Case Study: Community Health Partnership of Santa Clara County
A few years ago, when a primary care provider in the Santa Clara County, California safety net referred someone to a specialist for follow-up care, they relied on the patient to set up the appointment. Within six months of being referred, 50 percent of patients had not seen a specialist. Some referrals were simply lost by patients or staff or patients had trouble reaching specialists’ offices by phone, with calls put on endless hold or dropped entirely. In some cases, mailings to patients went to the wrong addresses. Language barriers compounded these problems.
“It was unacceptable”, stated Kent Imai, MD, medical director for Community Health Partnership (CHP), a consortium of nonprofit community health centers.
E-consult has helped CHP make the most of its resources to address high demand for specialists. In the first six months of e-consult use, the flow of referrals improved considerably. E-consult referrals are now triaged in less than 24 hours, notes Imai.
E-Consult Growth across the U.S. and Abroad
In 2006, e-consults began at San Francisco General and UCSF. In 2012, the Los Angeles Department of Health Services started e-consult to increase access to specialty care for the un- and underinsured.
E-consult programs grew across the country and internationally including FQHC-based programs like Community Health Centers, Inc., Connecticut, and academic medical center programs including AAMC CORE and the Bruyere Institute, University of Ottawa, Canada.
Grant-funded programs supported by Blue Shield of California Foundation and California Health Care Foundation spread e-consult use across California FQHCs and public hospitals.
The E-Consult Workgroup was formed to support programs across the U.S.
E-Consult spread following the incorporation of CPT codes for interprofessional internet consultation in CMS and California Medicaid (Medi-Cal) provider manuals and fee schedules.
E-Consult vendors and payers extended their support to providers and patients to improve access to care during the COVID-19 pandemic.
What is Needed to Support E-Consult Implementation and Sustainability?
Provider Engagement and Leadership
A provider champion is key to engaging the care team to embrace a process change that will improve patient access and create a more efficient referral process.
What Zuckerberg San Francisco General Did
ZSFG recognized early the importance of collaboration among primary care providers and specialists across the organization, and created specialty guidelines or templates to support providers to more easily participate in their eReferral program. Since its program launch over 10 years ago, San Francisco e-consult leaders have produced a number of publications on best practices and lessons learned.
The Importance of a Provider Champion
Dr. Tuot, Clinical Advisor to the E-Consult Workgroup, is also a practicing nephrologist and an active e-consult/eReferral participant. In addition to leading provider engagement at ZSFG, Dr. Tuot created an evaluation process that has been leveraged across hospitals in California and Nationally.
Dr. Tuot continues to support successful e-consult programs across the country in leading by example.
Payer Value Proposition and Ownership
E-consult programs are fostered by payer collaboration and consistent reimbursement, making workflows the same for providers whether they are treating Medicaid or Commercial-covered patients.
Anthem Blue Cross Approach
Anthem Blue Cross realized their Fresno, CA county-wide e-consult program required payer collaboration in order to support providers with one workflow for all Medicaid patients.
To do this, they formed the Fresno E-Consult Coalition with other managed care plans, FQHCs, and independent practice associations at the table.
Hear payer leaders' perspectives on e-consult collaboration.
Payer Collaboration Leaders
The plans engaged Fresno County FQHCs and the local medical groups to support one workflow and reporting mechanism for primary care providers using e-consult. The plans hosts county-wide roundtable sessions to foster conversations around patient/member and provider needs and increase access to care across Fresno and neighboring counties.
Learn more about the Fresno E-Consult Coalition.
Streamlined Provider Technology Workflow
Primary care providers need a simple e-consult workflow and “at-the-elbow” support in order to embrace a change that can dramatically improve the specialty referral process.
What OSU Did
In response to the COVID-19 pandemic, Ohio State University Wexler Medical Center leveraged Clinical Transformation in Technology (CTT) implementation framework to transition to telehealth, and leveraged its existing e-consult program to enable providers to support remote care delivery, patient and provider safety.
CTT Implementation Leaders
OSU's Department of Family and Community Medicine's Telehealth Workgroup employed the CTT framework to accelerate telehealth use and develop clinician recommendations in providing remote virtual care during the pandemic.
In a few weeks, patient visits went from 5% to almost 93% telehealth while maintaining high levels of patient satisfaction.
Patient/Member Education and Communications
E-consults are peer-to-peer communications that result in reduced wait times and expedited specialty advice for patients, however, patients need to understand that care is taking place behind the scenes.
The Association of American Medical Colleges (AAMC) set out to understand patient perspectives and preferences for use at 5 US academic medical centers in the process of adopting e-consult.
Although e-consults take place behind the scenes, when patients are engaged to receive specialist advice, they demonstrate increased satisfaction with the care they receive.
This webinar focused on patient perspectives on e-consult.
AAMC Implementation Leaders
Based on the University of California, San Francisco model, AAMC launched Project CORE: Coordinating Optimal Referral Experiences in 2014 to improve the clinician and patient referral experience.
More than 30 AMCs across the country have successfully implemented e-consults and e-referrals, tools built into the electronic medical record, improving quality of care and access in a patient-centered way.
In this study, UCSF assessed patient acceptance of e-consult.
Case Study - Kaiser Permanente, Colorado, Specialty Care Initiative
Meet Tracy Copeland
Kaiser Permanente Colorado supports a unique program allowing community safety net primary care providers to electronically request advice (e‐consult) with select Kaiser Permanente specialists regarding their uninsured adult patients. The program also offers opportunities for medical education for the primary care providers participating in e-consult. Tracy Copeland is at the center of the program, engaging and coordinating providers to improve access to care and the overall health of the community.
Click here for more information on Kaiser Permanente's Safety Net Specialty Care Program.
How do we launch an e-consult program?
Primary Care Organization (FQHC or Independent Practice)
Community Health Centers, Inc. a federally qualified health center in Middletown Connecticut, engaged its primary care providers, clinic specialists, and State Medicaid to support its initial effort.
At CHC, Inc., clinical leadership prioritizes the right type of care at the right time -- e-consult, ECHO (provider education) and/or live video telehealth specific to the patient need.
Health System (Hospital or Academic Medical Center)
The University of California at Irvine faces a growing aging population, a high cost of living and a shortage of physicians. UCI implemented e-consult to tackle lower-complexity referral problems that did not require an in-person evaluation, resulting in 80% of requests being resolved electronically.
View the webinar where Dr. Alpesh Amin, Chair, Department of Medicine, UC Irvine School of Medicine presented on their experience.
Health Plan (Medicaid or Commercial Payer)
Inland Empire Health Plan partnered with WISE Healthcare to pair primary care providers with specialists to ask questions, learn from his experiences and improve processes.
In its Multi-County E-Consult Initiative, IEHP held evening networking meetings allowing providers to share a meal and discuss how to strengthen their program.
View the webinar in which Dr. Priya Batra of IEHP speaks to specialty care access through telehealth.
E-Consult Technology Providers and COVID-19 Response
The COVID-19 pandemic had an immediate impact on primary care providers who were forced to limit in-person visits to ensure patient and provider safety. Delays in primary care visits exacerbated specialty care backlogs that were already months long. To address these unacceptable wait times, providers and technology vendors incorporated e-consult as a first step in their referral workflows. E-Consult technology vendors responded with free or low-cost programs for safety net providers. Providers have now expressed an increased level of acceptance of telehealth to improve their safety and optimize patient care.