Pooled Referral Systems Lisa Gaede

Bruce Povah & Diane Edlund

Jennifer Telford

Dr. Lisa Gaede

Dr. Bruce Povah & Diane Edlund

Dr. Jennifer Telford

Introductions

Financial Disclosures

(past 24 months)

Name: Dr. Lisa Gaede

No discussion of commercial products

Managing potential bias

Financial Disclosures

(past 24 months)

Name: Dr. Bruce Povah

Speaker Advisory Research Consultant

Interior Health √ √

BC Ministry of

Health √

Financial Disclosures

(past 24 months)

Name: Diane Edlund, B.Sc., CPHIT

Speaker Advisory Research Consultant

Interior Health √

Doctors of BC √

Ministry of Health √

COACH √

BCHIMPS √

McMaster

University √ √

BCCA √

No financial interest in commercial products discussed

Managing potential bias

Financial Disclosures

(past 24 months)

Speaker Advisory Research Consultant

Boston Scientific √

Ferring √

Pendopharm √ √

AbVie √

BC Cancer

Agency √

BC Ministry of

Health √

Name: Dr. Jennifer Telford

No discussion of commercial products

Managing potential bias

Benefits of Pooled Referral System

Challenges of Pooled Referral System

Objectives

Where do we Start?

Independent Silo’s of Practice

Separate Referrals

Separate Variable Waitlists

Inconsistency of Processes

Inconsistency of Workflow

Independent Pockets of Best Practices!

rebalance

What challenges do you see in referring patients for specialist care?

Why a Pooled Referral System?

Constant Flow of Referrals

Gate Open

Under

utilized

Not Happy

Constant Flow

Some

Chaos Low Output

Gate Partly Open

Gate Open

Happy HAPPY

Gate Closed

Chaos

Constantly Changing Capacity

Long wait-times

Who has the shortest wait list?

Referral to the wrong specialist

Who is the most appropriate specialist for an indication?

Specialists declining referrals

Who is accepting patients?

What types of patients?

Why a Pooled Referral System?

First Available and Appropriate Specialist

Triage Patients based on:

Urgency of Indication

Time on wait-list

Who referral was made by? (Specialist higher priority?)

Other?

Advantages of a Pooled Referral System

Which stakeholders should be considered when developing a pooled referral system?

How to engage?

How to develop a pooled referral system

Faxed Over the Wall

Family Physician Engagement

How did we engage family physicians?

Early engagement to ensure process makes sense

PDSA

Challenges can include users with different EMRs

Family Physician Engagement

What kinds of challenges do you envision for developing and using a pooled referral system?

Challenges of a Pooled Referral System

People

Process

Technology

Our experience

1) Engagement of specialists

2) Engagement of Family Physicians

3) Importance of triage

4) ? Disruptive to pre-existing relationships between physicians and/or for patients?

Challenges of a Pooled Referral System

8 Otolaryngologists

Central & South Okanagan

Multiple Offices

Multiple Subspecialties

iWaitLESS Project

Identified Areas of Resistance

Pride in Long Waitlists

Advantages of Long Waitlists

Poker Game

No Financial Advantage?

Specialist Engagement

Current State

Liability in Long Waitlists

Disadvantages of Long Waitlists

Poker Game

Burns Up Time

Financial disadvantage

Bringing Specialists On Side

Current State Assessment

Collaboratively Create a Future State Vision

Gap Analysis

Involve MOAs

Communicate Communicate Communicate

Strategic Approach

Create Common Goals

Specialist Engagement

Create a Brand

www.entegrity.ca

Do we have the right technology to support these changes?

Does the technology drive the workflow or does the workflow drive the technology?

How can we partner to create the right tools?

Electronic Medical Records

Same / Increasing Number of Referrals

Same Number of Practitioners

How do we lower the waitlist after we pool the referrals?

Efficiency to Meet Demand

Patients Contribute to Health Records

Intake Assessments > Encounter Notes > Dictation > Auto-Population of Medical Questionnaires

E-Booking – Waiting List Priority > Invitations to Book

Automated Appointment Confirmations

Website – Educating Patients and Referring Providers

Less Time Lost to Unproductive Encounters

Improve How We Work

How will we know we are successful?

We will measure the results!

PROMS & PREMS

Data Analysis / Reporting

Patient Engagement

Patient engagement in health care choices

Patient engagement in health care (re)design and quality improvement

Patient Engagement

What is gained through patient involvement?

Patient Engagement

Current benchmarks for gastroenterology wait-times based on physician consensus

Physician bias

Patient-centered care requires patient input

Patient Engagement

Partnered with a decision scientist

Measure how patients value health

Patient decision aids to elicit preferences

Wait-time for symptom type and severity

Wait-times for functional impairment due to symptoms

Patient Preferences

1. Prioritized based on the severity of their symptoms. 100% agreement

2. Patients with similar symptoms are prioritized based on time waiting on the list. 95% agreement

3. Patients requiring urgent care are to be seen within 2 weeks, semi-urgent care are to be seen within 2 months, patients requiring non-urgent care are to be seen within 6 months and no patient is to wait more than 1 year. 50% agreement

4. Patients are able to find out where they are on the waitlist. 100% agreement

5. Patients requiring non urgent care are supported more by their family doctor with help from the gastroenterologists group. 95% agreement

6. Able to see the gastroenterologist with expertise. 100% agreement

7. Patients from Vancouver have priority over patients from outside Vancouver. 15% agreement

Patient Opinions on Physician Goals

Agreement in 5 of 7 goals

Goal 3 Patients felt all of the benchmark wait-times were too

long

Goal 7 Patients did not think physicians should limit referrals by

geography

Expressed concerns re: availability of physicians in different jurisdictions

Patient Opinions on Physician Goals

Surveyed 200 patients attending our office

Further explore the 2 goals in question

Patient decision aid to elicit triage preferences

trade-offs of prioritization

Inputs on alternative models of care

Group sessions

Involvement of dieticians

General recommendations to PCP prior to or in lieu of GI consultation

Patient Engagement

Decision Aid

Functional status plays a role

Of 2 patients with the same symptoms, the one with greater functional impairment should be prioritized

Availability of specialists in other jurisdictions should be considered when declining referrals

Time on the wait list should be considered

Patients Opinions on Triage

Patient-centered care requires patient input at every level

Summary

Thank you – Questions?