Monthly Forecasting Template by iyi18451


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									Performance Objectives for Access to
Care & Referral Management: People,
   Systems & Business Practices

• 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

                      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

                                Multi-Service Market
                                 Success Stories -
•   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
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.

                                  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
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!

                  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

                    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

                  NCA – Initiatives under
• 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
                      Significance of Monitoring
                      Access to Care & Referral
• 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

                            Access To Care
• 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
• Retirees, their Dependents, and Survivors who are not
  enrolled in Prime

                      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%

                        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%
  – 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)

                        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
  – Centralized appointing all appointing for primary and
    specialty care (measurable by implementing)
  – Establish a single telephone number for all
    appointing (measurable by implementing)

                             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

                     Tactics to Improve Referral
• 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
• 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

                                   Optimizing the ATC & Referral
                                     Management Processes

Improve Referral Management and Demand
•   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

                        Support and Resources
TRICARE Access Imperatives
Commanders Guide to Access Success Download Site
Health Affairs Site (Policy Section)
TRICARE Manuals (change packages)
TRICARE Operations Center
  for the Appointment Activity Tool (AAT), Template Analysis Tool
  (TAT), TRICARE Online Reports, Enrollment & Population, & NED
  Discrepancy Report

                 Optimizing the ATC &
                 Referral Management
Performance measures that improve patient
 satisfaction are provider schedules and
 appointment availability open 30 days or

                                     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
                                                                                                                           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
        < 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

                                                                                          line up
                                                                                          is better

Source: TRICARE Operations Center                                 Data pulled 15 Nov 06

                                                   UNCLASSIFIED                                       22
                                                                    Provider Schedule Gap By Percent
                                                                            Oct 05 vs. Nov 06
Gap: Percent of Schedules/Day

                                                                                                                       < 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

                                                                                         line up
                                                                                         is better
   Average Appts Per Day

Source: TRICARE Operations Center                                Data pulled 15 Nov 06

                                                  UNCLASSIFIED                                       24
                     Patient Satisfaction with
                       Started initiatives:
                       1. APLSS Comments to Cdrs
                       2. 30-day Provider Schedules

 Percent Satisfied


                           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
               The Provider Perspective
• Healthcare costs
• Health outcome
• Medical Legal Aspects
• Healthcare-team effort

Health Care costs

                   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
            Health Outcomes cont.

• Humanistic outcomes:
 –Patient satisfaction
 –Quality of life
 –Emotional/Psychosocial health
 –Cognitive functional status
 –Symptom severity
 –Degree of disability
                   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


                    Health care team

• Access to Care/Referral Management
  Team effort
• Ramifications (to keeping the status quo)
  Inefficient and ineffective utilization of
  Decreased quality of care
  Increased litigation
  Dissatisfaction with the healthcare system as a

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