Integrating VA Specialty and 

Primary Care and Improving 

the Referral Process

Presenters: 

Ron Grewenow

Group Practice Manager, West Linn CBOC

Anais Tuepker

Investigator, VISN20 PACT Demonstration Lab

Referral Management Workgroup Members:

Corinne Dickey, Dani Alkadi, Daniel Tonkin, John Shea, Kathy Weinberg, Lan 

Nguyen, Ross Akimoto, Samantha Kraly, Shelly Essig, Sunita Chalasani, and 

Tempra Hickman
Why specialty-primary care integration 

is important

• Evidence of multiple perceived deficiences in the process 

(Mehrotra et al 2011, Bodenheimer 2008) - but little evidence 

of what works to fix it 

• Conceptually, improved primary-specialty care integration 

could contribute to 

• Improved patient health outcomes 

• Better patient experience

• More efficient use of system resources

• PACT requires a systemic culture change to succeed – limiting it 

to primary care creates organizational challenges (and rivalries)
Portland VAMC Primary Care 

Workgroup Initiatives

•As part of PACT transformation, Primary Care leadership 

identified areas for internal innovation and improvement:

Chronic Pain Management 

Referral Management

CHF Management

Pre-Operative Management

Team Formation & Function

•Workgroups composed of staff in all PACT roles from 

across facility – different CBOCs, different experiences

•Participants allowed to block out time for 

participation, providers had surrogate coverage for long 

sessions
Referral Management Workgroup 

Process

• Mostly face-to-face meetings 

• Used data review of all consults from last FY to 

develop initial focal points

– Frequent referrals (Prosthetics, GI, Dermatology, 

among others)

– CBOC –to-CBOC variation

• Invited specialty services to dialogue sessions 
Participating Specialties

• Cardiology

• Dermatology

• Endocrinology

• ENT

• GI/Liver 

• Hematology/Oncology

• Neurology

• Orthopedic Surgery

• Prosthetics

• Pain Clinic

• Rehab Medicine

• Pulmonology

• Urology

• + Computer 

Applications 

Coordinator (CPRS 

consult system) 
A few expected findings

• Primary care often doesn’t ask a clear 

question in the consult

• Volume of consults is challenging, results in 

delayed access
Surprises

• High level of variance in PCP practices related to consults

• High level of variance in Specialty processes for reviewing 

consults

• Patients not always aware why they were being referred

• Specialty would like MORE calls/paging from Primary Care

• Some specialty services do not access CPRS

• Specialty services don’t always have working knowledge 

that Primary Care is not “on the hill” (at the main VA 

facility): this has many practice implications (short stay 

consults, imaging)
Recommendations

Draft report has 20-30 recommendations

organized into:

• General Recommendations

• Recommendations internal to Primary Care

• Service Specific recommendations

• Recommendations beyond the scope of the 

workgroup
General Recommendation: 

Consult Template Overlay

– Reason for consult discussed with patient

– Guidelines/testing ordered

– Guidelines/testing completed (Comment Box)

– Clinical summary

– What is the question for this consult?

– What is the patient’s expectation for the consult? 

(optional for now)
Internal Primary Care 

recommendations

• Click & print patient information “what to 

expect” sheet unique to each specialty clinic –

with specialty clinic contact information 

– Content templated but determined with specialty 

input

– Admin order, can be in letter format

– Link to all specialty sheets to make process easier 

for facilitators
Specialty Specific recommendations

• Develop interdisciplinary panel to manage 

suspicious mass/rule out cancer pathway 

(came out of dialogue with H/O)

• Changing to an order menu format for 

Prosthetic items
Recommendations beyond the scope 

of the workgroup

• Improve processing of outside scanned 

records so specialists can easily locate relevant 

test results

• Specialty presence on an intermittent basis for 

education in the CBOCs 
Concluding thoughts

• Specialty of primary care is relationship to the 

patient

• Key to improving the consult process is 

improving the relationship between primary 

and specialty care

– Better communication between teams

– Better communication with patients about referral 

process
References

Mehrotra, A, Forrest, CB, and Lin, CY. 2011. Dropping the Baton: 

Specialty referrals in the United States. The Milbank Quarterly 

89 (1):39-68.

Bodenheimer, T. 2008. Coordinating care – a perilous journey 

through the health care system. New England Journal of 

Medicine 358 (10): 1064-1071.

Contact: Anais Tuepker

anaistuepker@va.gov

Thank you
Generalist-specialist collaboration in 

care for veterans with chronic illness

Case study: HIV care in rural Iowa

Michael Ohl, MD MSPH

Iowa City VAMC
Factors favoring generalism vs. specialism in 

chronic illness care

• Specialism: rarity, technicality, rapidity of 

innovation

• Generalism: complexity due to multimorbidity, 

comprehensiveness, holism

- HIV care has features of both, to varying 

degrees depending on the individual
HIV Care Challenges In Iowa City VAMC -

2010

• Access

- 30 veterans with HIV living > 1 hour drive from HIV specialty 

clinic in Iowa City, historically bypassing care in nearby CBOCs 

to receive all care in specialty clinic

• Comprehensiveness

- High quality HIV specific care, but....

- Limited systems and expertise in specialty clinic for 

comprehensive primary care
HIV Clinic

Telehealth Specialty Care

Clinical Video 

Telehealth

Veteran

CBOC PACT

PACT: Patient Aligned Care Team – VA’s Medical Home Initiative
CBOC PACT HIV Clinic

Current HIV SCAN – ECHO model

Clinical Video 

Telehealth

Veteran

CPRS

Face-to-face 

visits
Telehealth Collaborative Care

Face-to-face 

visits

Clinical Video 

Telehealth

CPRS

Telephone

Shared Registry

“True Team”: self aware as team, defined roles, responsibilities, and 

communication processes 

Veteran

CBOC PACT

Provider

Clinical Telehealth

Technician

RN Care Manager

HIV Clinic

Provider

Pharmacist

Psychologist

RN Care Manager
Telehealth Collaborative Care

Key Design Principles

• Integration of primary care by CBOC PACTs with 

HIV specialty care by video telehealth

• Clear definition of primary and specialty roles

- Defined care tasks

- Undefined tasks/undifferentiated veteran care needs

• Care coordination/information routing

• Population management across sites

- HIV patient registry with data for HIV and comorbidity/preventive 

care

- Goal: separate summary reports for CBOC PACTs and specialty team
Implementation Steps

• Face to face and vtel meetings with CBOC PACTs 

- Develop relationships/communities of practice

- Negotiate and define roles

- Mutual education

• Sequential addition of pieces

- Establish HIV clinical video telehealth

- Patient navigation brochures

- PACT nurse care manager “telehealth care coordination huddles”

- Structured telehealth collaborative care notes in CPRS

- Registry
Check-in at CBOC

Visit with PACT PC providers

Telemedicine visit with HIV team

Care coordination “huddle” 

with Patient, PACT RN care manager, 

and HIV clinic team

Structured TCC note in CPRS

Telehealth Collaborative Care Encounters TCC Encounters
Evaluation – selected findings

• 30 of 32 eligible veterans preferred TCC over 

traveling to ICVA specialty clinic

• Quality of HIV care maintained, all 32 maintained 

undetectable HIV viral loads on therapy

• Performance measures improved for some 

comorbidities

- e.g. VA smoking cessation counseling/pharmacotherapy offered 

measure improved from 29% to 100%

- Mean travel time 320 to 170 minutes per year 

(p< 0.001)
Evolution

• 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 load on simpler 

antiretroviral regimens)
Lessons Learned

• It is first necessary to establish trusting relationships 

between specialty and primary clinic teams, and 

create communities of practice around specific 

patient populations

• Role clarity is critical, focus on defining how 

undifferentiated care needs/tasks are triaged and 

unambiguous responsibility assigned

• Telehealth collaborative care and SCAN/ECHO are not 

distinct models, but two points on a continuum of 

generalist specialist collaboration in chronic illness 

care
Illness severity (VACS Index)

Stepped care SCAN/ECHO for

Veterans with HIV infection
Thank you

Questions?