Project Option 1.9.2 - Expanding access to surgical services to a Hispanic population
Unique Project ID: 84597603.1.5
Performing Provider Name/TPI: TEXAS TECH HS CTR FAMILY MED /TPI: 84597603
Project Description:
Project Goals: The overall goal of this project is to address a critical shortage of surgical providers in our region and to address the geographic distribution of these providers to further improve access. We propose to accomplish this goal through three strategies: 1) to recruit surgeons and surgical physician extenders to the region; 2) To expand the number of sites at which the performing provider offers outpatient general surgery clinic services, and 3) to streamline the referral process from primary care providers to the surgical program and back to primary care by creating and implementing an electronic referral system.
Baseline: Surgical care in Region 15 is in a state of crisis. A 2010 health needs assessment, sponsored by the Paso del Norte Foundation and which serves as primary guidance in forming the Region 15 Regional Health Plan, documented that the area is underserved in 18 of the 24 assessed specialties, and surgery was the second greatest numerical need[i]. There is a need for approximately 50 surgeons in our RHP and more than 95 when including our traditional referral areas including southeastern New Mexico and Juarez.
The situation at the Paul L. Foster School of Medicine mirrors this regional shortage. The average time to 3rd new patient appointment for the six surgeons that provide general surgery services is 44 days.
For various process reasons and after a preliminary review of our appointment structure in the Department of Surgery, we are confident this is an underestimate of the true time to 3rd appointment. Part of our DY2 project will be to revise our appointment templates to allow more accurate measurement of this metric. We provide services in a single central clinical location, the Alberta campus, and our referral mechanism is a traditional combination of paper, fax and phone call. We propose to begin to address this need through the hiring of additional general surgeon and surgery physician extender FTE’s over the period DY2-5.
For purposes of baseline of the numbers of surgical providers, we consider the baseline to be the number of providers providing general surgery working at the beginning of DY1. For purposes of numbers of unique patients, we will consider the baseline to be an annualized rate based on the last 4-6 months of DY2. It is necessary for us to complete the template redesign process to be sure we accurately count unique patients as general surgery patients.
Challenges: We are proposing to recruit a large number of surgical providers to a region which is highly underserved to care for a low income population. Compensation in our organization does not match that of the private community. The association with a medical school and a surgical residency will mitigate this to some extent.
5 year expected outcome for providers and patients: The performing provider expects to see improvements in access as measured by the time to 3rd new patient appointment to see a surgeon; In addition we will provide outpatient surgery clinic services in at least one additional location to make pre-operative consultation and post-operative care more convenient, and provide evening hours. We will reduce the time to 3rd new appointment for general surgery referrals to 25 days or less.
Rationale: The status of surgical services is particularly acute at the Paul L. Foster School of Medicine. At the present time, the six surgeons who provide some general surgery services, each staff a single half-day clinic every week. The remainder of their clinical time is spent covering hospital inpatient areas, and staffing the region’s only level 1 trauma center. General surgery consultations in the clinic are intermixed with hospital post-operative visits and referrals from emergency departments. The result is that less urgent general surgical referrals are frequently bumped for urgent referrals and those non acute conditions cannot be managed until such time as they become urgent, frequently following presentation to the emergency department.
This situation is exacerbated by a critical shortage of primary care providers in the Region meaning that many patients are not able to exhaust non operative options prior to arriving at a point that operative care is indicated. There is very limited capacity to refer a post-surgical patient for long term care of a chronic condition which may have precipitated the need for surgery. We propose to address this aspect of the problem through a separate project, in which we intend to establish the Kenworthy Family Medicine Clinic as a Primary Care Medical Home. In the face of a geographically distributed provider base, electronic means of communication are critical to achieving efficiencies in the referral process and return to the primary care provider. As part of the infrastructure development for this project, we will investigate, deploy, and utilize an electronic referral system between primary care providers and surgical services within the enterprise. Sharing of a common EMR across our enterprise assures that all clinical information is centralized and available immediately to any provider.
Overall, the existing state of surgical services at PLFSOM represents a state of perpetual crisis, with limited ability to respond to anything but the most urgent of needs. Since surgical services are so scarce and the demand is so great, each surgeon reviews his or her own schedule essentially daily, reviewing consults to try and identify the most urgent. Less urgent patients are routinely bumped for those that are more urgent. This is highly inefficient use of provider and staff time, and disenfranchises many patients yet it is necessary to ensure the most urgent patients are seen. Routine indicated surgical procedures may be deferred for up to 6 months based on surgical availability. Surgical clinic volumes are enormous, typically averaging 35+ patients/ half day.
Geographically, the population of our region is divided into three distinct areas, separated by the FranklinMountains which split El Paso into the west, central and east areas. Our current clinic location is in the central region, resulting in long drives and difficult access conditions for many patients, particularly for those who depend on public transportation. By establishing at least one additional, geographically distinct, outpatient clinic location, we will be able to provide pre- and post-operative consultation, evaluation, and post-operative care, in a location more readily accessible for many patients. This outpatient clinic is not intended to be an ambulatory surgery clinic.
We propose to address the access and capacity issues through the recruitment of six surgical providers over DY2-5. We anticipate adding four FTE surgeons and two surgery focused physician extenders to the care management team. These providers can, in cooperation with surgeons, provide a full spectrum of pre- and post- operative care including pre-operative histories and physicals as well as post-operative wound checks and dressing changes. By providing a continuum of care providers in a single location, united by a common electronic health care record, we can match patient needs to provider expertise and training, freeing surgeons for the most critical and complex decision making and procedural tasks, thereby increasing throughput.
Project Option 1.9.2 was chosen because it reflects the primary elements of our proposal: more providers in geographically distinct area(s) with extended hours, linked by an e-referral system back to our primary care providers.
We have chosen metrics that reflect 1) the numbers of new surgical providers we recruit to the performing providers faculty 2) the resultant increase in numbers of unique general surgery patients seen by performing provider, 3) increasing access by establishing a second clinical site to provide general surgery services and making it more convenient, especially for those who cannot readily take off from work for a doctor’s appointment by establishing night hours, and 4) the planning, deployment and utilization of an e-referral system which will increase the efficiency of the referral process and optimize utilization of scarce resources.
Taken together, these metrics will provide a comprehensive view of the improvements in access we have achieved by this project and document the increased efficiencies of an electronic referral system.
An electronic referral system is a component of another our proposed projects. In both situations, we anticipate a significant amount of customization work by specialty to assure that all relevant information is provided to determine the urgency of the referral, and minimize the requirements for multiple consultations due to lack of complete patient information and studies.
As the single largest multi-specialty provider group in the Region, and the largest provider of primary and specialty care within the Region, PLFSOM provides nearly 250,000 outpatient visits a year. Unfunded and low income patients rely heavily on our services. In the outpatient setting, approximately 35% of our patient visits have no third party funding and an additional 35% have Medicaid or Medicaid like coverage. Depending on the clinical department in question, between 75% and 85% of our population self identifies their ethnicity as Hispanic. The expansion of surgical resources and additional service locations by the Performing Provider represents the best opportunity to integrate care management, primary care, and necessary surgical consultative services through a single provider referral network and the use of a common EMR system to meet well documented unmet needs of our unfunded and Medicaid patient base.
We chose Project Option 1.9.2 because it reflected the most practical way to achieve increased access in the near term.
Project Components: We will meet all required project components.
- Increase service availability with extended hours: As part of our second clinical site, we will offer evening hours to better meet the needs of patients, particularly those with a limited ability to take off from work to see a physician.
- Increase number of specialty clinic locations: A core part of this project is to establish a 2nd, geographically distinct site to provide outpatient consultative services.
- Implement transparent, standardized referrals across the system: We will implement an electronic referral system which will track referral source, data and time of referral and allow for standardized reporting of access times.
- We will develop a electronic referral request customized to general surgery and train providers and referral sources on the use of this form.. We provide monthly feedback to high volume referral sources on the access times, and completeness and accuracy of these forms and we will review its functionality on a regular basis in our EMR steering committee.
Unique Community Need:
CN.2 Specialty Care
How the project represents a new initiative or significantly enhances an existing delivery system reform initiative. This project builds upon an existing base of general surgery capacity within the Performing Provider which is inadequate to meet the needs of our indigent and unfunded population. The components of an additional clinical site, evening hours, and e-referral are entirely new for the organization.
Related Category 3 outcome measures:
OD-6 Patient Satisfaction: IT-6.1 Percent improvement over baseline of patient satisfaction scores.
We propose to utilize the RAND VSQ-9 Patient Satisfaction Survey (attachment A) as a stand-alone measure of patient satisfaction. The Performing Provider has experience with Press Ganey survey instruments within the past decade. Overall response rates were very low, in the single digit range. We believe there are a series of structural issues that drove this poor response. Our population is heavily enriched in low income patients. Challenges related to incorrect and changing addresses, and the comprehension level required completing more complex survey tools such as CG-CAHPS limits response rates. Also, our Region shares an international border with Juarez, Mexico. We believe that many patients in our population choose not to respond to such a survey, not fully understanding the importance of their response, and not recognizing that their participation has no impact on their residence in the region. For these reasons we believe a short survey, administered at the point of service, represents the best option to obtain meaningful data across a wide patient representation. The RAND survey has been validated for accuracy and validity [ii] and contains questions which focus on high level patient satisfaction domains and will provide actionable information to improve our regional care delivery. We acknowledge that this survey will not provide results which are directly comparable to CG-CAHPS on a national level. They will, however, provide valid, actionable data on which to assess the impact of this project in Region 15.
Rationale for selecting the outcome measures: Patient satisfaction is a high level indicator of the overall success of our efforts to improve access to surgical services.
Relationship to other projects and measures: This project links to Project Area 84597603.2.1 which is the establishment of the Kenworthy Family Medicine clinic as a primary care medical home. It will be important that many of these patients come from and return to an identified primary care provider to ensure optimal non-surgical management of any associated chronic conditions.
Relationship to other Providers Projects in the RHP: A number of providers are proposing projects to expand access to primary care. We anticipate that this expansion will result in increased demand for surgical services. As such, these projects and ours complement one another for the Region.
Plan for Learning Collaborative: We will participate in RHP sponsored semi-annual learning collaboratives.
Valuation:The Performing Provider considered a series of factors in establishing a valuation for each project. These included the amount of human resources required to meet the milestones of the project, through new hires as well as the assignment of existing support personnel such as Information Technology, EMR and administrative support. We considered what non personnel resources would be required, such as equipment specialized for a certain specialty, and what, if any, additional space would be required to house the initiative. We considered timing issues related to when we had to add resources compared to when a corresponding milestone could be achieved. We also considered the amounts of potential professional fee revenues the project may generate, and offset these against resource demands.
We made a risk assessment for each project, considering the complexity, the scope, the extent to which any single point failure in the milestones would jeopardize downstream success, the degree of inter-dependence on other projects within the waiver program, as well as institutional initiatives outside the waiver, and the amount of time required to manage the project. We made an assessment of potential general community benefit.
Finally, we considered organizational priorities, and to what extent the Performing Provider was able to justify partial support of these efforts as meeting existing institutional requirements or objectives.
Attachment A
[i]Paso del Norte Blue Ribbon Committee for a Strategic Health Framework. Phase One: Needs Assessment Report. March 24, 2011. On File.
[ii] Accessed September 29, 2012.