eConsults Increase Safety-Net Patient Capacity by Improving Access to Specialty Care

At a time when community health centers (CHCs) are challenged to integrate care across the continuum and deliver value, eConsult platforms are a means of digitally enhancing safety-net capacity by increasing access to specialist care while retaining patients in primary care settings when it is appropriate and more cost-effective to do so.

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Safety-Net Services

Over 24 million Americans rely on CHCs, including Federally Qualified Health Centers (FQHCs), as their initial point of access to healthcare services. The health services being offered to these “safety-net patients” must evolve to meet the changing demographics and health needs of this complex population. CHCs must evolve their service-delivery models from just identifying and treating patients with acute conditions to being able to manage this population with a high prevalence of chronic and complex conditions, across a continuum of care. Up to 25 percent of CHC visits generate referrals to outside providers, and these sites could benefit from improved solutions to deliver closer integration between hospital and clinic-based components of care.

Coordinating Safety-Net Services

Delivering a high level of care coordination across numerous providers in varying settings is critical for safety-net clinics, which are mandated to provide primary care, preventive medical care and designated nonmedical services, including counseling, transportation and language services for their patients. New models of care such as the Primary Care Medical Home and new technologies like the electronic health record (EHR) are improving care management and reducing its fragmentation at individual sites, but outcomes vary from clinic to clinic.

The Neighborhood Home

The Neighborhood Home is a framework for structured, reciprocal relationships that integrate specialty care and extend the principles of the medical home to all practicing physicians. This definition conceptually outlines how to transform healthcare delivery in ways that mirror the approach that other industries are taking to service delivery in the 21^st Century.

Digital networks are becoming a crucial tool to help support goals of the Neighborhood Home model. The ideal model of digital connectivity would increase efficiency and extend care capabilities at the primary care site by connecting providers with specialists and hospitals to rapidly and effectively coordinate care. In order for this model to succeed at scale, there are six major areas that must be addressed:

• Interoperability
• Logistics
• Organizational change
• Legal and regulatory considerations
• Business model and associated reimbursement
• Privacy and cybersecurity

Networked virtual care modalities that could contribute to the Neighborhood Home concept include (in no order of viability or potential benefit):

• EHRs
• Store-and-forward telehealth
• Video telehealth
• eConsults
• Secure messaging

These telehealth modalities are in use throughout the U.S., in both private and public healthcare settings, and are supported at varying levels by both payers and providers. However, despite routine use of these various tools, few have succeeded at scale in delivering on the promise of the Neighborhood Home. This is a result of the inability for these solutions to meet the conditions required for successful widespread adoption and scale outlined above, with one exception: eConsults.

A Systems Approach to Creating National, Regional and Local eConsult Networks to Deliver Safety-Net Care

This table outlines how current functionalities associated with eConsult platforms meet the pre-conditions to scale to large networks of care.

Pre-Condition

Met/Not Met

Notes

Interoperability

X

Interfaces with EHRs across primary and secondary care

Logistics

X

Robust clinical models with templates ready to scale. Comprehensive training and quality assurance. Data systems for use and outcomes.

Organizational Change

X

Acceptance by clinicians and patients with workflow integration.

Legal and Regulatory Considerations

X

Models can extend across state lines and have governance arrangements between primary and secondary care safety-net delivery sites.

Business Model and Associated Reimbursement;

X

Existing fee scales in place. CMS plans to issue proposed rule change for virtual consultation reimbursement in 2019.

Privacy and Cybersecurity

X

HIPPA-compliant platforms fit within EHR operating arrangements.

Business Case for System-Level Implementation of eConsult Platforms Across CHCs

• Creating means for safety-net hospitals and CHCs to coordinate their independent activities, without altering their governance structures
• Evolving the focus of care delivery — from access to specialty visits to access to specialty expertise
• Building capacity for necessary in-person specialist visits by replacing referrals for 73 percent of routine clinical issues with PCP-delivered treatment, supported by specialist eConsults
• Enabling enhanced teamwork and care coordination activities that are Medicare reimbursable
• Improving population health for opioid users, substance abuse and patients with depression by supporting primary care to manage these patients through virtual collaboration with mental health specialists
• Integrating virtual peer collaboration with video conferencing capabilities
• Maintaining patient care in the primary care setting when appropriate and cost-effective

Adam Darkins is CSO of AristaMD.

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