Involving specialists in value-based care is hard. Not only is specialty care a more diverse space, but it's also more tied to traditional fee-for-service reimbursement and episodic care delivery. We’ve previously discussed how engaging specialists in accurate HCC capture is a ‘no-regrets’ opportunity in this hybrid financial incentive state—but what ambitious, yet feasible behavior changes remain for specialists? In this series, we discuss the three you should start with.
Well-managed patients in specialty care create a bottleneck to access for new patients. Yet, it’s rare for provider organizations to establish effective patient hand-backs from specialty to primary care when appropriate. This is due to two mutually-reinforcing challenges: First, it’s easier for specialists to continue to see patients in their panel, rather than shift course. Second, patients themselves may prefer to stick with their specialist and resist hand-back efforts.
What we mean: Once patients are well-managed in specialty care, a hand-back is the process of transitioning patients from specialty to primary care for ongoing care management.
Start by setting cues for specialists on when to consider passing patients back to primary care. Zuckerberg San Francisco General Hospital (ZSFG) and Trauma Center made hand-backs part of the standard of care in their gastrointestinal (GI) clinic after measuring a 6+ month wait time for routine appointments. ZSFG leaders collaborated with PCPs and specialists to create a set of discharge standards for certain clinical scenarios, such as normal endoscopy with normal pathology, pathology with advanced neoplasia, and malignant colonic neoplasm.
ZSFG found that promoting communication between providers led to a significant increase of discharges from GI back to primary care, an increase in the ratio of new to follow-up appointments, and a decrease in median wait times for new appointments. A follow-up study found that providers were generally satisfied with the hand-back process, and discharge policies increased the overall complexity of specialist patient panels.
There is a perception that patients prefer to continue seeing their specialist—even if it’s no longer clinically necessary. An effective conversation between a patient and their provider can go a long way, and this can make patients less hesitant about returning to primary care.
Training and scripting resources on how to have hand-back conversations with patients will mitigate this concern. That way, if a patient pushes back, they feel equipped with how to respond.
We can’t improve population health without specialists. The three strategies outlined in this series are ambitious, yet feasible behavior changes that work under hybrid financial incentives primarily by addressing the specialist-PCP communication gap. Building avenues for collaboration and a shared culture is at the core of referral considerations, e-consults, and hand-backs—and will remain central to future value-based care work. Focus your efforts here to start engaging specialists.
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This expert insight series is sponsored by Episource, an Advisory Board member organization. Representatives of Episource helped select the topics and issues addressed. Advisory Board experts wrote the post, maintained final editorial approval, and conducted the underlying research independently and objectively. Advisory Board does not endorse any company, organization, product or brand mentioned herein.
Tuot D, et al., “Increasing Access to Specialty Care: Patient Discharges From a Gastroenterology Clinic,” AJMC, 20, no. 10 (2014): 812-819.
Selvig D, et al., “Gastroenterologist and primary care perspectives on a post-endoscopy discharge policy: impact on clinic wait times,” BMC Health Services Research, 18, no. 16 (2018).
This expert insight series is sponsored by Episource. Advisory Board experts wrote the post, conducting the underlying research independently and objectively.Learn more
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