**Transcript of Cyberseminar**

**Patient Aligned Care Teams (PACT) Demonstration Labs**

**Primary/Specialty Care Integration: Insights and Challenges in Improving the Consult Process**

**Presenters: Ron Grewenow, MD; Anais Tuepker, PhD, MPH**

**December 19, 2012**

**Primary/Specialty Care Integration: Insights and Challenges in Improving the Consult Process**

**December 19, 2012**

Molly:We are at the top of the hour now, so I would like to introduce our presenters. We have Ron Grewenow, Dr. Ron Grewenow. He is the Group Practice Manager at the West Linn Community Based Outpatient Clinic for the Portland VA Medical Center. Joining him is Anais, Dr. Anais Tuepker. She is part of the VISN20 PACT Demonstration Lab. Finally, we have Dr. Michael Ohl. He has worked for the Veterans Rural Health Resource Center in Central Region and part of the VISN23 PACT Demonstration Lab for Iowa City VA Medical Center, and works for the Division of Infectious Diseases at University of Iowa. So we would like to thank them for lending their expertise and at this time, I would like to turn it over to Dr. Tuepker. You are going to see a pop-up that says, “Show my screen.” Go ahead and click on that and we will get going. 

Anais Tuepker:Okay, excellent. So you have my screen now, Molly?

Molly:Yes, we do. Sorry, I did not mention this earlier. For the presenters and audience members, to minimize that dashboard in your viewing screen, just hit the orange arrow in the upper left hand corner. Thank you.

Anais Tuepker:Thank you. Well, thank you everyone for listening in this morning and we hope that it will be interesting to you. We have a lot of things we are going to talk about this morning, so I will just get going. Dr. Grewenow and I are going to talk about some work that we have been doing here in the Portland VA in VISN20. We are really focused on the beginning piece of the relationship between primary care and specialty care. So we are going to talk about the referral process, the consult process, and some work that we have been doing to try and improve that. Then Dr. Ohl is going to talk about what is really the next step in the relationship between primary and specialty care, moving into really that ongoing care, coordination of care for patients with HIV. We are trying to look at different steps along that pathway of coordinated care, which is so important to PACT. We hope that you will enjoy and have lots of questions. So without more introduction, I am trying to move forward. 

Just briefly, the audience probably already knows this, but this kind of frames our work. Why is specialty-primary care integration important? Just to, I think people who are practicing in the field, they know from their daily interactions with patients that this is important. But just to think about it a little more from a systemic viewpoint, it is conceptually something that is a necessary piece of continuous coordinated care. Right now, there is evidence of many deficiencies in the process. I have given just two references. I give the full references at the end if you want them. But there is very little evidence of what works to fix it. The research that is out there has been focused on identifying problems in communication, problems in coordination of scheduling, agreement on what the actual clinical problem is, but there has not been a lot of evaluation of how to fix it. That is an important area for all of us to be thinking about going forward. We are looking at specialty-primary care integration within PACT. At least that is the lens that we are looking at it here as part of the VISN20 Demonstration Lab. 

Conceptually, this integration is important because it could contribute to improved patient health outcomes. It could contribute to better patient experience. It also could be an important piece of more efficient use of system resources, meaning that there would be less duplication, there will be better use of both specialist and primary care provider and primary care team time because patient access is often one of the pieces that both specialty and primary care, especially within our VA system, are working to improve. There are challenges to access. If we can really use time more efficiently, that would be a big improvement.

One other thing we wanted to point out just briefly is that the PACT initiative really requires, we believe, a systemic culture change to succeed. So limiting it to primary care would really create organizational challenges for the successful implementation of any piece of it. It also might create rivalries. I just briefly want to say what we mean by that. We have in our dialogues with other parts of the system; there has been a perception often that PACT is something that is “Oh that is primary care.” Therefore, sometimes there is a tendency to say, “Well, there is a real problem here. Can primary care fix it?” Certainly, primary care has a lot of work to do to address some issues. We are going to talk about that. But by limiting the idea of the medical home to just primary care, it could work against the systemic change that we really need to achieve that continuity. It is important for the success of the idea of PACT to involve everybody. 

I am going to talk just briefly about the Workgroup Initiative. The Portland VA Medical Center, as part of their PACT transformation, our primary care leadership identified several areas for internal innovation and improvement. There were five workgroups that were set up. You can see them there: chronic pain, referral management, CHF – congestive heart failure management, preoperative management, and then team formation and function which is really about how the idea of the PACT teamlet could be best implemented. 

Our workgroup was the referral management workgroup. It has been—and all of these workgroups were composed of staff from all different roles within the PACT teams. I skipped over it, really, at the beginning. I meant to thank all of our team members on our workgroup. So we have really everyone in different roles equally participating and people from different community-based outpatient centers. So we have really different clinics, different types of practices. Some are here in Portland, which is an urban center. Some are from more rural CBOCs. They all bring different experiences of the challenges in coordination. It is worth noting that the participants were allowed to block out time for their participation and the providers had surrogate coverage for our longer meeting sessions. 

We mostly had face-to-face meetings. We reviewed data as an initial starting point from all consults from last fiscal year. We used that as a starting point to develop kind of a focus of where we wanted to dive in. We looked at what were the most frequent referrals; prosthetics, GI, dermatology were always at the top of the list for most of the CBOCs. But there was some variation between the clinics. That helped us to refine our understanding of why people might be putting in more consults from a particular setting to have to do with the training of the providers they had or the resources available in the community, things like that. That generated some very good discussion. It gave us an idea of what we wanted to focus on.

Then we decided to invite specialty services to dialogue sessions. We prioritized those that we had a lot of interaction with based on the data, but we also invited really quite a broad range, not just the top two or three. As you can see, we ended up having dialogue sessions. These were 90 minutes to two hours in length and we would have representatives from the specialties come meet with our team at a time that worked for everybody, which is no small feat to organize. We had input, as you can see from a number of specialties. We also had input from the computer applications coordinator who could talk to us about some of the technical issues for CPRS consult redesign because we, fairly early on, realized that we might need to or want to make some changes there.

 I am going to hand the phone over, the presentation over to Dr. Grewenow, who is going to talk about our findings. Here you go.

Ron Grewenow:First of all, thank you, Anais, and thank you to the audience for giving us the opportunity to share what we have been learning so far. As we entered into discussions and began the dialogue with the specialties, there were a few findings that we had suspicions about that were rather quickly confirmed. The first one was that primary care often is not very clear in a consult request as to what the primary care provider wants the specialist to do. What is the question to be answered? A number of specialists commented that frequently they do not even see a question. It is a consult based on a diagnosis, not on some intervention plan, treatment, that the specialist is queried about being able to provide. We also quickly understood that the volume of consults is very challenging for specialists. The result of that volume is a delay in access. From the specialist’s point of view, having clarity in the consult improves their ability to rapidly meet the needs of the patient. 

There were a number of surprises that came out of our discussions. One of them was the very high level of variance in primary care provider practices related to consults. By that I mean the reason for referral, the work-up prior to referral, there is great variance even amongst providers who appear to have the same level of training and experience. That was a little surprising to us. There is also a very high level of variance in the specialty processes for reviewing consults that goes all the way from never looking at the consult until the patient is in the office and then sometimes not even looking at the consult, or to the point of intensively reviewing the chart and converting visit consults to e-consults and completing them without seeing the patient or taking an e-consult and converting it to a visit consult. So the great variation amongst the specialists in terms of what they do with a consult once they have received it. We were surprised to find that patients frequently were unaware that they were being referred or what the purpose of the referral was. 

Another significant surprise was that specialty care actually was interested in having more phone calls or paging from primary care to discuss referral issues. They have a very strong interest in doing as many consults in the e-consult format as possible. Some specialty services, however, do not access CPRS on a routine basis. That was a surprise to primary care providers because CPRS should be the main communication system for patient issues. A stumbling block for Portland is the medical center-centric thinking from some specialty services that primary care was at the medical center. In fact, we have virtually no primary care at the medical center. It is all in CBOCs. This creates some inherent problems in certain types of consults that are generated when specialists think, “Well, why couldn’t the primary care provider simply arrange the transfusion or the iron infusion?” Primary care does not have that access anymore since we have moved primary care into the communities. 

Looking at the conversations that we have had, our workgroup has come up with about 20 to 30 recommendations in the draft report. They fall into four basic categories: general recommendations regarding the consult process, recommendations that are internal to primary care, some service specific recommendations, and recommendations beyond the scope of the workgroup which really involve basic medical center practices. 

An example of a general recommendation, and this is kind of our leading recommendation coming out of this process, is a redesign of the consult template. We are suggesting that all consults that involve guidelines, testing requirements prior to consultation, all of those guidelines and testing requirements should be at the very top of the consult. So a primary care provider opens it, sees that for the neurosurgical consult, an MRI is requested or needed. If that has not been done, they stop the consult process and take care of the MRI. Right below those guidelines, there should be a statement that the primary care provider indicates, yes or no, they have discussed the reason for the consult with the patient. They then proceed to indicate that testing, required testing has been ordered. If it has not been completed, why not? Then the basic communication issues, a free text box for the clinical summary followed by a free text box in which the primary care provider states clearly the question to be answered by this consult, then an additional free text box indicating patient expectations for the consult. As an example, some patients are insistent on seeing a specialist because they have a comp and pension claim pending and they feel that that helps their documentation. Or if a patient is expecting a knee replacement in an orthopedic referral, it is helpful to orthopedics to know that that expectation exists. The last part of the consult would then be specialty-specific questions. For instance, a pulmonary sleep consult has are there records of sleep studies or where are they, things like that that are service-specific. That is our general recommendation. 

The internal to primary care recommendation revolves around providing an information sheet or letter to each patient once a consult has been entered. That would be set up as an administrative order initiated by the primary care provider. The clinic support staff then has a link to a single location in which there are a number of documents. They are specialty-specific letters that are put together jointly by primary care and the specialty service that are given to or mailed to the patient that indicate they have been referred to X clinic, the primary reasons for that referral, who to contact if they need to change an appointment, what they need to expect out of that consult, how much time it is likely to take, when they will likely be scheduled. We feel that that would significantly improve the patient’s perception and preparation for consultation.

There are a couple of specialty-specific recommendations, one that came out of our discussions with hematology/oncology. As a brief background, Portland VA has a pulmonary nodule pathway for any pulmonary nodule and that is tracked. There is a specific process for working up those nodules. When there is a suspicious mass or rule out cancer somewhere else in the body, we have no specific way of knowing does that go to surgery, surgery oncology, oncology, pulmonary, neurosurgery? There are so many options that a recommendation is an interdisciplinary panel that by consult manages suspicious mass, rule out cancer that is identified in any patient. The other major recommendation that we have that is specific to a service is to change prosthetic ordering from a consult to an order menu process similar to what is done for pharmacy to assist the primary care provider in identifying what is available and being specific in their orders. 

There are two significant recommendations that are beyond the scope of the workgroup. One is for the medical center to improve the processing of outside scanned records so that specialists have an easier time of locating relevant test results from outside providers. They spend a great deal of time in VISTA imaging, trying to find those tests now because of the problems with labeling that information. The second recommendation is to support the desire of many of our specialty colleagues to come to CBOCs on a regular basis for education, for mini clinics, and for improving communication. 

A concluding thought that the specialty of primary care is relationship and its relationship within the PACT teamlet and its relationship between the teamlet and the patient. The key to improving the consult process is improving relationship between primary care and specialty care. As a little side note, members of the workgroup have commented several times that the process of engaging specialty care in discussion has already had an influence on communication and consult processing and effectiveness. I thank you for your time and I am giving the phone back to Anais for her concluding comments.

Anais Tuepker:I will just thank our whole team again and I want to make sure that Dr. Ohl has plenty of time to get through the interesting material he has. So are we saving all questions until the end, Molly?

Molly:Yes, we will. 

Anais Tuepker:Okay, so I will turn it over to Dr. Ohl now. 

Michael Ohl:Hello, my name is Michael Ohl. I am an infectious disease physician at Iowa City VA. I would like to say a few things about the issue of generalist-specialist collaboration in the care for veterans with chronic illness. I view this as somewhat distinct from what we have just been talking about. That is the consult and referral process to initiate a new episode of specialty care around a defined question. Here, I am thinking about the veteran with one or usually more chronic conditions who is simultaneously receiving care in primary care and one or more specialty clinics at the same time. We know this is a common situation and it presents problems for integration of specialty and primary care that are not well addressed by the traditional consult referral process. I would like to make my comments about this issue in the context of a case study of a program we have been working on here in Iowa City for caring for veterans with HIV infection in a rural area. 

My slides do not want to advance. Okay, I apologize for that. I think it is useful to take a brief moment and think about the aspects of specialism or generalism that are salient to chronic illness care in different settings. So we think about specialism as being particularly relevant for conditions that are rare and are characterized by technical complexity of management or by rapidity of innovation where the state of the art of care is rapidly changing. Generalism is a philosophy I think is well suited for situations of complexity due to multimorbidity, multiple interacting chronic conditions. We know this is the norm in chronic illness where the focus is on comprehensiveness and holism. By holism, I mean the recognition that the sum is more than some linear function of the parts. For the veteran with chronic illness, high quality care is much more than guideline appropriate care for each of her or his individual conditions. We can think of a number of patient populations with chronic conditions that require aspects of both specialism and generalism on an ongoing or longitudinal basis, for example chronic kidney disease approaching transplant or dialysis or rheumatoid arthritis or other rheumatologic conditions requiring biologics or other ongoing intensive immune suppression. 

Care for the veteran with HIV is certainly a case where aspects of both generalism and specialism are necessary. Historically, HIV medicine has been technically complex, rapidly evolving. That is still the case for many veterans with HIV, but not all. Certainly, there is a need for generalism. Veterans with HIV have a chronic condition. Their average age is 54. They have multiple interacting comorbidities and particular clusters of comorbidities, for example cardiovascular and metabolic conditions, hypertension, hyperlipidemia, diabetes, coronary disease for example or interacting mental health and substance use conditions that are the norm. 

We need to think about aspects of both generalism and specialism, but how do we organize that? In large cities, the traditional approach has been to create high-volume HIV specialty clinics that employ co-located interdisciplinary teams. Essentially, primary care occurs in these clinics. It is carved out from the general primary care delivery system. Increasingly, these clinics have developed systems and expertise for delivering comprehensive primary and preventive care for an aging population. This model works great in large urban areas, but it does not adapt to rural settings such as Iowa. This was the case in 2010 when we were caring, for example, for about 30 veterans who lived more than an hour’s drive away from the HIV specialty clinic each way and who were historically bypassing care in more nearby CBOCs in order to receive all of their care in the specialty clinic. There was a fundamental problem with inadequate access. There was also a problem with comprehensiveness. Although the HIV specialty clinic was doing well by any measure in providing HIV-specific care, this small specialty clinic lacked the systems and expertise necessary to deliver comprehensive primary care for an aging population. Veterans expressed interest in receiving care in CBOCs closer to their homes provided that concerns about privacy and HIV stigma could be addressed and assured. 

The question was how to organize this care. So in talking with veterans and primary care teams in the PACTs and the CBOCs, we considered several models. The first one that obviously comes to mind is clinical video telehealth where we use telehealth technology to deliver team-based HIV specialty care to the veteran in the CBOC. I think in many cases when clinical video telehealth programs are established, there is a focus on creating the visit structure and the technology. But there is not much thought given to integrating the specialty care delivered by telehealth with the primary and preventive care delivered locally by the CBOC. So in our case, this model would have addressed the access problem, but not the comprehensiveness problem. 

We also thought about SCAN/ECHO. I am going to assume that since this is predominantly a VA audience that many of you are familiar with it. In its essence, SCAN/ECHO is a model for improving the capacity of primary care teams in CBOCs to deliver specific aspects of specialty care. It is essentially about knowledge transfer. The primary care team delivers all of the care with access to structured case-based mentoring from an outside HIV or specialty care team. We considered this strongly, but it became clear as we talked to veterans and primary care providers and CBOCs, they, at least initially, did not want this for HIV care due in part to the perceived complexity of HIV medicine. What was suggested instead was a collaborative care model where specialty care delivered by telehealth was integrated with local primary care. So this is what we have been working on here in Iowa City for over the past year as this cartoon illustrates. Essentially, this is about taking two care teams that are geographically distant, a specialty care team and a primary care team, and trying to integrate them into a virtual care team that sees itself as owning responsibility for care for a particular patient population, in this case veterans with HIV. 

So how did we go about putting this together? Well, the first bullet I think I just mentioned.  It became clear as we talked about this and I think this is intuitive. This is really about role clarity. It’s about what is in the camp of primary care and what is in specialty care’s camp and how do we define these things unambiguously so it is clear who has responsibility and how information flows in time to the right person to deal with it. As we started thinking about this, it became clear that there were sort of two large bins or categories for care tasks. There were the defined care tasks. I think about this as maybe 80 percent of care tasks for veterans with HIV. It is the HIV care or comorbidity care that is predictable, for which guidelines exist, that can generally be mapped to VA performance measures, which are in most cases valid and frankly can be engineered. Algorithms can be developed. Care coordination agreements can be established with these algorithms in them. We do this in VA all the time. This is important. It is clearly part of what we had to do. But I would submit to you that it is not where most of your time should be spent. I would say focus on the 20 percent or whatever it is for your patient population of care tasks that are other, that are undefined or undifferentiated, things that are not clearly predictable and then who owns responsibility for this? How will these tasks be triaged? How will information flow so the veteran gets what they need rapidly? This is key in a way that is transparent to the veteran because patients really do not distinguish between primary and specialty care; they are just providers. They are just healthcare. Veterans with HIV do not think about my HIV care needs and my non-HIV care needs. That is an artificial duality that makes sense to us in healthcare, but to a veteran with HIV there are just my care needs. That is how it should be. So it is really unclear who to call about what when and how that information should flow. I would say focus on processes for dealing with the 20 percent that cannot be engineered and how information is going to flow and how to make navigating that transparent to the patient. 

How do we go about implementing this? We started and this really goes back to what Ron and Anais were just saying, by building relationships between primary and specialty care. We have face-to-face and then a series of video teleconference meetings between our HIV specialty care team and the CBOC primary care teams. What this is most importantly about is developing relationship and communities of practice, a shared sense of being this virtual care team if you will at least so many hours out of the week with shared ownership for the care of a particular patient subpopulation, in this case veterans with HIV. We talked about how do we define roles and how do we negotiate who does what, when? How do we deal with these undifferentiated care needs? What is the role of the PACT nurse care manager? What is the role of the specialty care nurse care manager? How do we triage these things? Then there is an education component, which I think is often overestimated or overemphasized in the case of specialty-primary care relationships. Yes, we did some education from specialty care for primary care groups on what are the key aspects of HIV care that are relevant to co-management of veterans of HIV. Importantly, primary care provided education on what are the right approaches or systems for dealing with complex clusters of comorbidity, for example interacting cardiovascular risk factors and their management. 

Then we went about sequentially adding pieces to this model, as you see laid out, which I think might be most easily summarized in the form of a really trivial flow chart. This is what a visit to a CBOC looks like for the just over 30 veterans in what we call telehealth collaborative care for HIV infection across eight CBOCs in the Iowa City now. So the veteran presents to a local CBOC. In most cases, but not all, they see their local primary care provider and then after that visit, they walk down the hall. They see us as an HIV team by clinical video telehealth. At the end of that visit, the PACT nurse care manager in the CBOC drops into the telehealth visit and sits down with the veteran and with us. We have what we care a care coordination huddle where we review the specific care tasks for that veteran and then we assign responsibility. What is in specialty clinic’s court? What is in primary care’s court? What is in the veteran’s court for follow-up in a way that is transparent to the veteran in front of them. Then we record this in a structured, what we call telehealth collaborative note in CPRS. 

We have been doing this for a little over a year. We have completed a mixed methods evaluation. I am going to really summarize this. For any researchers in the audience, you will be left wanting to know a lot more, but I think the key bullet points about this evaluation are that the majority of veterans who were eligible for this, in other words lived closer to a CBOC than a specialty clinic, preferred this over traveling to the specialty clinic. This program maintained the previously existing high quality of HIV care in that all, that should be 30 or so veterans, maintained undetectable viral loads on continuous antiretroviral therapy. Performance measures for some comorbid conditions actually improved. For example, the VA smoking cessation counseling and pharmacotherapy measure improved from 29 percent to 100 percent for veterans who lived closer to CBOCs before and after this model was implemented. The median travel time per veteran per year actually decreased, not surprisingly. 

This next point I think is important. As we have been doing this for a bit more than a year, there has been a natural, or if you will organic, evolution on how this model has worked for some veterans. As veterans and CBOC providers have developed comfort with this model, care has migrated to become more like SCAN/ECHO for selected veterans with less severe HIV infection, well-preserved immune function and stably suppressed viral loads on simpler antiretroviral regimens. What I am referring to as Atripla cruise control. In this case, the care is more at the center of mass, if you will, of care is more in the CBOC and the specialty clinic is less involved. 

What are some very broad lessons we have learned through this process? The first is really what Ron mentioned at the end of his talk. It is really about developing trusting relationships between specialty and primary care teams and creating  communities  of practice, in this case around specific patient populations, a shared sense of ownership for these populations, be it HIV care or pre-dialysis or severe rheumatologic conditions, whatever you may think of.

Secondly, and I think this is intuitive, role clarity is critical. Who does what? What is in whose court? How does the information flow? But I would submit although the 80 percent that can be put into an algorithm and a care coordination agreement is important, focus your time on the 20 percent or so that is undifferentiated and how this is going to be triaged and this is really centered on the relationship between the veteran, the specialty nurse care manager, and the primary care nurse care manager, and how information flows in a hierarchical fashion that is transparent to the veteran. 

Then this last point, I think is relevant as VA thinks about different initiatives for improving access to specialty care. In our experience, telehealth collaborative care, essentially clinical video telehealth, and SCAN/ECHO are not distinct models. They are two points on a continuum of generalist-specialist collaboration in chronic illness care. It is natural to expect that veterans will move back and forth between these in time as their own illness severity or complexity changes or their or their provider’s comfort level with the care changes or if the resources on the spoke side of the CBOC changes. So this is where we see this going, finally, with our Iowa City program. We are thinking about moving towards a stepped care SCAN/ECHO program for veterans with HIV infection. One step is SCAN/ECHO. For the veteran with less severe complex condition or where the preferences of the provider and CBOC and provider and veteran are aligned to think about SCAN/ECHO or there is less resource-intensive use of the specialty team and then for veterans with more severe complex treatment refractory conditions or just based on the preference of their primary care provider-veteran dyad, thinking about how this can step up to tele-health collaborative care with more resource intensive use of the specialty team resources. This has to maintain fidelity to VA’s clinical video telehealth and SCAN/ECHO models, but I think it is also key to think about how we provide flexibility to move back and forth between these different models for specific veterans. This, I think, can facilitate implementation. 

So with that in mind, I would like to stop to say thank you to all of you for your time and to open it up for questions or scathing rebuttal or whatever people may have.

Molly:Thank you very much, Dr. Ohl. We do have a number of questions that have come in for both groups. For those of you who joined us after the top of the hour, to submit a question or a comment just simply type it into your question section on the Go to Webinar dashboard and press send. Michael, if you do not mind just leaving that slide up so we have something to look at during the Q&A, that would be great. Thank you. Okay, so we will just alternate back and forth between the groups.

For the Portland Group, in your presentation, you had referenced that you had 20 recommendations. Could you give more examples? I see that you are still muted. 

Ron Grewenow:I do not have them right in front of me, that actually, the 20 recommendations was a guesstimate as to what we are going to finally decide. We are still in the process of organizing our final report. Anais has, she is pulling it up from our file, so I am going to give the phone to her. 

Anais Tuepker:Well, I do not want to take a lot of time looking them up, but I think some of the other—I will just try and think of what some of the other ones were. As we said in the presentation, there were four different areas. The primary care internal recommendations largely centered on organization of tasks for team members. I am really trying to think of a good concise example to give, but I think the best answer for right now is that we are going to be doing this report. It might be better to wait. Or if someone wants to contact us after the presentation, we can send them the complete list if they are interested in the details. We tried to pick out the ones for the presentation that were the leading recommendations because, obviously, changing this and improving communication I think both Michael’s excellent presentation and ours emphasized improving communication as a main piece. So a lot of them relate to different specific actions to improve communication. 

Molly:Excellent, thank you for that reply. The next question that we have for Michael: this idea of forging relationships with CBOC is great, but what hurdles did you overcome? The reason I ask is we are trying to establish CVT wound visits with the CBOC and we found that they do not have the supplies needed. What have you found? 

Michael Ohl:An hour would not be enough time to talk about all of the individual hurdles. I think they are probably going to be different for every VA or CBOC that you go to. For us, hurdles included space and conference rooms which were part of the telehealth scale up. It included things like doing HIV-specific labs in CBOCs, for example CD-4 counts and viral loads in a CBOC setting as opposed to a main facility setting, that are more relevant to telehealth in general. I think the things that have to be thought about are how this can be integrated into the processes of care in the CBOC with minimal production or disruption of workflow. A common approach is to hire more people to be clinical telehealth technicians in the CBOCs or in the far site and I think that is a great approach, which may or may not be doable. If you do not have access to people whose time is carved out to make these visits happen and the scheduling is a logistical issue, which I would say, too, is part of this, then to think about how to make the telehealth fit into the workflow that currently exists for primary care because to the extent that you make it easy and provide value, it will be implemented. To the extent that you create turbulence or provide additional work or it is not immediately clear what the value is to the local teams, then this is going to be more telehealth equipment gathering dust. Lastly, hurdle scheduling, in particular since we tried to do co-visits or sequential visits between primary care and specialty care, that is something which is technically complex, frankly not that interesting. It is doable. What we ended up doing is putting the specialty care scheduler in charge of keeping it through a web-based scheduling system together with spoke site schedulers. I can talk more offline about that. 

Molly:Thank you for that reply. Switching back to Anais and Ron: in your workgroup, did you collect information about number of consults that are being canceled or discontinued and reasons why?

Ron Grewenow:I do not have exact numbers. Canceled consults were a significant piece of the discussion. The reasons ranged all the way from could not get a hold of the patient to schedule it within the scheduling guidelines of the VA to the proper testing was not done so the consult was canceled so it would not stay in pending status and count against the specialty team. There were a number of reasons for canceling. Those are the two major ones: could not get a hold of the patient and get it scheduled, or the provider had not followed the guidelines for pre-referral testing. Here is Anais with some other thoughts.

Anais Tuepker:Yeah, I just wanted to add to that to pick up on a point that Michael made. I think also the issue of role clarity came up in these discussions about discontinued cancellations. Certainly, the points Ron mentioned were probably the main ones, but they also in discussing this point also generated a lot of thought about what is specialty’s role and what is primary care’s role and who should have followed up with the patient to make sure this procedure or test was ordered, who is really responsible for kind of the next step. I think that actually is addressing that again through better communication. One of the vaguer recommendations we have because we are still trying to work on the logistics of how you make this happen is to develop some clarity and some kind of written or, in some way, documented expectations of who does what. There were many reasons to do that, but one of them is to decrease that discontinued cancelled rate. 

Molly:Thank you for that reply. Dr. Ohl, I know you went over this briefly, but again, could you briefly describe what SCAN/ECHO is?

Michael Ohl:SCAN/ECHO is an acronym that means specialty care access network/enhancing community health outcomes. It is an initiative in VA nationally that I think is up and running in some places, for which there is frankly not much awareness other places. But the briefest explanation is that it is modeled after a program started by Dr. Sanjeev Arora and colleagues of the University of New Mexico to improve access to hepatitis C treatment in rural clinics in New Mexico. So the idea is that in a hub and spoke network, rural spoke sites, primary care spoke sites will participate in video teleconferences in communities of practice with other rural sites and a specialty care hub site. Then will go through the treatment of actual specific patients in rural settings, in that case for hepatitis C, and that the sessions include a mixture of CME and case-based mentoring, case-based management, will actually develop increased expertise for dealing with aspects of specialty care and become their local expert in their primary care clinic around a particular condition, be it hepatitis C or VA’s also looking at congestive heart failure, diabetes, COPD, chronic pain. So really it is about developing communities of practice over regions and improving the capacity of rural clinics to deliver aspects of primary care and also perhaps decrease their perceived sense of isolation in a rural site by connecting them to a broader community of practice. 

Molly:Excellent. Thank you very much for that reply. I am not sure who this was directed at, but can we see or receive an example of the “What to Expect” sheet?

Anais Tuepker:This is Anais replying. We would be happy to share that. We are finalizing all of this. We hope to finalize it in January. Anyone who is interested can contact me and I will be sure to send them our report which includes examples of some of these templates that we are recommending.

Molly:Thank you for that reply. Next for Dr. Ohl: for video telehealth, it seems very inefficient for the specialist to have to wait around for the specific time of the video telehealth session. How does this really work?

Michael Ohl:Well, we condense what we call our telehealth collaborative care clinic into one half day a week in the middle of our HIV specialty clinic. We meet on a Tuesday afternoon. We start with face-to-face visit with veterans. Then for an essentially two hour period in the middle of the afternoon, we have our telehealth collaborative care visits with veterans across different CBOCs. We actually, in half hour visits, usually go back and forth between different CBOCs. We try to schedule the veterans to come in and see their primary care provider just before or after their telehealth visit on those Tuesday afternoons. The veterans, of course, love this because it is one co-pay, right? It is one stop shopping for primary and specialty care. It is not always possible to combine those visits, but it is a good point. We do not sit around waiting for veterans to be seen in primary care any day of the week so that we are ready to see them. We condense this in Tuesday afternoon clinics. One could imagine having different specialty collaborative clinics like this set up at different times. I hope that is answering the question. 

Molly:Thank you very much. For the referral management workgroup, what strategies did you use to gain the patient’s perspective on the referral process? Do you have plans to continue to evaluate the patient’s perspective as recommendations are implemented?

Ron Grewenow:Two pieces of our project that are still in process are surveys for patients and patient perception of the referral process as satisfied, unsatisfied, what are their basic questions, and also a survey of primary care providers. We do not have results back yet from those, but they are being included. The goal with patients is to use all sites in the Portland system and survey any patient at the time they come in for their primary care visit. Ask them to fill out a survey, if they have been referred to specialty care in the previous six months. 

Molly:Thank you for that reply. The next question we have, I am not sure who it is directed at. Do you have your documentation on role clarity to share? Is it for the facility or per service?

Michael Ohl:Well, for us, it is related to patient populations for veterans with HIV. A care coordination agreement can define the tasks that are predictable. VA has structured care coordination forms that can often be filled out and this can be an algorithm. This can be engineered. We can share this. My email is available. In VA outlook, Michael.ohl@VA.gov, I would stress them thinking about how the undifferentiated or the unpredictable information flows between primary and specialty care. Ron and Anais?

Anais Tuepker:We would be happy to share that, but we do not really have documentation of role clarity. In fact, that has been one of the areas that both, I think, stepping back a little bit, I think that has been an issue for PACT implementation more generally within primary care. I know that one of the things that other groups are working on is developing documented role descriptions, but I think also as Michael is alluding to, you need to have that written down and shared and someplace where everyone knows what it is. You also need to be attentive to what is going on outside of that document. One of the things that Ron mentioned in our presentation, there was a surprising level of interest from many of the specialty services to have more phone conversations, more kind of informal contact. We think that that is—we were surprised and happy to hear that. That is something I think people will be working on. I am getting a little off topic, but the point that I am trying to make is that A, we do not have a description of that role clarity to offer right now; B, I think that is one of the things that is one of the recommendations that specialty service members sit down with primary care service members and do develop those kinds of documents. Hopefully, that will be happening for some of the services in Portland in the coming year. But then C, I think it is important to do that, but not to then lose sight of other things you can do to enhance communication. 

 Michael Ohl:If I may add one brief point to that, this is a very practical point from experience. VA has care coordination agreements. The paperwork can be intimidating when you look at these agreements. I think it is first important to develop the relationships in the communities of practice and talk about these issues. I would advise against rolling out the intimidating paperwork on day one, if I think the relationships are built and you start to build these communities of practice and talk about these issues, then it is time to say, “Fine, let’s write this down. Let’s make concrete what we just talked about.” But if you start the conversation with “We need to populate this mammoth document,” it could be a real party killer. 

Anais Tuepker:Well said, Michael.

Molly:Thank you all for those replies. Also for the Portland Group: did you consider how the national VA quality indicators impact your investigation in improving the referral process? For example, the specialists should see the patient within a certain time frame? Are there any unintended consequences as a result of these performance measures?

Ron Grewenow:I think the performance measures often are reflected in specialty clinic cancellation practices. We were aware of those, but chose not to focus on VA national administrative guidelines, but to work more on figuring out how primary care and specialty care can better meet the needs of the patient in improving the relationship. If the relationship between primary care and specialty care is working well, then the only other significant factor that we can think of is resources. Resources at that point drive things like the timeliness guidelines. If the relationship is working well, the patient will get the services that they need. They should be able to get them in a timely fashion assuming that the resources are there. Resource allocation, we felt, was beyond the scope of what we were charged to do. So we really have truly focused on communication, relationship, and process issues that impact that. 

Molly:Thank you for that reply. We do have about ten pending questions. Do our presenters have a few minutes to stay on and answer those?

Michael Ohl:Sure.

Anais:Yeah, we are fine in Portland. 

Molly:And Dr. Ohl?

Michael Ohl:Yeah. 

Molly:We may have lost his audio for just a minute. We will move on to another question for Portland while we wait for him. How responsive have the PC/specialty care been to redesigning the consult template?

Anais Tuepker:I will let Ron answer most of this, but my perception from our dialogue sessions was they were surprisingly open to it. I think one important thing is to recognize, and maybe it was not clear from our presentation, we are not really suggesting that what is there already needs to go away. We are suggesting that some things move around and that some important questions that are not systemically answered get prominence. But I am talking more. I want to let Ron answer this because he was really involved in this. 

Ron Grewenow:I cannot think of a specialty service that had any problems with the template overlay particularly because it should focus the primary care provider on asking about clarifying the specific question to be answered by the consultant. They said if you can do that, we do not really care what you do with the rest of the consult, in essence. Yes, we had uniformly positive response to the suggestions that some modifications on the consult might significantly improve the communication. As some of the specialists do hold fairly tight to specific things that they want answered in a consult and we were not suggesting that those go away, but only that we add to to improve clarity. They thought that was a great idea. 

Molly:Thank you very much. I will check to see if we have Dr. Ohl on the line. This one is for you, I believe. Would you please talk more about recruitment?

Michael Ohl:Yeah.

Molly:Yeah, you are back, thank you. Would you please talk more about recruitment of staff from CBOCs? How did you get the providers engaged?

Michael Ohl:I think that is a critical element. I think, like any change initiative, it is about developing a shared sense of urgency. So one advantage, frankly, that we have for HIV care is there are just not many veterans with HIV. We are talking about a few veterans per CBOC. So if you are going to do this for a higher prevalence condition, you are first of all going to have to find a way to carve out some time because this is going to be a big workload. If you are talking about something smaller, well then, you can count on goodwill to some extent to help you develop these programs at least initially. So it is about developing a shared sense of urgency. We visited each CBOC that eventually ended up participating. I think eventually a total of eight, and made visits. We started not with data, but with narratives, with stories of veterans who were challenged to access care who had issues with comprehensiveness, for aging veterans. With veterans’ permission we told some general stories about challenges veterans had faced. I think those stories helped develop a sense of shared urgency or need for change. 

Then I think the other thing to get buy in after doing that is to start by asking or presenting the problems and then by asking what the solutions are as opposed to going off and pitching particular solutions to start. Develop a shared sense of urgency and then ask what the best solutions are and listen. 

Molly:Thank you for that reply. We will move on to a question for the Portland group. How responsive have PC/specialty care been to redesigning the consult template? 

Anais Tuepker:I think we just had that question. 

Molly:My mistake, I repeated that yes.

Anais Tuepker:But yes, they were very responsive and thought it was a good idea.

Molly:Here is a following one. What are you doing to get specialty care to visit the CBOCs? 

Anais Tuepker:Well, one issue I think again and that is very specialty-specific and also CBOC-specific because it does come down to resources. The two main constraints I think are the specialty clinics, the staffing they have available to travel to the clinic, to the CBOCs. Then within the CBOCs, there is a real issue of space and being able to have a space, have time in the schedule. It is kind of that is something that we are talking with specialty services on an individual basis and each of the CBOCs is initiating that conversation as well. Another thing that was really nice about our process, I think, because our workgroup has representation from different CBOCs, we were able to when those kinds of discussions would come up in our dialogues or when the topic would come up, someone would be able to say, “At our clinic, we would really love that” and we have a champion who is really interested. Another clinic they might say, “We just started another initiative. It is probably not a good fit for us right now.” I think basically it is just on a case by case basis, but starting with a dialogue where people from the specific services and physical settings are all there. No one is speaking for anybody else is a good way to start. Ron, do you want to add anything?

Ron Grewenow:The question about specialty participation or activity at CBOCs is very much a question of resources. Our most remote CBOC has just moved into a new space, almost triple the square footage. With that came funding for some specialty care. When the resource is there, the specialists are happy to be there. We have another CBOC that is about to enter the construction phase. In that planning is space for specialty care presence in that CBOC. Currently, one of the services, plastic surgery, is going down to Salem, which is about 50 miles away from the medical center. They go down there I think twice a month and hold a half day clinic where they do follow-up for basically folks that live south of the medical center. So they do follow-up surgical care. It works great for the patients. The providers enjoy doing it. So when the resources are available, there does not seem to be much of a difficulty getting the specialists interested in integrating into the CBOCs because, again, it is about relationship. You can have electronic communication, but when it is face to face or when specialists and primary care providers are working side by side in a clinic situation that is when relationship really develops. 

Molly:Thank you for that reply. We are down to the last half a dozen questions or so. This is also for the Portland group. Are any, and let me know if you have already answered this, are any examples of specialty clinic referral information sheets available?

Anais Tuepker:They are not yet available, but we would be happy to share them. We hope to have them early in the New Year. Email me if you want us to make sure you get a copy of that. 

Molly:Excellent, thank you. The next question we have: was there resistance to adopting the consultation template you created? We have heard that patients will be able to review progress notes via My HealtheVet and some concern by providers about how patients will interpret these notes. I am not sure if patients will also be able to see specialty consults, but it seems as though your template is more patient-centered and possibly will help providers write notes in a way that is more acceptable to patients.

Anais Tuepker:Yes, it is our intention that the consult is more patient-centered. We did, as Ron said, really tried to take seriously the charge of PACT that we are trying to make the patient part of the team. So for example, in our dialogue sessions, part of what we would ask are what are the challenges for the patients and try to use that as something that we used to get the discussion going. We are hoping it is more patient-centered. We did not hear a lot of push back from anyone about the template. One thing we did, one of the points on the template is what are the patient’s expectations? We feel that that is important to have in there, but there was some, I am not sure, concern or just being practical that some providers would not really be comfortable with that yet or not used to it. That is why we would have that be an optional box for now so that people can get used to the idea. We are thinking that this template is in line with the move towards greater patient access. Ron, do you want to add anything?

Ron Grewenow:No.

Anais Tuepker:Okay.

Molly:Thank you. What was the length of time to complete the template consult request—I am sorry, was the length of time to complete the consultation request taken into consideration? Multiple consults/clinical reminders to be completed at a time of visit could be time consuming and cause the clinic to run behind schedule. 

Ron Grewenow:Time is always of concern to a primary care provider. Streamlining the consult to make it easier is part of the goal, but also the accuracy of communication actually reduces the amount of work that a primary care provider has to do in the more global picture. If a consult is poorly written and the guidelines are not followed and it is canceled, then the provider still has to go through all that work again. That actually takes more time. Part of our goal is also education. Those are some of the recommendations that were not on the slides. Primary care providers need some help in understanding this process. We, as a referral management team, are going to have some probably responsibilities to bring other providers up to speed in terms of the importance of putting quality communication together to improve the efficiency. Hopefully, that will help specialty care meet its timeliness guidelines. 

Molly:Thank you for that reply. We are down to the last three questions. Dr. Ohl did have to leave us for another meeting. So if you have any other questions, you have that are directed at him, just let me know and I will send them to him offline and get written responses. If PACT is not even in play at our CBOC, does any of this apply to us?

Ron Grewenow;I think it does because PACT, to my way of thinking, PACT is terminology that is used to describe good patient-centered care. You can have good patient-centered care and not call it PACT. You can call things PACT and not have a good patient-centered care. So the real issue is not the terms that we use to describe things or the term for a process. The essential issue is good patient-centered care and improved communication. I think that can occur no matter how you are set up. The resources become significant issues in locations where PACT has been tied to resource allocation. If it is not a PACT site, then the probability that there are restrictions or limitations on support staffing is highly probable. That does complicate the issue, but it should not eliminate the focus on improving patient-centered care. 

Molly:Thank you for that reply. This one may have been directed towards Dr. Ohl, just let me know: Is the telehealth collaborative care being scheduled or do the CBOCs set this up?

Anais Tuepker:It sounds like that one is directed to Dr. Ohl. 

Molly:Thank you and for the final comment/question: it seems as though since initiating PACT with a team approach, there has been an increase in subspecialty consults. The HMO role of the primary care provider traditionally was to be the gatekeeper and patients would at least need to be initially evaluated for a particular problem or complaint before referral is made to avoid unnecessary subspecialty consults. I now see where a patient might only have spoken to a nurse on the telephone and discussed the problem with a PCP before subspecialty consult is submitted. It is rumored that the VA primary care provider’s goal is to see the patient only annually and keep follow-up visits to a bare minimum. Is this a shift paradigm where the primary care provider is less a gatekeeper and more of a subspecialty triage person. 

Anais Tuepker:That is an interesting point. I am not really sure how to respond to that because it is not something that was so much discussed in our workgroup’s process, but I think that is an interesting thing to keep in mind. Probably, also, it is going to vary from specialty to specialty. There are some—I know within our facility where patients are able to even go directly to specialty. I do not really have an answer to that, but I think it is an interesting point. Ron wants to jump in. 

Ron Grewenow:The question has some bearing on what we have noticed is the variance in referral patterns by primary care providers. Certainly, there’s a broad range of comfort for dealing with certain specialty-related issues on the part of primary care providers to follow-up with Dr. Ohl’s comments. There are some primary care providers who are perfectly comfortable doing basic HIV care management on their own. Other providers who see a diagnosis of HIV and take a deep gasp and go to a consult. So there is a great variability depending upon the experience of the individual primary care provider. There are also system pressures and larger panels where a primary care provider may push that provider to earlier referral for the management of a variety of disease processes rather than squeezing in extra time to do the work themselves. You would have to look at some of those system issues, volume issues on the primary care provider to determine if there is an active movement, if you will, to increase consults. The other thing is that nurse-entered consults may be appropriate in the PACT model when there is good communication within that PACT team and the provider has said, “Yes, this is appropriate given the situation or the information from the patient.” Why would they have a gatekeeping visit if you know that patient well enough on the team to know they need the specialty care? 

Molly:Great. Thank you for that reply. That was our final question that came in. Other people wrote in saying, “Thank you for the excellent presentations.” At this time, I would like to see if either of you would like to give any concluding comments. 

Anais Tuepker:No, just thank you very much everyone for listening and for those of you who are still there, for hanging in there. Please do feel free to contact us. We hope the group is still going to have some more work to do. We would be happy to share it. 

Molly:Excellent. Well, thank you to both of you and, of course, to Dr. Ohl for sharing your expertise. Thank you to our audience members who joined us and especially to those who are still with us. So that does formally conclude today’s cyber seminar and I hope that each of you has a great rest of the day and Happy Holidays. Thank you.

Anais Tuepker:Thanks, bye. 

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