3007 – Leveraging Physician Collaboration to Increase Patient Engagement through Proactive Care Management Referrals
Research studies suggest that engaging physicians is a critical component in improving care transitions and reducing readmissions (Lonowski, 2012). According to recent findings from an outside consultant, Cedars-Sinai Medical Network’s primary care physician (PCP) referrals should make up 50% of successful referrals to ambulatory care management (ACM). Prior to our intervention, majority of the patients with complex needs were identified through an internally developed high-risk registry and only 25% of referrals came directly from PCPs. Although there is an electronic care management referral order in the EMR and a direct phone line for referrals to care management, these systems are underutilized by the PCPs that lead to missed opportunities. We hypothesized that this was due to a lack of understanding among PCPs of the care management services that they can activate to assist patients. PCP-patient collaboration are key drivers of patient engagement in ACM and other unnecessary hospitalization avoidance efforts that can have a big impact on patient buy-in to actively participate in services that can improve their health (Kodner, 2015).
The goal of this micro pilot was to increase patient engagement through increased referrals generated by PCPs and the degree of physician involvement. Educational topics over a period of eight weeks were presented to weekly physician meetings on various aspects based on identified issues. Case examples and intensive follow-up on care management utilization were also presented. The electronic referral order set was revised to cover the most commonly used reasons for referrals to care management. Referral rates, patient engagement, and physician satisfaction were tracked during this 8-week pilot with thirty-nine PCPs who participated in two preexisting geographic groups. There was a 70% increase in the number of referrals from PCPs; enrollment rates among referred patients increased from 30% to 72%, and PCP satisfaction increased.
1. Demonstrate the opportunity to leverage physician and care manager collaboration to identify, assist, and coordinate the care of high risk patients.
2. Present a collaborative approach for physicians and care managers to increase physician referrals and patient engagement
3. Illustrate use of electronic health record technology to maximize referrals to care management.