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Service Delivery Innovation Profile

Formalized, Technology-Enabled Referral Relationships Between Medical Center and Community Clinics Enhance Access and Reduce Inappropriate Emergency Department Visits


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Snapshot

Summary

A collaborative program known as Healthy Linkages leverages information technology to formalize referral relationships between the University of Mississippi Medical Center and community-based clinics serving uninsured and underinsured patients. Under the program, emergency department patients with nonemergent conditions get connected to a medical home (rather than being treated), while patients receiving primary care from Federally Qualified Health Centers and county clinics gain access to specialty care. An electronic referral system within the emergency department allows personnel to directly schedule same-day primary care appointments at a Federally Qualified Health Center. A toll-free telephone line allows community-based providers to arrange specialist appointments at the medical center, while video equipment gives providers the capability to confer with university-based specialists as necessary. The program has enhanced access to primary care, reduced return emergency department visits, and generated significant cost savings.

Evidence Rating (What is this?)

Moderate: The evidence consists of post-implementation data on patient referrals to a medical home, pre- and post-implementation comparisons of appointment wait times and the proportion of nonemergent patients who return to the emergency department within 6 months, and estimates of the cost savings generated by reductions in emergency department-based primary care and diagnostic testing during the first 6 months of the program.
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Developing Organizations

Mississippi Primary Care Association; Mississippi State Department of Health; University of Mississippi Medical Center
Healthy Linkages is a collaborative effort between the University of Mississippi Medical Center; the Mississippi Primary Care Association, which represents the interests of 21 Federally Qualified Health Centers with more than 160 service delivery sites through the state; and the Mississippi State Department of Health, which runs 82 county health department clinics.end do

Date First Implemented

2008

Problem Addressed

Many patients, particularly those with low socioeconomic status, face challenges in obtaining primary care, leading them to seek treatment at the emergency department (ED). Due in large part to poor linkages between medical centers and community-based clinics, those who present at the ED often do not follow up on suggestions to go to a community clinic (and instead return to the ED), while those able to access community-based primary care often have difficulties getting referred to needed specialists.
  • Many inappropriate, costly ED visits: Many uninsured and underinsured individuals use the ED for nonemergent (often chronic) conditions that could be better handled in lower-cost settings. For example, prior to introduction of Healthy Linkages, roughly 25 percent of ED visits to the University of Mississippi Medical Center (17,000 out of 70,000) were for nonemergent needs. This situation created many problems for both patients and the medical center, including inadequate preventive care, poor management of chronic conditions, ED overcrowding,1 and unnecessarily high costs.2 For example, prior to introduction of this program, the University of Mississippi Medical Center ED had invested in dedicated space and staff within the ED to address primary care needs.
  • Inadequate linkages between ED and primary care: Patients who come to the ED for nonemergent care often get referred to a Federally Qualified Health Center (FQHC) or county clinic, but then do not follow-up with those providers or get frustrated due to long waits for an appointment. For example, before implementation of this program, University of Mississippi Medical Center ED staff routinely instructed patients to go to an FQHC for future primary care needs. Yet only 10 percent of referred patients did so (in part due to wait times of several months for appointments), with the rest continuing to come to the ED for primary care.
  • Inadequate linkages and access to specialty care: Uninsured and underinsured patients who do access community-based primary care often face significant barriers when they need specialty care. The few specialists who accept referrals from safety net providers often rely on inefficient referral systems, leading to long wait times, incomplete information, and suboptimal provider–patient interactions.3,4 In Mississippi, FQHC providers treating high-risk obstetrics patients and county health department providers treating cardiac patients often found it difficult to arrange for specialist consultations, and in many cases did not know who to call to schedule an appointment. As a result, these patients often presented to the ED.

What They Did

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Description of the Innovative Activity

A collaborative program known as Healthy Linkages leverages information technology to formalize referral relationships between the University of Mississippi Medical Center and community-based clinics serving uninsured and underinsured patients. Under the program, ED patients with nonemergent conditions get connected to a medical home (rather than being treated), while patients receiving primary care from FQHCs and county clinics gain access to specialty care. An electronic referral system within the ED allows personnel to directly schedule same-day FQHC appointments. A toll-free telephone line allows community-based providers to arrange specialist appointments, while videoconferencing equipment offers these providers the capability to confer with university-based specialists as necessary. Key program elements include the following:
  • Electronic scheduling of primary care appointments: Previously, dedicated ED clinicians treated patients with primary care needs in a designated area, provided information on the nearest FQHC, and suggested that patients go there for future primary care needs. Under Healthy Linkages, these patients do not receive treatment in the ED. Instead, through a partnership between the hospital and the largest FQHC in the state, a member of the triage staff schedules an appointment (often for the same day) at the FQHC (that uses internal medicine residents) through the center's electronic medical record (EMR) system, which includes a scheduling module. Going forward, this scheduling process will be available at other FQHCs around the state, thus allowing patients to be directed to the medical home nearest their place of residence.
  • Patient education and transportation assistance: ED staff emphasize the importance of receiving primary care in a medical home rather than the ED. They also give patients a brochure explaining the concept of a medical home. Patients without transportation receive a bus voucher that allows them to get to the nearby FQHC.
  • Facilitated specialty appointments: FQHC and clinic providers can arrange for specialist consultations by calling a toll-free telephone access line set up by the medical center to schedule specialty appointments.
  • Remote specialist consultation via videoconferencing: All FQHCs have videoconferencing equipment to facilitate specialty consultations. This service can be particularly valuable for FQHCs located far from the medical center.

Context of the Innovation

Located in Jackson, the University of Mississippi Medical Center is a 722-bed institution that includes adult, children's, women's, and critical care hospitals and handles roughly 70,000 ED visits annually. The Mississippi State Department of Health operates 82 county health clinics that focus primarily on women's care. The Mississippi Primary Care Association represents the interests of 21 FQHCs that collectively see approximately 315,000 patients each year with nearly 930,000 visits. The impetus for this program came in part from Hurricane Katrina, which exposed the need for formal communication about patient referrals between the university, the health department, and the FQHCs. (No such communication existed prior to the disaster.) An additional impetus came from the aforementioned problem of nonemergent ED patients not heeding the advice of ED staff to seek primary care at an FQHC.

Did It Work?

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Results

The program has enhanced access to primary care, reduced return ED visits, and generated significant cost savings.
  • Enhanced access to primary care: Each day, roughly 5 nonemergent ED patients receive a same-day appointment at the nearby FQHC. Prior to implementation of this program, these patients either would have been treated in the ED or would have had to wait 3 to 6 months to be seen by the FQHC.
  • Fewer return ED visits for primary care: Since implementation of the program, the percentage of nonemergent ED patients who come back to the ED for primary care within 6 months has fallen from 42 percent to 29 percent. This decline suggests that more patients now receive primary care in their medical homes rather than the ED.
  • Significant cost savings: The medical center estimates that it saved approximately $1 million in the first 6 months due to reductions in the provision of high-cost primary care and diagnostic testing in the ED. Part of this savings has come from the elimination of several ED positions previously dedicated to primary care.

Evidence Rating (What is this?)

Moderate: The evidence consists of post-implementation data on patient referrals to a medical home, pre- and post-implementation comparisons of appointment wait times and the proportion of nonemergent patients who return to the emergency department within 6 months, and estimates of the cost savings generated by reductions in emergency department-based primary care and diagnostic testing during the first 6 months of the program.

How They Did It

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Planning and Development Process

Selected steps included the following:
  • Creating oversight committee: In 2006, Dr. James Keeton (the Vice Chancellor for Health Affairs of the medical center), the State Health Officer at the time, and Mr. Robert Pugh (the head of the Mississippi Primary Health Association) formed a Healthy Linkages committee. The three leaders named appointed members from their organizations to serve on the oversight committee.
  • Hiring consultant: The committee hired a consultant (the Bard Group, Boston, MA) to help develop a formal patient referral process.
  • Designing referral process: A design team (including a subset of committee members along with clinicians from the three organizations) worked with the consultant to identify the needs of each organization, map out a new referral process, and create an implementation timeline. The team presented the new process to the oversight committee to obtain approval.
  • Enabling electronic access: Medical center personnel received password-protected access to the EMR and scheduling system of the nearest FQHC, located a few miles away.
  • Hiring project director: The committee hired a project director to oversee a pilot test of the new system and its subsequent expansion.
  • Discussing system with department managers and frontline staff: Medical center leaders and the project director met with managers and frontline staff in the ED, cardiology department, and obstetrics/gynecology department to explain the new referral process and use of the toll-free telephone access line. The project director provided ongoing updates to department heads as the initiative progressed.
  • Pilot testing and expansion: In 2008, the cardiovascular and obstetrics/gynecology departments within the medical center pilot tested the new referral process, in partnership with the largest FQHC in the state and one county health department clinic. Over time, the new specialty referral system has been rolled out to all state FQHCs and county clinics. The medical center plans to work with other FQHCs to offer the same service.

Resources Used and Skills Needed

  • Staffing: The program required the hiring of one full-time project director who oversees and coordinates the program. However, as noted, the program has allowed the ED to eliminate several positions dedicated to the provision of primary care.
  • Costs: Data on program costs is unavailable. Major upfront costs included consulting fees and the purchase of videoconferencing equipment, while ongoing costs consist of the project director’s salary and benefits.
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Funding Sources

Health Resources and Services Administration; University of Mississippi Medical Center; Mississippi State Department of Health; Mississippi Primary Care Association
Originally, the University of Mississippi Medical Center, the Mississippi Primary Care Association, and the Mississippi State Department of Health each funded one-third of the project director's salary. At present, the University of Mississippi Medical Center and Mississippi State Health Department share the costs of this position. An Emergency Communications Network grant from the Health Resources and Services Administration supported the initial implementation by funding the purchase of videoconferencing equipment.end fs

Adoption Considerations

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Getting Started with This Innovation

  • Build trust among stakeholders: Initially, FQHC leaders may be reluctant to give medical center personnel access to their electronic systems. To overcome this resistance, senior leaders of each organization should meet frequently over a period of time to build personal, trusting relationships. During these meetings, the leaders should discuss their specific concerns (e.g., the potential for patient "poaching" and inappropriate use of information) but also focus on the program's ability to promote their shared mission of better access to high-quality care. Medical center leaders should be willing to discuss initiatives (such as community clinic development) that might be concerning to community partners. During the development of Healthy Linkages, medical center leaders assured the first participating FQHC that all patients without a medical home (including those with insurance) would be referred to the center.
  • Solicit outside assistance: A consultant can serve as a neutral party who helps to navigate the interests of all entities involved.
  • Hire dedicated project director: A dedicated project director should oversee implementation and address the needs of various stakeholders. Ideally, stakeholders should contribute equally to the project director’s salary so that the individual is equally accountable to each of them.
  • Consider impact on personnel: Eliminating the provision of nonemergent ED care may have staffing implications. Consequently, program leaders should hold upfront discussions with relevant department managers to set and manage expectations related to staffing. As noted, the University of Mississippi Medical Center ED no longer needed several staff dedicated to providing primary care.

Sustaining This Innovation

  • Build on initial successes: Successful electronic referral relationships with one or two FQHCs can help a medical center build similar relationships with other community partners around the state.
  • Ensure consistent processes: Work processes that remain consistent over time will ultimately be incorporated into the workflow and consequently are more likely to be sustained.
  • Continue committee meetings: The oversight committee continues to meet monthly to resolve program-related issues in a timely manner. The committee also works to nurture existing relationships between stakeholders and discusses new opportunities as they arise. (See bullet below for more details on new opportunities.)
  • Leverage new opportunities: Healthy Linkages has facilitated closer relationships among Mississippi providers, which in turn have led to the development of other successful joint ventures. For example, prior to implementation of the program, the medical center had been operating several community-based clinics at a financial loss due to inefficient operations. Thanks to the trusting relationship established through Healthy Linkages, the Jackson-Hinds Comprehensive Health Center (the largest FQHC in the state) now runs these clinics, with the medical center maintaining ownership and providing medical resident staffing. The medical center hopes to develop similar ventures with other FQHCs across the state. The program has also given the state's 21 FQHCs a forum to discuss common issues and challenges and to share best practices, something they previously did not do.

More Information

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Contact the Innovator

Michael L. Jones, RN, MSN, MBA
Chief Community Health Officer
Healthy Linkages Project Director
Office of the Vice Chancellor
The University of Mississippi Medical Center
2500 North State Street
Jackson, MS 39216
Phone: 601-815-9693
Email: mljones2@umc.edu

Claude Brunson, MD
Senior Adviser to the Vice Chancellor for External Affairs
Office of the Vice Chancellor
Professor of Anesthesiology
The University of Mississippi Medical Center
2500 North State Street
Jackson, MS 39216
Phone: 601-984-1012
Email: cbrunson@umc.edu

Innovator Disclosures

Mr. Jones and Dr. Brunson disclosed that the Mississippi State Health Department and the University of Mississippi Medical Center jointly fund the project director position for the Healthy Linkages program.

Footnotes

1 Garcia TC, Bernstein AB, Bush MA. Emergency Department Visitors and Visits: Who Used the Emergency Room in 2007. NCHS Data Brief, No. 38, May 2010. Available at: http://www.cdc.gov/nchs/data/databriefs/db38.htm.
2 EDs slash unnecessary visits using interfaced computer, common protocols. ED Manag, 2006 Apr;18(4):37-4. [PubMed]
3 Kim Y, Chen AH, Keith E, et al. Not perfect, but better: primary care providers' experiences with electronic referrals in a safety net health system. J Gen Intern Med. 2009;24(5):614-9. [PubMed]
4 Shaw LJ, de Berker DA. Strengths and weaknesses of electronic referral: comparison of data content and clinical value of electronic and paper referrals in dermatology. Br J Gen Pract. 2007;57:223-4. [PubMed]
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Original publication: August 29, 2012.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: July 30, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: August 05, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.