiaries with their initial specialty care appointment
prior to leaving the MTF
• Metrics for All Levels:
– Appointment occurring within 60 minutes of the beneficiary
leaving their PCM
– Provider schedules (primary/specialty) reflect at least 45 days
out (all appointment types measured 10% gap)
– Specialty appointments booked prior to leaving the MTF
– Establish marketing/education plan to actively promote this
initiative
14
Tactics to Improve Referral
Management
• Centralized management of all referrals, resulting, and
Right of First Refusals (ROFRs) both internal/external to
the MTF: 100% tracked, system AHLTA
• Centralized management of capacity and capability
reporting
• Centralized metrics for number of referrals and referral
results, ROFRs (accepted, rejected and appointed) and
direct care referrals sent to network: 100% tracked,
system support AHLTA
• Centralized management of durable medical equipment
requests: 100% tracked, system AHLTA
15
Optimizing the ATC & Referral
Management Processes
Improve Referral Management and Demand
Forecasting:
• Time taken to disposition referrals entered into ALTHA/CHCS
– (no greater than 72 hours entry to appoint)
• Number of direct care referrals that actually resulted in an appointment
– (by initiator, specialty, disposition status)
• Number of referrals redirected back into the direct care system
• Referral patterns reporting by specialty
• Identify the potential to:
– Return specialty care services back to the MTF
– Identify opportunities to utilize venture capital resources
– Reduce overall costs for delivering specialty care
– Enhance efficiency of the referral management process
– Increase patient satisfaction
• Establish a mechanisms that reports through your MTF/MSM chain of
command regarding potential for recapturing specialty care
16
Support and Resources
TRICARE Access Imperatives http://www.tricare.mil/tai
Commanders Guide to Access Success Download Site
http://www.tricare.mil/tai/cguide.htm
Health Affairs Site (Policy Section)
http://www.ha.osd.mil/policies/default.cfm
TRICARE Manuals
http://www.tricare.mil//tricaremanuals/download/default.cfm
TRICARE Manuals (change packages) http://manuals.tricare.osd.mil/
TRICARE Online http://tricareonline.com
TRICARE Operations Center http://www.tricare.mil/tools/TOC.htm
for the Appointment Activity Tool (AAT), Template Analysis Tool
(TAT), TRICARE Online Reports, Enrollment & Population, & NED
Discrepancy Report
17
Optimizing the ATC &
Referral Management
Processes
Performance measures that improve patient
satisfaction are provider schedules and
appointment availability open 30 days or
more
18
Army - 30-Day
Provider Schedule Initiative
• Significant portion of dissatisfaction related to providers not keeping 30-day
schedules loaded at all times
– Source: Army Provider Level Satisfaction Survey (APLSS)
• Big drop off at 1st of month when looking from mid-month
– This is called the Provider Schedule Gap (PSG)
• Calculation of PSG
– Average # of provider schedules from previous 30-days
– Average # of provider schedules for next 30-days
– Less weekends, holidays, training holidays
– Difference between the two averages is the PSG
– Source: TOC
• Army TSG required 10% PSG by May06 and 5% PSG by Aug06
• Objective: Improvement in patient satisfaction for 3 access measures
UNCLASSIFIED 19
MEDCOM 30-Day
Provider Schedule Gap
11 Sep 05 – 9 Nov 05
Difference
937 or 22%
Number of Providers with Loaded Schedules
1st of month
drop off
11 Sep – 10 Oct 11 Oct – 9 Nov
Average Prov/Day with
4,261 Loaded Schedules 3,323
Source: TRICARE Operations Center Data pulled 10 Oct 05
UNCLASSIFIED 20
MEDCOM 30-Day Provider
Schedule Gap Trend Analysis
Oct 05 – Nov 06
Down is
Provider Schedule Gap better
% of Schedules/Day
# of Schedules/Day
Target
< 5%
Source: TRICARE Operations Center Data pulled 15 Nov 06
UNCLASSIFIED 21
MEDCOM 30-Day Provider
Schedule Gap Trend Analysis
Oct 05 – Nov 06
Average Provider Schedules Per Day
Average Schedules Per Day
Green
line up
is better
Source: TRICARE Operations Center Data pulled 15 Nov 06
UNCLASSIFIED 22
Provider Schedule Gap By Percent
MTFs
Oct 05 vs. Nov 06
Gap: Percent of Schedules/Day
Target
< 5%
Source: TRICARE Operations Center Data pulled 10 Oct 05 & 15 Nov 06
UNCLASSIFIED 23
MEDCOM All Appointment
Gap Trend Analysis
Oct 05 – Nov 06
Average Appts Per Day – All Appts
Green
line up
is better
Average Appts Per Day
Source: TRICARE Operations Center Data pulled 15 Nov 06
UNCLASSIFIED 24
MEDCOM
Patient Satisfaction with
Access
Started initiatives:
1. APLSS Comments to Cdrs
2. 30-day Provider Schedules
Target
Percent Satisfied
Source:
APLSS
UNCLASSIFIED 25
Army - 30-Day Provider
Schedule Initiative
• Results
– Breaking poor business practices
– Cut PSG by half
• Adding nearly 700 schedules/day in the next 30-day window
• Adding nearly 15,000 appts/day in the next 30-day window
– Improving patient satisfaction
• Phone service: +6.5%
• Consideration of patient’s schedule: +5.5%
• Time between appt and visit: +4.6%
• Still improving on the best methodology to calculate the measure
– Minimize impact of deployments, BMM, GME
– Automate the process
UNCLASSIFIED 26
Overview
The Provider Perspective
• Healthcare costs
• Health outcome
Clinical
Humanistic
Financial
• Medical Legal Aspects
• Healthcare-team effort
27
Health Care costs
28
Health Outcomes
• Clinical outcomes:
– Morbidity, mortality
– Psychologic metabolic measures
– Clinical events
– Length of stay
– Safety and efficacy of treatment
– Treatment effectiveness
– Rate of cure/recovery
29
Health Outcomes cont.
• Humanistic outcomes:
–Patient satisfaction
–Quality of life
–Emotional/Psychosocial health
–Cognitive functional status
–Symptom severity
–Degree of disability
30
Health Outcomes cont.
• Utilization outcomes:
– Inpatient stays and procedures
– Ambulatory visits, tests
– Medication, equipment, supplies
• Economic outcomes:
– Direct costs-health care cost
– Indirect costs- lost income, loss of
productivity/work, early retirement, days of
restricted activity, bed days
31
MEDICAL LEGAL
32
Health care team
• Access to Care/Referral Management
Team effort
• Ramifications (to keeping the status quo)
Inefficient and ineffective utilization of
resources
Decreased quality of care
Increased litigation
Dissatisfaction with the healthcare system as a
whole
33
