Growing ORaNGEs: Expanding Primary Care Provider’s Scope of Practice in

1. Growing ORaNGEs: Expanding Primary Care Provider’s Scope of Practice in O R N G E rthopedics heumatology eurology astroenterology ndocrinology

2. Kaiser Specialty Care Access Initiative (SCAI) Future of the Safety Net Yolo County Amy Jean Ham Project Manager amyh@communicarhc.org David Katz, MD Medical Director davidk@communicarehc.org Patty Perez Case Manager patriciap@communicarhc.org

3. Future of the Safety Net Yolo County (FSNYC) CommuniCare Health Centers serving as Lead Agency for SCAI FSNYC Membership: CommuniCare Health Centers Community Medical Centers First 5 Yolo Kaiser Permanente Redwood Community Health Coalition Sierra-Sacramento Valley Medical Society Sutter West Medical Group Sutter Davis Hospital UC Davis Medical Center Winters Healthcare Foundation Woodland Healthcare Yolo County Board of Supervisors Yolo County Health Council Yolo County Health Department

4. Implementation Team • Chief Executive Officer, Robin Affrime • Medical Director, David Katz, MD • Chief Operating Officer, Daniel Albano • Nurse Manager • Program Manager, Amy Jean Ham • Case Manager, Patricia Perez

5. Staffing • Program Manager, Amy Jean Ham • Case Manager, Patricia Perez • Nurse Manager • Medical Director, David Katz, MD • Information Systems, Kristie Stanley

6. Five Primary Care Sites • CommuniCare Health Centers Davis Community Clinic Salud Clinic Peterson Clinic • Winters Healthcare Foundation • Esparto Family Practice • Four Medical Care Systems • Kaiser Permanente • Sutter Davis Hospital/ • Sutter West Medical Group • Woodland Healthcare • UC Davis Medical Center

7. Three Strategies to Increase Access to • Specialty Care: • Build/Expand Specialty Networks (Fair Share) • Specialty care physicians to provide care in their medical offices for uninsured patients and the uncompensated care is distributed according to a ‘fair share’ method agreeable to the participating medical care systems • Telemedicine • Improve access through spread of existing or new applications of telemedicine • Expand Primary Care Provider Capacity (Scope of Practice) • Increase the specialty care knowledge level capacity of safety net primary care providers

8. Kaiser Permanente • Sutter Davis Hospital/Sutter West Medical Group • Woodland Healthcare • UC Davis Medical Group Fair Share Distribution (Endocrinology, Rheumatology and Neurology) (Gastroenterology, Orthopedics) (Gastroenterology, Orthopedics) (Trauma and Tertiary Care)

9. 3. Expand Primary Care Provider Capacity (Scope of Practice) Increase the specialty care knowledge level capacity of safety net primary care providers • Activities: • Identifying Key Competencies • Integrating Scope of Practice and • Patient Care • Building Relationships • Provider Commitment

10. Identifying Key Competencies • Survey of Skills • Based on template provided by San Mateo Medical Center and Ravenswood Family Health Center • A National Survey of Procedural Skill Requirements in Family Practice Residency Programs - Josie L. Tenore MD, SM; Lisa K. Sharp, PhD; Martin S. Lipsky, MD • Data collection from referrals • Identifies common referral diagnosis.

11. Survey Outcomes Identifying key competencies for training • Majority of providers identified competency in casting and joint injections but also requested more training. • While 83.3 % of providers stated competency in identifying indications for referrals of headaches – have large volume of headache referrals. • Majority of providers wanted more training in evaluation and treatment of seizures. • Majority of providers requested training in management of disease altering medications for Rheumatology. Determined that this training was most appropriate for MDs. • Providers suggested training in Parkinson’s Disease treatment which was not on additional skill list.

12. Integrating with Patient Care • Imbedding Guidelines • Using InterQual Criteria to ensure referral is appropriate prior to authorization. • “Passport” into specialty care • Challenge: changing referral process, getting provider buy-in. • Case Management • Meet weekly to discuss referrals. Use meetings to determine how to best use resources including internal expertise. Also used to identify high-volume areas and training potential. • Building Relationships

13. Organizational Relationships • Representation • All health systems represented in planning process, coalition and workgroups • Support from administrative and clinical leaders • Benefits • Simplifying referral process, case management, monitoring referral volume, decreasing no-shows, ensuring complete resources • Memorandum Of Understanding • Formalized Commitments and Roles • Health Systems • YCHIP • Ancillary/Diagnostic Services • More to come

14. Provider Relationships • Phone Consults • Prior to referral, PCPs have phone consultation with Kaiser specialist to discuss case, testing and options for care within the “medical home”. • Case Management Discussions • Regular meetings are scheduled with specialty care providers to discuss cases and treatment options. • Mini-fellowships • Providers accompany patients to specialty care appointments.

15. From the Medical Staff • Provider Commitment • Ease in referral • Case management lightens provider load • Decreases primary care liability • Increased retention/recruitment of providers • Productivity Implications • Some referral activity non-reimbursed • Decrease in face to face patient care may result from phone consultations • Scheduling changes • Telemedicine • Phone consultations • Extended visits for procedures

16. QUESTIONS?