Taxonomy II Part I-B.1 (Coordination of Health Care Services)

Last Updated on April 16, 2022 by Lee Burnett, DO, FAAFP

(14 May 2006 09:55)





(Coordination of Health Care Services)

SD II.2 (L19) In what ways does your FP residency promote coordination of health care services so as to enhance patients’ access to care, the process of care and/or outcomes of care?

MCE Birmingham         (Social worker at our clinic)

Dayton Community       (Working with social workers/local social service agencies)

Decatur                        (In the daily care of patients)

Indiana U Methodist     (Access to EMR at hospital or office)

Kansas U                     (circle placed around phrase “coordination of”)

Klamath Falls               (Enrollment of undesignated hospitalized patients into FP clinic/follow up/primary care)

Lexington                     (One patient at a time in active efforts by docs and FP staff)

Mercer                         (We hired a patient care coordinator to manage all referrals for imaging studies and all referrals to specialists)

Riverside                      (It is a key player in the primary care of uninsured patients in the community and county)

Salt Lake City              (Comprehensive care – includes psychological, nutritional, pharmacological)

UC Irvine                     (Use of case managers with selected patients)

UC San Diego              (Question is too broad; we have a medical case manager)

Whittier                        (Time consuming question; unclear)

Site-visited profiled residencies:

Northridge                    (Family Practice is designed to do all of this)

UCLA                          (We serve as gatekeepers; patient advocates and we practice comprehensive care)

Harbor                         (We enhance patients’ access to care, by using programs as feeders to care.  We triage at health fairs and shelters. Many of these health activities lead to necessary medical interventions.  We have quality assurance programs.)

UCSD Traditional         (We have night clinics.  We provide a lot of services on site, including behavioral services, so that families do not have to go anywhere else to get care; we see patients in nursing homes; we provide care to homeless persons at St Vincent de Paul Village and student run clinics where the care is provided free.  The question is too broad. Work on dividing it.)

Scripps Chula Vista      (We work with health educators and with social workers; we provide continuity to the hospital’s discharge procedures.)

UCSD St Vincent         (We have a medical case manager that works with all physicians, especially those in the combined (i.e., FP-Psychiatry) residency.)

UC Irvine                     (Coordination is the central theme of the family health center’s activities.  The FHC, through its funding designation as a Federally Qualified Health Center, is able to provide laboratory, radiological and dental services; on-site ophthalmological and podiatric services; and pharmacy benefits in the context of a global payment for all services. In addition, support staff employed by the FHC help patients get access to state, federal financial services, including eligibility for Medi-Cal, and comprehensive perinatal screening support. A staff nutritionist is onsite; patient education programs are on-site.  Patient care is provided in a community health center that can address health care coordination.)

White Memorial            (1, We work with HMO managed care contractors; 2, through White Memorial Medical Center, we have county contracts for mental health, obstetrics and other medical services; 3, we have an information center to optimize enrollment of uninsured patients into payments mechanisms and  coordination of care with Medi-Cal providers.)

Riverside                      (Patients are seen regardless of ability to pay.)

Durant                          (We help to arrange referrals for our Medicaid patients. For indigent patients, we have a sliding scale.  The residents are advocates for indigents.  We run a huge indigent pharmaceutical procurement point of access.  We believe around $750,000 worth of drugs have been obtained for indigents)

OSU Tulsa                   (We participate in the state HMO process; and in state requirements for producing information packets to Medicaid recipients on hours and services; this information facilitates access)

USC Univ&SG            (We do outreach at health fairs; once people are in the system, we work to keep them in the system; including chronic diseaes.  All referrals are documented and tracked.  Coordination is taking these services and plugging them into the practice guidelines, then doing charts audits and peer audits on chronic disease management)

SD II 2.1 (L19) In what ways does your FP residency promote coordination of health care services so as to enhance:

(a) patients’ access to care

Modesto                      (We have an integrated system with specialty and primary care.  We use primary care to restrict specialty services.  We have a shared information system across points of access, facilitating access to care.)

Saints                           (We accept Medicaid; we interface with health care authority as far as transportation)

Indiana U Methodist     (We serve as primary care doctors; Medicaid Select is a managed care program for drug abusers)

Whittier                        (We work with city and hospital administrators and agencies such as churches and adult day care centers to evaluate potential new practice sites; for provider recruitment; as a point of access for screening and education; and for transportation)

Pomona                        (We are directly involved in development of referral to subspecialty services; we are the clearinghouse for community services; we see WIC recipients and refer them for comprehensive health services at other sites)

Arrowhead                   (We are the primary care provider for all patients; we coordinate the patients referrals to specialty clinics throughout the county system)

Loma Linda                  (We have a free school clinic associated with Healthy Families.  We are the only one in area that provides Health Family services with physicians onsite.  We participate in Sac Norton Clinic for the uninsured and underinsured with a free medication program)

Stockton                      (We refer patients to the proper agencies within the county)

Louisville                      (we try to keep appointment slots open on a daily basis to accommodate access, even though we are way oversubscribed at all of our practice sites; we are a point of access for the indigent)

MCE Birmingham         (we look for specialty services for our Medicaid patients, who are rarely welcome in specialists’ offices, for psychiatry, ENT and counseling; we use a social worker for referrals and follow-up and to help patients find ways to pay for medications)

Glendale                       (Because we are able to handle a wide range of services in the family health center, we minimize referral to specialists.  We triage only the most ill to referral specialists)

OU Tulsa                     (We have clinics everyday, including Saturday, Sunday and Tuesday evening; a partial open-access model for same day services; a social worker helps with referrals to local agencies)

OU Oklahoma City      (Our residency has an ongoing dialogue with the OU Division of Health Care Policy and Research. We work closely with the Oklahoma Health Care Agency to maximize patient access to care)

(b) and/or the process of care

Modesto                      (Residents refer to clinics and participate in clinics.  They take care                    of the long-term follow-up of patients seen)

Saints                           (the State of Oklahoma signs up residents as primary care physicians for the Medicaid program)

Indiana U Methodist     (an electronic medical record system is in place both at the family health center and in the hospital, accessible in both places)

Whittier                        (We conduct quality assurance and quality improvement; provide faculty supervision; conduct evidence-based medicine reviews, conduct morbidity and mortality conferences)

Pomona                        (We coordinate care processes through our appointment mechanisms; we encourage patients to continue with their assigned residents.  We have extended weekend hours; and provide open access with certain physicians every day Monday through Saturday)

Arrowhead                   (We have a process where we assign patients to both faculty and residents as a panel of patients; we use chart audits and other auditing tools, and case discussions to assure that patients get good care)

Loma Linda                  (most of it is through the existing IHP and Molina Healthcare programs; group visits for diabetics; a process for getting lab and

x-ray services for the uninsured at the Sac Norton Clinic)

Stockton                      (we follow care that is given elsewhere, but where the follow-up occurs here)

Louisville                      (we engage in a process of quality assurance where monitor the care we provide — by disease state or other markers of effectiveness or efficiency; we have an established program on chronic disease management, including self-care management)

MCE Birmingham         (we have a scheduling referral clerk (an uncompensated position) to dog it through until someone sees a patient who needs referral; we obtain the same kind of service from our social worker, especially for post-partum care)

Glendale                       (We promote a multidisciplinary team with a social worker, psychologist, and pharmacist; mental health is integrated into care, as are home visits and a geriatric assessment clinic; we have used hand-held technology to improve the processes of care)

OU Tulsa                     (We have triage nurses that patients can access; we have staff that check people in for their appointments; who coordinate referrals and authorizations; and who help to enroll patients into the Medicaid and the indigent drug benefit programs)

OU Oklahoma City      (We include residents in our clinic management committee; we have Medicaid case managers; a social worker; and a CQI committee)

(c) and/or the outcomes of care?

Modesto                      (We have no way to provide statistics about outcomes, although we do follow-up care)

Saints                           (We participate in CAP (part of the OPTI program) for low-back pain and diabetes; and COPD, asthma & diabetes collaboratives)

Indiana U Methodist     (-)

Whittier                        (-)

Pomona                        (We are an outpatient department of the hospital and are involved with quality of care and outcomes that are reviewed by JCAHO)

Arrowhead                   (we have a QI process where we look at different aspects of care where we determine if the outcomes meet a set standard)

Loma Linda                  (Research to see if diabetes group visits improve outcomes)

Stockton                      (we follow up on all referrals to make sure the patients have received what they need)

Louisville                      (As part of our chronic disease management, we monitor using markers of effective management)

MCE Birmingham         (We do formal QI.  We look at outcomes.  Within the hospital we all work on QI committees.  Senior residents set up a QI project, such as on diabetic care and immunizations)

Glendale                       (When we send someone out to a referral specialist, we monitor them and bring them back to their medical home.  Because we have so many services on site, we can monitor no-shows for mental health and other services.  We met with IPA representatives regularly to get chronic disease outcomes, to review lipids, asthma medications, hemoglobin levels)

OU Tulsa                     (we educate residents on a regular basis; we use patient care projects to evaluate both resident and faculty care and provide feedback to them; a Pharm.D. does education in diabetes, asthma and hypertension, and does diabetes studies which are showing improvements)

OU Oklahoma City      (We do studies; we have peer reviews and reports; We do peer review and CQI; we have monthly morbidity and mortality conferences; we hold hospital departmental meetings on the CQI reports; we have an elaborate patient satisfaction system; monthly questionnaires; resident monthly production reports; and a facile complaint review system)

Last Updated (23 May 2006 19:52)

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