Coalition of Safety Net Access Providers March SPA by MikeJenny


									Creating healthier communities through collaboration, partnership, and implementation of innovative programs

Coalition of Safety Net Access Providers                                                        March 2011

SPA 2 providers will work collaboratively to provide timely and convenient access to appropriate, high
quality, coordinated specialty care to the low-income, under and uninsured residents of the San
Fernando and Santa Clarita Valleys.

                                PHYSICIAN SUB-COMMITTEE UPDATE

The C-SNAP physician specialty training sub-             Dr Kampp provides an eight hour Dermatology
committee started year 2011 with zest. The               clinic at Mid-Valley CHC and is contracted with
committee met early in the year to discuss a             VCCC to read the scans from our Kaiser SCI
shadowing project in Neurology with one                  Teledermatology project.
physician from Northeast Valley Health
Corporation (NEVHC) selected to shadow Dr.               In addition to representatives from Kaiser
Charles Flippen, Neurologist at Olive View-              Permanente, twenty-three Physicians and
UCLA Medical Center. The paper work to allow             Medical Assistants from Northeast Valley Health
the physician                                                                            Corporation, Meet
to participate                                                                            Each Need with
is in process.                                                                            Dignity (MEND),
Look for future                                                                           Tarzana
updates!                                                                                  Treatment
                                                                                          Centers, Mission
One of the                                                                                City Community
other projects                                                                            Network, Valley
of the                                                                                    Community Clinic,
committee is                                                                              Mid-Valley CHC,
to work with                                                                              and El Proyecto
our VCCC                                                                                  Del Barrio were
staff to set up                                                                           represented.
physician education sessions. To achieve this,
we planned our third educational session to              During our site visit from Kaiser, we shared that
focus on Dermatology. This session was held              we would be holding a third physician training
on February 11, 2011 at the Mid-Valley                   session and it was suggested that we video tape
Comprehensive Health Center (CHC) with                   our sessions. Taking the suggestion to heart,
Dermatology specialist Jeremy Kampp, MD                  two of our VCCC intern’s video-taped the
providing the training during his lunch hour.
                                                                                           (continued on page 2)
Physician Sub-Committee Update
                                (continued from page1)

session. VCCC had everyone who attended the                  HIPPA compliant and does not require any
session sign a photo release so we can share                 consent from the patient for referrals.
the session at our upcoming steering group
meeting. We are in the process of reviewing the              Other PPP clinics are interested in pursuing this
tapes to ensure HIPPA compliance in order to                 path for their dermatology consults. With the
make them available for future use by other                  experience that TTC gained being the first clinic
providers on our C-SNAP website.                             to set up the Telederm project, Chris Vigiano
                                                             offered to help draft a standardized model for
After Joni’s welcome, Dr. Michael Rodriguez,                 other clinics to utilize.
facilitator, shared the reason the physician sub-
committee was formed and its objectives and
goals.                                                         Miscommunication between Primary Care
                                                                     Physicians and Specialists
Using a case study approach, Dr. Kampp shared
five different scenarios using scans he received             According to a new study by researchers at the
from the teledermatology project. Removing                   Center for Studying Health System Change
patient identifiers, Dr. Kampp held a lively                 (HSC) published in the January 10, 2011
discussion of possible diagnoses and treatments              Archives of Internal Medicine, primary care and
with the participants.                                       specialist physicians have decidedly different
                                                             views about how often their colleagues
Dr. Kampp talked about the Teledermatology                   communicate with them.
project he is working on with the C-SNAP project,
informing the participants that he has been                  The study finds
involved with the telederm project for the past six             • 69.3% of primary care physicians reported
months and has seen 40 to 50 referrals from                        regularly (“always” or “most of the time”)
Tarzana Treatment Center and LA County’s San                       sending a patient’s history and the reason
Fernando Health Center. The majority of these                      for the referral to the specialist. Only
referrals were successfully treated at the primary                 34.8% of specialists said they regularly
care clinic facilities by primary care providers.                  received such information.
With good quality images, Dr. Kampp has all the                 •   80.6% of specialists said they regularly
information that is necessary to do a consult via                   send consultation results to the referring
email. The average consult turnaround time is                       primary care provider. Only 62.2% of
about 48 hours which enables patients to receive                    PCPs said they received such information.
medical care much faster and more efficiently
with the least amount of waiting time.                                 (Source: Center for Studying Health System Change
                                                                                                         January 10, 2011)
TTC is using a secured system called CISCO,
where they send patient information in an                    During the question and answer session, many
encrypted file. Dr. Kampp is given a secured                 physicians wanted Dr. Kampp to demonstrate
password to retrieve the files for review. Since             how to do punch biopsies. This procedure is
TTC gets patient consent for all their                       very costly and not getting paid is a barrier for
telemedicine practices, a separate consent form              the primary care providers. However, there was
is not necessary for TTC to refer dermatology                significant interest so Dr. Kampp will demonstrate
consults to Dr. Kampp. However, this may not                 the process at the next session.
be the same for other PPP clinics. All the county
referrals go through the RPS system, which is                                                       (continued on page 3)

Physician Sub-Committee Update
                                 (continued from page2)

During the brainstorming period, physicians                   In addition to the specialty education, some
expressed the need to address several critical                physicians asked that patient financial
areas during future educational sessions.                     responsibility information be provided so patients
Primary care providers unanimously agreed that                can be informed that they will incur some
GI, neurology, endocrinology, dermatology,                    financial charges when they go for their
rheumatology, cardiology and nephrology are                   consultations with any specialist. Gretchen
services with major access issues. These                      McGinley, Director of the Office of Ambulatory
specialty clinics areas are a challenge when                  Care issued the Provider Information Notice
referring patients and basic referral criteria is             (PIN) below to all Public Private Partners to
essential. Everyone agreed that most of the GI                address this subject in October, 2010.
referrals are denied, so clarification is necessary
as to the cut off points for this specialty.                              Contributed by: Joni Novosel and Surekha Vasant


The problem of “no-shows” at public hospitals is           4PatientCare can tell the difference between a
nothing new, but an intervention that includes             human and an answering machine. If an
voice recognition and SMS text messaging for               answering machine is encountered, patients are
patients is. Supported by a grant from Kaiser              asked to call the appointment desk at Olive View
Permanente Community Benefits to improve                   if they will not be able to keep their appointment.
specialty care access, the Valley Care
Community Consortium enlisted 4PatientCare to              Call result details are reported to the scheduling
help lower the no-show rate in targeted specialty          desk via fax, secure email,or Web. Patients who
clinics at Olive View including Cardiology,                are not planning to keep their appointment can
Dermatology, ENT, Neurology, and                           be rescheduled or cancelled. The key is that
Gastroenterology.                                          each valuable appointment slot can now be
                                                           allocated to a waiting patient.
Appointment data for patients is generated
automatically from the Affinity scheduling system          In September 2010, 4PatientCare began calling
and sent securely to 4PatientCare. Patients                patients scheduled in the Neurology clinic. This
receive up to three calls and as of January2011,           was followed by Gastroenterology and ENT in
patients who have cell phones started receiving a          December 2010. Beginning in January 2011,
text message.                                              Cardiology and Dermatology patients were
A three-call model was selected for initial rollout.                                                  (continued on page 5)
It includes a pre-appointment call,
comprehensive reminder, and a reminder with
confirmation. The pre-appointment call occurs
three weeks prior to the appointment date. It is
                                                           Hospital care accounted for 31% of all national
used when the appointment is scheduled more
                                                           health expenditures in 2008. According to a
than 3 months prior to the visit. This call is
                                                           new report published by the National Center for
designed to have the patient commit to the
                                                           Health Statistics, in 2008, national health care
upcoming appointment. Given the long time lag
                                                           expenditures in the United States totaled $2.3
between when the appointment is originally
                                                           trillion, a 4.4% increase from 2007. Additional
scheduled and the actual date of the
                                                           2008 findings:
appointment, patients easily forget.

After the pre-appointment reminder, the patient               •   The average per capita expenditure on
receives a comprehensive reminder 3 to 5 days                     health in the United States was $7,700
prior to their appointment (the exact number of               •   Expenditures for hospital care accounted
days depends on the appointment day of week).                     for 31% of all national health expenditures
Using voice commands (no “press 1 for this, 2 for             •   Physician and clinical services accounted
that”) the patients are able to confirm, cancel, or               for 21%
indicate that they would like to reschedule their             •   Prescription drugs for 10%
appointment.                                                  •   Nursing home care for 6%

                                                               Data Source: Data are compiled from various sources by the
The evening before the appointment, patients                                    Centers for Medicare & Medicaid Services
receive their final voice-based appointment
reminder. For those with a cell phone, a text                 Publication: Health, United States, 2010. Centers for Disease
                                                              Control and Prevention's National Center for Health Statistics,
message is sent several hours prior to the                                                                  February 2011.

IMPROVING APPOINTMENT SHOW RATES                                          (continued from page 4)

OV-UCLA provided 4PatientCare with appointment attendance results from Affinity, which captures
five appointment status values.

             Appointment Status                             Description
         Arrived                        Patient Arrived for their appointment
         Booked                         Patient did not show for their appointment
         Cancelled                      Appointment cancelled prior to appointment time
         Departed Not Seen              Patient arrived, but left prior to being seen
         Departed Seen                  Patient was seen as scheduled

The no-show rate was calculated as follows:
                                     # of Appointments with a status of Booked
                   No-Show Rate=
                                     Total # of Appointments

Run charts for the period of March 2010 to January 2011 were generated to reflect pre- and early
post-intervention periods.

While there was measurable improvement in all clinics, it is clear that Neurology did not have the
dramatic results seen in GI and ENT.

New technology brings with it opportunities for workflow changes that
previously were not possible. Since 4PatientCare provides feedback
of cancellations prior to the appointment date, there is an opportunity
to fill a now vacant slot with a waiting patient. Between 3% and 12%
of patients classified as “no-show” in Affinity were contacted by
4PatientCare and cancelled their appointment. Thus, the “true” no-
show rate is even lower than reported, and there is an opportunity to
increase capacity in these specialty clinics by ensuring that
4PatientCare “cancelled” appointment slots are made available to
waiting patients.

In the future these “late” cancellation slots may be best used for
“urgent” appointments, without having to “pre-reserve” slots that may go unused.

The initial results from the pilot demonstrate dramatic improvement in show rates in two of the three
clinics analyzed. Further investigation is required to fine-tune the configuration for Neurology. Policy
and procedures to ensure cancelled appointment slots are well utilized need to be investigated. We
plan to compare no-show rates in the targeted clinics to specialty clinics that are not involved in the
4PatientCare pilot including Ophthalmology, Rheumatology, and Orthopedics. Analysis of this data
                                                            and future clinic implementation will be

                                                                Contributed by: John Harding, 4PatientCare - Voice
                                                                                               Enabled Healthcare


The Office of Ambulatory Care Provider Information Notice 10-10 “Patient Referrals to County
Hospitals or Clinics” (see page 3) detail patient and referring provider responsibilities regarding
referrals into County specialty services. DHS has several types of programs to assist patients in
paying for DHS services. The information below provides a sketch of these programs.

                                     (Legend: 1 = CHC & MACC; 2 = Inpatient & Outpatient County Hospital clinics)

1. ORSA or Outpatient Reduced-Cost Simplified Application (1,2)
       a. Covers: outpatient medical care, tests and medicines. You cannot use ORSA for
          inpatient care
       b. Eligibility: Low income (under 133 1/3 % FPL and uninsured). Must apply for Medi-Cal; if
          you do not want to apply you may use pre-payment plan. Must provide and sign
          statement on information about family size, income and expenses—may be later asked
          to bring written proof. Must bring proof of LA County residency.
       c. You must reapply for ORSA each year.

                                                                                          (fictitious MRUN # shown)

NO-COST OR LOW-COST MEDICAL CARE                                          (continued from page 7)

2. Pre-Payment Plan (1,2)
        a. Covers: Outpatient care at County hospitals, Comprehensive Health Centers (CHCs),
           and Multi-Service Ambulatory Care Centers (MACCs). Does not cover medications.
        b. For each outpatient visit you pay: $60 at Health Centers or CHCs except Urgent Care;
           $80 at County Hospital Outpatient Clinics and MACCs, except Emergency Rooms; $60
           for prenatal services for first seven visits, remaining visits at no extra charge; $80 at
           CHC Urgent Care; $120 at County Emergency Rooms; $400 at Outpatient Surgery
        c. If you pay within 7 days of choosing this option, you do not need to provide income or
           family size.

3. Ability to Pay Plan (ATP) (1,2)
          a. Covers all types of care at County Hospitals.
          b. The amount you pay is based on your income. You must see an ATP worker to tell you
             what amount you pay which is based on your income.
          c. For inpatient, you must reapply for ATP each time you to into a County hospital.
             Application is good for a one month stay. For outpatient, you must apply once per year.
             Must apply for Medi-Cal; if you do not want to apply you may use pre-payment plan.
             Application: must bring proof of address, identity, income and deductions. ATP worker
             can accept signed sworn statement.

4. Kidney Dialysis, Tuberculosis and Post-Polio (1, 2) - There are special programs to cover
   these services. Apply at DHS sites.

5. No Extra Cost Medicines (1, 2) – Hospital outpatient clinic patients can get medicines at no extra
   cost for emergency and public health service. In other cases it is included in ATP or ORSA
   payment amounts. Financial services workers at DHS sites can explain this.

6. Out-of-County Discount Payment Plan (OOC/DPP): For Out-of-County/Out-of-
   Country/Foreign Visitor/Non-immigrant persons (2)
         a. This is a discount on medical care services received at only at County hospitals and
            hospital based clinics to patients who are not LA County residents.
         b. There is a 5% discount on medical received for patients with incomes up to 350% of
            FPL. The charges for services are not to exceed Medi-Cal rates

7. Child Delivery Plan (2)
         a. Covers labor and delivery services for pregnant women at County hospitals
         b. Each mother must pay $2,000 within 7 days of leaving the hospital but does not have to
            apply for Medi-Cal. Mother must apply for Medi-Cal for the baby.

Please consult the PIN 10-10 and its supporting documentation for additional details.


                                 November 2010    December 2010    January 2011
Neurology                                   136              129            112
Gastroenterology                             32               60             46
Dermatology                                  47               43             34
Surgery ENT                                  26               24             25
Cardiology                                   19               25             20


Clinic Name                                              Number of Days to Next Appointment
                                                  January 2011    December 2010     November 2010
Chest                                                        158                125            123
Surgery Audiology                                            138                145            145
Rheumatology                                                 133                165            171
Diabetic                                                     125                 97            104
OB/GYN - Gynecology Urology                                  124                128            128
Endocrinology                                                106                120            148
Surgery Laser (Part of Optometry)                             78                 85             85
OB/GYN - Gynecology Endocrinology                             76                180            175
Surgery Proctology                                            75                 68             89
OB/GYN - Gynecology (Re-design Clinic)                        71                 81             80
Renal                                                         68                 75             95
Surgery Ophthalmology                                         68                 61             40
OB/GYN - Gynecology - Oncology (Re-design Clinic)             65                 16             30
Surgery Optometry                                             62                 65             47
Surgery Urology                                               55                 71             71
Memory Loss                                                   53                 42             70
OB/GYN - Gynecology - PAP/Colpo                               48                 48             41
OB/GYN - Gynecology - After Care                              47                 49             34
Hematology                                                    42                 32             30
OB/GYN - Post Partum                                          41                 60             67
Oncology                                                      41                 21             23
Podiatry                                                      39                 49             48
OB/GYN - Sterilization English                                36                 36             25
Surgery Vascular                                              33                 33             54
Surgery Plastic                                               29                 24             36
Infectious Disease-Specialty                                  28                 25             26
Surgery General                                               28                 25             32
Surgery Cleft Palate                                          27                 27             34
MDA Neuromuscular                                             22                 22             10
OB/GYN - Prenatal Intake                                      22                 22             27
Orthopedic Adult                                              19                 12             12
Infectious Disease                                            16                 16             19
Surgery Breast                                                12                 12             12
OB/GYN - High Risk Prenatal                                   10                  9             12
OB/GYN - Sterilization Spanish                                  1                22              8
OB/GYN - Antepartum/Genetics                                    0                 0              0

                                           C-SNAP UPDATES
                                    Valley Care Community Consortium
                                          Bonnie Bailer, President
                                     Joni Novosel, Executive Director
                                            Carla Niño, Editor


To top