# data[].attributes.body
Does the cost of implementing new program software and training staff benefit an organization in regards to stream-lining a new electronic process? Please explain.

# data[].attributes.body
Is there a workflow process in your area of nursing that has changed from a paper process to an electronic  process? If so, was it beneficial? Please explain.

# data[].attributes.body
Azamar-Alonso, A., Costa, A. P., Huebner, L. A., & Tarride, J. E. (2019). Electronic referral systems in health care: a scoping review. ClinicoEconomics and Outcomes Research : CEOR, 11, 325–333. doi:10.2147/CEOR.S195597

Liddy, C., Drosinis, P., Fogel, A., & Keely, E. (2017). Prevention of delayed referrals through the Champlain BASE eConsult service. Canadian Family Physician Medecin de Famille Canadien, 63(8), e381–e386.

Patel, M. P., Schettini, P., O'Leary, C. P., Bosworth, H. B., Anderson, J. B., & Shah, K. P. (2018). Closing the referral loop: an analysis of primary care referrals to specialists in a large health system. Journal of General Internal Medicine, 33(5), 715–721. doi:10.1007/s11606-018-4392-z

Popejoy, L. L., Galambos, C., Stetzer, F., Popescu, M., Hicks, L., Khalilia, M. A., Marek, K. D. (2015). Comparing Aging in Place to Home Health Care: Impact of Nurse Care Coordination On Utilization and Costs. Nursing economic$, 33(6), 306–313.

Rea, C. J., Wenren, L. M., Tran, K. D., Zwemer, E., Mallon, D., Bernson-Leung, M., Toomey, S. L. (2018). Shared care: using an electronic consult form to facilitate primary care provider-specialty care coordination. Academic Pediatrics, 18(7), 797–804. https://doi-org.ju.idm.oclc.org/10.1016/j.acap.2018.03.010

# data[].attributes.body
The scope of this workflow redesign includes three departments and two system programs. The departments include  Inpatient Care Mangers (IPCM), AgeWell Housecalls (AWHC), and Baptist Primary Care Ambulatory Care Coordination (BPC ACC). The system programs include Allscripts  Care Manager and Allscripts Care Director.

Care Manager is currently utilized by the IPCMs and BPC ACCs for documentation and communication regarding patients in other areas of the organization. Care Director is currently utilized by AWHC for documentation purposes. Care Manager can easily place a referral to AWHC through tasking functionality within the programs. The two programs can easily communicate because they are both a product of Allscripts with the purpose of interoperability.

The involved departments and system programs will not have a dramatic change. The mode of communication regarding referrals will improve with the electronic referral process versus the current manual faxing method

# data[].attributes.body
Increasing patients utilization of primary care will reduce unnecessary hospitalization and readmissions.  By stream-lining an electronic referral process, referrals are able to be easily tracked and there is less of a chance of a referral getting lost in the paper shuffle.

Centers for Medicare and Medicaid Services (CMS) implements reimbursement penalties for 30-day readmissions for chronic illnesses. Patients are more likely to have a readmission if they are unable to transport to their Primary Care Physician for follow-up appointments. The aim of improving the referral process is to increase access to the AWHC program for patients who qualify. Currently, AWHC has an 8% readmission rate which is 7% less than the golden Medicare standard of 15%.

Internal customers include all involved departments. The IPCM and BPC ACC will benefit by creating less workload and a stream-lined electronic referral process in a system that they are already using. The financial department will also benefit as an internal customers by cost savings in Medicare reimbursement penalties.  AWHC will benefit by ensuring all referrals received will be addressed and increase in patient population.

External Customers include the patients. Patients will benefit with increased access to primary care services that do not require them to physically go to the doctor's office. AWHC patients are all very frail and physical unable to go the a doctor's office for follow-up appointments.

Improvement in the volume of referrals sent to AWHC will give more patients access to primary care services at home.

Adding the notification of accepting or denying referrals to the referring clinician to the work process will facilitate better communication between care team members.

# data[].attributes.headline
Required Resources, Departments and People

# data[].attributes.subject
Required Resources, Departments and People

# data[].attributes.body
The resources needed for this project will be an upgraded software programs and computers in which the program runs.

The departments involved in the workflow redesign will include AWHC, BMC ACC, and IPCM. Additional, the Informatics department will be involved in customizing the programs to support the electronic referral process.

The people required to make this workflow redesign successful will be the directors of the involved departments for approval of the steps included in the new workflow design. The intake care coordinator and ACC with AWHC will be included. The registered nurses and social workers that work in the IPCM and BPC ACC positions will also be involved in the process.

# data[].attributes.body
Team Lead - Brenna Waxman and Amanda Francisco
Project Manager - Brenna Waxman
Project analyst - Amanda Francisco

The cost of this project including time spent by staff and implementation of software improvements will be divided by the three departments that are utilizing the referral process.

The cost will be approved in advanced by the directors of the corresponding departments who will be utilizing the updated referral process.

# data[].attributes.body
The new referral process for AWHC will be tested prior to the Go-Live date for the new workflows. A Monday thru Friday work week before the Go-Live date will be utilized as a "test week". The AWHC intake coordinator and ACC as well as two nurses from the BMC ACC and two nurses from the IPCM will be involved in the test week. A meeting will be conducted prior to the test week with all individuals involved. An informatics team member will be available throughout the test week should any issues or concerns arise throughout the test week. A meeting will be conducted at the end of the test week to work out any kinks before the Go-Live date.

# data[].attributes.body
All programs involved in this new workflow are already in use by the corresponding departments. Allscripts Care Manager is currently utilized by the IPCMs and BPC ACC. Allscripts Care Director is currently utilized by AWHCs for documentation purposes. Training would only have to include the new referral tasking functionality within the programs.

Prior to the Go-Live date,  training sessions will be implemented for each department involved in the workflow redesign. Care Manager and Care Director will be in training mode where the IPCMs and BPC ACC are able to practice sending referral tasks within the programs. AWHC intake and ACC will also be able to practice receiving referral tasks and sending are communication task regarding the acceptance or denial of patient. This training will take place over two different training sessions lasting up to two hours for each session. The training sessions will give opportunities to address any questions or concerns by all individuals involved.

Hot sheets will also be created to be distributed to the team members whose workflow will change based on the new referral process. The hot sheets will include step-by-step instructions to creating and sending a referral and communication task in the programs.

# data[].attributes.body
During the "Go-live", informatics team members will be available to each involved department via email or direct phone call to assist with any issues. If needed, an informatics team member will go to the site where assistance is needed. Since the IPCMs and BPC ACCs are spread out over three counties, it is impossible to have an informatics team member at all sites at the same time during the "Go-live".

# data[].attributes.body
A monthly report will be generated to track the number of referral tasks sent to AWHC by the IPCMs and BPC ACCs as well as the number of accepted referrals and denial referrals. Additionally, a monthly report will be generated to track the number of communication tasks being sent back to the original referrer. This monthly report will be compared to the monthly report for the number of referrals into AWHC to ensure that communication tasks are being sent back.

If inconsistencies are identified, then retraining will be necessary.  If the number of referrals begin to decline over time to AWHC, then retraining might be necessary.

# data[].attributes.headline
Improve the Referral Process, , Improve Safety

# data[].attributes.subject
Improve the Referral Process, , Improve Safety

# data[].attributes.body
Website One

# data[].attributes.attachment_link.readable_text
When I worked as a primary care physician, referrals were a great concern of mine. Even though electronic medical records were in use, I had no way of knowing that a referral had taken place unless I proactively followed up.

My personal solution was as low-tech as they come: I used sticky notes to keep tabs on what I considered critical referrals - a patient with a breast lump referred to a surgeon for evaluation, for example. I stuck the notes in a folder and referred to them periodically so I'd remember to check the patient's medical record and make sure the appointment had been scheduled, the specialist's notes were available, or a plan of care was in place. I emphasize this was my system; I had no idea what other PCPs in the practice did to keep track of their referrals. There simply was no standard.

Why is this so important? Because a referral that falls through the cracks can lead to significant delays in sometimes critical diagnoses and subsequent delays in treatment.

Unfortunately, referral processes are too often problematic, and we need to change that. Patient referrals in ambulatory settings are on the rise in the US, having increased from 40.6 million in 1999 to 105 million in 2009. With that volume of activity, there is tremendous risk of harm when details get lost or miscommunicated within faulty systems.

IHI, in partnership with CRICO/Risk Management Foundation of the Harvard Medical Institutions, recently convened a panel of subject matter experts to evaluate what can go wrong in the referral process and develop recommendations for improving it. The outcome of this work is a range of recommendations for making the referral process more efficient, effective, and painless for clinicians and patients alike.
Closing the Loop
Our panel found that current referral practices are vulnerable owing to a lack of standard protocols, ambiguous roles and responsibilities, shortage of staff to monitor the process, and a lack of clear policies and instructions. (For example, what should be done if a patient does not show up for an appointment?) Every step in the process - from ordering the referral to communicating the plan of care to the patient and family - offers a risk of a breakdown.

These gaps in the referral process can lead to missed or delayed diagnosis and delayed treatment. A 2013 study found that breakdowns in the referral process occurred in 20 percent of diagnostic errors in primary care. When malpractice claims are made in the ambulatory setting, almost half involve a failure to follow up, many of these related to specialist referrals, according to CRICO.

Closing the Loop: A Guide to Safer Ambulatory Referrals in the EHR Era outlines a nine-step, closed-loop process in which all relevant patient information is communicated to the correct person through the appropriate channels and in a timely manner. The recommendations in the report address each of the steps and suggest actions for clinicians, leaders of health care organizations, and EHR vendors.

Some of these recommendations require improving interoperability of EHR systems, but many of the steps outlined can be put into practice with existing technology and without adding to the administrative burden of clinicians.

For example, clinicians within a practice can begin by developing a standard protocol for ordering referrals, ensuring all relevant information is available to the specialist, setting definitions for urgency, and specifying the urgency with every referral. Clinicians can improve the process simply by being more clear and direct in communicating to patients about what they should expect and the timeline for the referral.

The most important lesson to take from this work is that health IT on its own cannot fix the referral process. In some cases, the use of EHRs can bring new risks. We absolutely need to improve the current technology for managing referrals, but equally important is having standard processes by which all clinicians in a practice make and track referrals and optimize communication with other clinicians and with the patient.
Tejal K. Gandhi, MD, MPH, CPPS, is IHI's Chief Clinical and Safety Officer. You may also be interested in:
While it may take a while to achieve a fully functional closed-loop process, there are things we can do today to start this work. And by engaging all stakeholders, we can eventually achieve a much more robust process.
The Time Has Come to Improve Safety in Ambulatory Care
Closing the Loop: A Guide to Safer Ambulatory Referrals in the EHR Era

# data[].attributes.attachment_link.title
Improve the Referral Process, Improve Safety

# data[].attributes.attachment_link.description
When I worked as a primary care physician, referrals were a great concern of mine. Even though electronic medical records were in use, I had no way of knowing that a referral had taken place unless I proactively followed up.

# data[].attributes.headline
Electronic Referrals With Alliance Medical 

# data[].attributes.subject
Electronic Referrals With Alliance Medical 

# data[].attributes.body
Video One

# data[].attributes.attachment_link.title
Electronic Referrals With Alliance Medical

# data[].attributes.body
Video Two

# data[].attributes.body
Website Two

# data[].attributes.attachment_link.readable_text
What is the Hospital Readmissions Reduction Program?

HRRP is a Medicare value-based purchasing program that lowers payments to Inpatient Prospective Payment System (IPPS) hospitals with excess readmissions.

Section 3025 of the Affordable Care Act required the Secretary of the Department of Health and Human Services to establish the HRRP starting October 1, 2012 (i.e., Federal Fiscal Year [FY] 2013).

Why is the Hospital Readmissions Reduction Program important?

The HRRP makes Americans' health care better by linking payment to the quality of hospital care. It gives hospitals an incentive to improve communication and care coordination so patients and caregivers are more involved in post-discharge planning.

We've included measures of conditions and procedures that make a big difference in the lives of large numbers of people with Medicare. The HRRP, along with the Hospital Value Based Purchasing (HVBP) and the Hospital-Acquired Condition (HAC) Reduction Programs, is a major part of how we add quality measurement, transparency, and improvement to value-based payment in the inpatient care setting.

Research shows hospital readmission rates are different across the nation. This gives us an opportunity to improve the quality of care and save taxpayer dollars by giving providers incentives to reduce excess readmissions.

What are applicable Hospital Readmissions Reduction Program hospitals?

Applicable hospitals under HRRP are defined in section 1886(d)(1)(B) of the Social Security Act.

Maryland hospitals are included under the program in readmission measure calculations, but they're waived from payment reductions because they participate in the Maryland All-Payer Model. You can find more information about Maryland hospitals in section 1886(q)(5)(C) of the Social Security Act.

What measures are included in the Hospital Readmissions Reduction Program?

We use the excess readmission ratio (ERR) to assess hospital performance. The ERR measures a hospital's relative performance and is the ratio of predicted-to-expected readmissions. We calculate an ERR for each condition and procedure included in the program:

Acute Myocardial Infarction (AMI)

Chronic Obstructive Pulmonary Disease (COPD)

Heart Failure (HF)

Pneumonia

Coronary Artery Bypass Graft (CABG) Surgery

Elective Primary Total Hip Arthroplasty and/or Total Knee Arthroplasty (THA/TKA)

HRRP doesn't include the Hospital-Wide All-Cause Readmission (HWR) measure, which is included in the Hospital Inpatient Quality Reporting (IQR) Program.

What counts as a readmission under the Hospital Readmissions Reduction Program?

The 30-day risk standardized unplanned readmission measures include:

Unplanned readmissions that happen within 30 days of discharge from the index (i.e., initial) admission.

Patients who are readmitted to the same hospital, or another applicable acute care hospital for any reason.

Readmissions to any applicable acute care hospital are counted, no matter what the principal diagnosis was. The measures don't include some planned readmissions.

How does the Hospital Readmissions Reduction Program adjust payments?

For each eligible hospital, we calculate the payment adjustment factor. The payment adjustment factor tells us what percent a hospital's payment is reduced. We apply the payment adjustment factor for all discharges in the applicable fiscal year, no matter the condition.

You can find more information in the QualityNet Payment Adjustment Factor section.

What is the Review & Corrections period for the Hospital Readmissions Reduction Program?

The 30-day Review and Corrections period allows applicable hospitals to review and correct their payment adjustment factor and component result calculations (i.e. Dual Proportion, Peer Group Assignment, Neutrality Modifer, ERR, and Peer Group Median ERRs) for HRRP. Hospitals can't send in corrections to the underlying claims data or add new claims to the data extract.

Each program year, we let hospitals know the exact dates of the Review and Corrections period.

How will I know if CMS changes the Hospital Readmissions Reduction Program?

Changes to the program happen through rulemaking. These changes are published yearly after a public comment period, with the Inpatient Prospective Payment System /Long-Term Care Hospital Prospective Payment System (IPPS/LTCH PPS) Final Rule.

Where can I find more information about the Hospital Readmissions Reduction Program?

You can find more details on our Hospital Readmissions Reduction Program page.

# data[].attributes.attachment_link.description
Hospital Readmissions Reduction Program (HRRP) What is the Hospital Readmissions Reduction Program? HRRP is a Medicare value-based purchasing program that lowers payments to Inpatient Prospective Payment System (IPPS) hospitals with excess readmissions. Section 3025 of the Affordable Care Act required the Secretary of the Department of Health and Human Services to establish the HRRP starting October 1, 2012 (i.e., Federal Fiscal Year [FY] 2013).

# data[].attributes.body
Website Three

# data[].attributes.attachment_link.provider_name
Allscripts | Changing what's possible in healthcare

# data[].attributes.attachment_link.readable_text
Financial Management and Operational

Optimize your collections, streamline operations, boost your revenue cycle and improve performance across your organization, with our practice management, clearinghouse, revenue cycle management and performance management solutions .

# data[].attributes.attachment_link.title
Solutions | Allscripts | Changing what's possible in healthcare

# data[].attributes.attachment_link.description
Optimize your collections, streamline operations, boost your revenue cycle and improve performance across your organization, with our practice management, clearinghouse, revenue cycle management and performance management solutions .

# data[].attributes.body
Closing the Referral Loop: an Analysis of Primary Care Referrals to Specialist in a Large Health System

# data[].attributes.body
Shared Care: Using an Electronic Consult Form to Facilitate Primary Care Provider-Specialty Care Coordination

# data[].attributes.body
Prevention of Delayed Referrals Through the Champlain BASE eConsult Service

# data[].attributes.body
Electronic Referral Systems in Health Care: A Scoping Review

# data[].attributes.body
Comparing Ageing in Place to Home Health Care: Impact of Nurse Care Coordination on Utilization and Costs