Integrated Health Networks Learning Session II

1
Building Coalitions through Service
AgreementsBenefits and Process

• Integrated Health Networks Learning Session II
• Vancouver, BC
• Feb 8, 2008

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Outline

• Introductions Panel and Participants
• Introduction to Service Agreements
• The Process of a Service Agreement
• Discussion
• Take Home Messages

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Service Agreements

• Service Agreement
• An understanding or agreement between any 2
  entities, one of which sends work to the other.
• Both parties need to understand the work, the
  process, and agree on expectations of each other.
• A clearly defined relationship between services.

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Service Agreements

• Service Agreements can be made at all levels
• Between Community Nursing and the Family Doctor
• Between the doctor and the lab/x-ray
• Between the doctor and the specialty clinic
  (Mental Health, Palliative Care, Diabetes clinic)
• Between the primary physician and the specialist

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Service AgreementsWhats in it for patients?

• Patients describe an experience in the health
  system as constant, repeated waiting
• Waiting FOR and AT the appointment with the
  doctor
• Waiting FOR services (ie. lab, Diagnostics, and
  hospital admissions)
• Waiting BETWEEN providers (ie. Specialists,
  Treatments)
• Lack of communication between providers creates
  duplication of history taking and
  investigations, delays in next steps ie.
  Procedures, etc

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Service AgreementsWhats in it for providers?

• Typically, work is sent from the family doctor to
  another service, like the lab or a specialist
• This is fraught with inadequate information
  transfer, unclear communication pathways, and
  unmet expectations on both sides.
• Worst of all, If the patient is urgent, the
  doctor must call in person.
• This system is characterized by frustration and
  dissatisfaction on all sides, unreliability and
  rework, delays, and high cost.

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Service AgreementsWhats in it for
specialists?

• The purpose of the service agreement is to
• Reduce demand on specialists.
• Concentrate their work on that which only
  specialists can do.
• Sort the work in the process of requesting it,
  so
• the right work gets to the right person/place at
  the right time, without unnecessary triage or
  oversight.
• So- the Sender sends the right work packaged in
  the right way-

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Service AgreementsWhats in it for FPs?

• In return-
• the Receiver agrees to do the work right away,
  and returns the expediently, and in a way that
  can be managed by the family practice team.

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Four Components of a Service Agreement

• Define and discuss the work
• Sender sends right work packaged the right way
• Receiver does right work right right away
• Referee monitors agreement

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Define and Discuss the Work

• What is the work?
• Who is sending it?
• How much work exists?
• (Define the demand and supply.)

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Areas to Target

• High volume diagnosis or need
• Diabetic care
• Mental Health services
• Colonoscopy
• High Volume of referring family physicians
• Areas for targeted education (ie Shared Mental
  Health)

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Face-to-Face Communication is Crucial!

• Organize all service providers or key
  representatives to meet facilitated if
  necessary
• Present the data
• Discuss the data, practices, history, problems,
  potential solutions and recommendations
• Draft list of appropriate reasons for referral
• Draft list of work up needed before the specialty
  appointment
• Circulate the proposal to everyone affected and
  consider all comments

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Structured ConsultA Tool to assist packaging the
right way
Sender Sends the Right Work Packaged the Right
Way
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Colonoscopy Ordered
Chart reviewed by RN to find indications/ contrain
dications and last exam

Chart Reviewed by Surgeon
Meets Criteria
NO
YES
RN Calls patient to schedule and educate Rn sends
prep
Call to Provider to Clarify
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(No Transcript)
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Provider Orders Colonoscopy

Provider fills out structured consult
Surgery schedules test, educates, sends prep
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Approval Process

• Agreement must be negotiated between the 2
  services involved
• Signatures by representatives from each service
• Approval by Staffs of each services.
• The people that do the work must change the
  work

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Example

• Service Agreement between
• Cardston Family Practice Clinic
• Regional Vascular Protection Program

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Cardston Clinic and the Vascular Protection
Specialty Program

• Remote geographic area with high incidence of
  diabetes and vascular complications
• Low availability and long wait times to get into
  the diabetes clinic
• Poor communication in both directions led to FPs
  feeling out of the loop once a patient was
  enrolled.
• This led to less use of the specialty program,
  and ongoing unsatisfactory clinical outcomes.

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Cardston Clinic and the Vascular Protection
Specialty Program

• The Process...
• Regular meetings between the Steering Committee
• Flow Maps of current situation created
• Multiple revisions made by all providers
  involved.
• A common VISION formed
• Final Draft of the Service Agreement
• Evaluation

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Cardston Clinic and the Vascular Protection
Specialty Program

• Define the work
• What is the work?
• Multiple patients with diabetes
• Priorities
• High HgA1C and hospitalized in past year
• High HgA1c and ER visits in past year
• High HgA1c
• Total number of patients cared for with a
  diagnosis of diabetes

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Cardston Clinic and the vascular Protection
Specialty Program

• Send the work in the right way-
• Who is sending the work?
• Family Docs
• How?
• Referral forms sent to a central intake office
• Agreement with the specialty clinic on who they
  want to see and what info they need
• Clinical Guidelines for referral
• Referral form properly filled out
• Food record
• Blood Glucose log

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Cardston Clinic and the vascular Protection
Specialty Program

• Receiver is accessible to do the work Right
  away
• Relocate the diabetic clinic into the community 1
  ½ days/wk
• Agreed to offer a visit within 1 week.
• Agreed to defined feedback mechanism and referral
  back when stable.

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Cardston Clinic and the vascular Protection
Specialty Program

• Evaluation
• Measures being collected and reported Quarterly
  (based on data easily available thro the EMR)
• Delay to appointment
• Process of referral (Satisfaction with forms and
  feedback)
• Clinical Outcomes (HgA1C)

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Summary

• Define and Discuss the Work
• Sender sends the right work in the right way
• Receiver is accessible to the sender, and does
  the work with as little delay as possible
• An measurement audit follows the process.

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How to do it
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Team Exercise

• Pick a work process
• Flow map the current process in detail
• Where are the bottle-necks?
• Where are the opportunities?
• Who needs to be at the discussion table?
• What improvements could be measured and tested?
• Prepare to share what you learned