SFCCC improving coordination between Primary Care and SFGH Specialty Care

SFCCC improving coordination between Primary Care and SFGH Specialty Care

As part of the Kaiser funded Specialty Care Initiative, SFCCC, along with leaders from San Francisco General Hospital and Trauma Center (SFGH) and SFDPH Community Oriented Primary Care (COPC), have worked for the past three years with primary care providers and specialty providers to improve access to specialty care by enhancing the referral process, referral guidelines, communication, and provider and patient education across San Francisco’s healthcare safety net. Our work thus far has focused on developing processes, technical infrastructure, and communication tools before a patient’s specialty clinic visit.

Having been chosen as 1 of a handful of coalitions across the state to be refunded by Kaiser for an additional In the next two years, the San Francisco coalition is now working on projects that focus on improving care coordination after a specialty clinic visit and to develop quality indicators to improve the quality of communication between referring providers and specialist reviewers.  Our goals are as follows:

2011-2012 Goals: Address barriers to Specialty-PriCare communication after a specialty consultation
1.         Clinical Notes
a.         Ensure the availability of clinical notes in the LCR (aka Lifetime Clinical Record – SFGH’s Electronic Health Record)
b.         Reach consensus on the essential communication components of a high quality Specialty Care note
2.         Develop formal discharge criteria for a few clinical entities with a focus on communication and patient safety
3.         Serve as advisors for the eReferral ratings program
4.         Discuss panel management in specialties and ownership of clinical entities in specialties or primary care

Discussions with primary care providers have helped identify three areas of specialty care to prioritize for developing post-visit guidelines pertinent to the transition from specialty to primary care:
 
1.             Endocrinology: already involved in the Specialty Care Initiative, and is a high volume specialty at SFGH, was recommended by PCPs and by the Division Chief to improve co-management of thyroid and other conditions.
2.             Gastroenterology: also already involved in the Specialty Care Initiative and the highest volume of all the SFGH specialty clinics
3.             Orthopaedic Surgery: SFGH’s busiest surgical clinic, with an average of 293 eReferrals per month in 2010.
 
Working on these 4 goals with these 3 areas of Specialty Care is part of our continued commitment to improve access to and the quality of specialty care in the safety net by enhancing the patient-centered medical neighborhood model within San Francisco’s safety net.