Taxonomy II Part I-B.3 (Subspecialty Referrals)

(26 May 2006 22:01)

NATIONAL PROJECT ON THE COMMUNITY BENEFITS

OF FAMILY MEDICINE RESIDENCY PROGRAMS

CUMULATIVE QUESTIONNAIRE RESPONSES

TAXONOMY II PART I-B.3

(Subspecialty Referrals)

*NPCB P2 II.2.6 (SD II.2.6 (new)) Are there specified members of your residency faculty and staff who have responsibility for coordinating referral to subspecialty services?  Yes __ No __ If yes, describe:

Yes:

Mercer                         (There is one full-time and one part referral clerk)

Klamath Falls               (We have a methodology that every referral has a special form that goes to the referral team, which has a list of questions about the circumstances of the referral)

Lehigh Valley                (A bilingual referral coordinator oversees all referrals, whether or not patient is insured)

Mercy Toledo              (All faculty and staff are involved)

Las Vegas                    (A staff member does referrals)

Springfield                    (3 referral coordinators)

Glasgow                       (We have two receptionists; one handles and keeps track of a majority of referrals and the accompanying paperwork)

Yes (Phase 2 Responses):

Sparrow                       (We have liaison faculty to deal with different disciplines)

Ventura                        (All do; we are a system)

Long Beach                  (We have two FTE staff members; our two OB faculty members do referrals for high-risk OB)

Crozer-Keystone          (We have an HMO coordinator for referrals of our managed care patients)

Jefferson                       (We have a referral coordinator)

McKeesport                 (Our staff coordinates referrals)

Oahu                            (We have a referral coordinator)

Shadyside                     (We have a staff member)

Johnstown                    (We have a staff nurse)

Altoona                        (We have a full-time medical assistant who does referrals all day long)

St Margaret                  (At our largest family medicine center, we have a full time FTE staff member for referrals; the RNs do it within their workload at the smaller health centers)

Fairfax                          (We have 1.5 FTE staff referral specialists)

No:

Dayton Community

Miami Valley

Decatur

Natividad

Kaiser LA

Tyler                            (“We all wing it”)

Fresno

Lexington                     (Responsibilities are diffused throughout the nursing staff)

OHSU Portland            (We have a referral center with 5-6 FTE who trouble-shoot, make appointments, obtain prior authorization or whatever is needed)

No (Phase 2 Responses):

Huntsville

U Penn

*NPCB P2 II.2.7 (SD II.2.7 (new)) In your community, does your residency program encounter difficulty in finding referral specialists who will not see your Medicaid patients? Yes __ No __ If yes, explain:

Yes:

Dayton Community       (Orthopaedic surgeons, neurosurgeons, neurologists and endocrinologists – both adult and pediatric in each of these categories)

Miami Valley                (Particularly in neurology; some difficulties in orthopaedics and neurosurgery)

Mercer                         (Particularly psychiatry, neurology and dermatology)

Lehigh Valley                (Some apecialties are not a problem, if there is a contract with that department; but dermatology, neurology, neurosurgery and endocrinology are very big problems)

Klamath Falls               (We get a lot of California Medicaid patients, whose reimbursement for out of state services is very poor; therefore, surgeons and OB/GYNs will not see California Medicaid patients unless they are admitted to the hospital)

Lehigh Valley                (The managed Medicaid patients have referral specialists that are inaccessible geographically to patients; those in the network have a very limited number of spots for Medicaid, sometimes resulting in a six to eight month wait)

Mercy Toledo              (Dermatology, gastroenterology, orthopaedics and gynecology)

Tyler                            (A lot of specialists will not see Medicaid patients)

Fresno                          (Long waits for dermatology, neurology, GI, orthopaedics, surgery)

Springfield                    (We have had to develop rapport with specialists for them to see patients; patients themselves cannot get access to specialists)

OHSU Portland            (Many doctors will have a clinic to see Medicaid patients once or twice a month; many are closed to Medicaid)

Yes (Phase 2 Responses):

Sparrow                       (Absolutely)

Long Beach                  (Straight Medicaid, which is 15% of our patient mix, is a problem, especially to find referral neurologists, orthopaedists or dermatologists.  Those patients often have to go to Harbor/UCLA Medical Center, although some can be admitted and treated as inpatients)

U Penn                         (Dermatologists)

Crozer-Keystone          (Patients have to leave Delaware County, usually having to go to Philadelphia County to obtain services from subspecialists in neurology, dermatology and rheumatology)

Jefferson                       (Orthopaedists are very difficult)

McKeesport                 (Quite a few do not accept Medicaid; we refer patients to whomever will take them.  Children are not a problem, since we have a Children’s Hospital that will see Medicaid patients)

Oahu                            (The lack of participation in the Mililani area of specialists in ENT and dermatology, GI, neurology, and psychiatry in the Adult Medicaid program, means that patients have to travel into Honolulu for referrals and have long wait times)

Johnstown                    (Orthopaedists, dermatologists and dentists)

Altoona                        (This varies with the specialists census – rheumatology, urology, GYN care, neurology, ENT, dentists)

St Margaret                  (There are problems with dermatology, which usually has a nine month waiting period for Medicaid referrals)

Fairfax                          (Gynecology, rheumatology, endocrinology, most of the surgical subspecialties, neurology)

No:

Decatur                        (all specialists take their fair share; very seldom is there any problem.  However, rheumatology limits referrals to one or two a day)

Kaiser LA

Las Vegas

Glasgow

Lexington

No (Phase 2 Responses):

Huntsville

Ventura

Shadyside                     (Medicaid dentists are hard to find)

*NPCB P2 II.2.8 (SD II.2.8 (new)) In your community, does the residency program encounter difficulty in finding referral specialists for uninsured, underinsured or indigent patients? Yes __ No __ If yes, explain:

Yes:

Dayton Community       (There is difficulty with every referral specialist for patients in these categories)

Miami Valley                (Neurology, orthopaedics, neurosurgery; there is a shortage of neurologists in Dayton.  However, the patient care coordinator can find specialty services in Cincinnati on a next day basis)

Mercer                         (Most of the sub-specialists require cash up front.  It is very hard to get into the indigent system)

Natividad                     (See response to SD II.2.7)

Klamath Falls               (Same reasons as in SD II.2.7, but not as much a problem)

Lehigh Valley                (Pretty much not possible, unless the person is admitted to the hospital; not necessarily true for referrals of cancer patients to hematology and oncology)

Mercy Toledo              (Same response as to SD II.2.7, except the problem is even worse for the uninsured)

Tyler                            (Same response as to SD II 2.7)

Las Vegas

Fresno                          (Same response as to SD II 2.7)

Springfield                    (Same response as to SD II 2.7)

Glasgow                       (It varies by specialist, with GYN the greatest problem)

OHSU Portland            (Same response as to SD 2.7; some require $250/visit)

Yes (Phase 2 Responses):

Sparrow                       (Absolutely)

Long Beach                  (because most of our medically indigent patients are at the Westside CHC, which has a referral relationship with Harbor/UCLA Medical Center, it is actually easier to obtain referrals for our indigent patients than our Medicaid patients at Long Beach Memorial Medical Center)

U Penn                         (Dermatology)

Crozer-Keystone          (Each specialist takes a percentage)

Jefferson

McKeesport                 (This is a big and growing problem here, even if we do not see that many here; we want to open a free clinic)

Oahu                            (No referral specialists will see the medically indigent)

Shadyside                     (Referral specialists will help out; however, as billing services are centralized, it is sometimes harder to get their help, but we find ways to get around this)

Johnstown                    (There is a free clinic in the hospital with services available once a week)

Altoona                        (As with Medicaid, this varies with the specialists census – rheumatology, urology, GYN care, neurology, ENT, dentists; there is a free clinic staffed by volunteer physicians with very limited services, but the wait time to get in is over three months)

St Margaret                  (Referral specialists want to see the money up front.  This is particularly acute since St Francis Hospital, the major disproportionate share hospital in the community, closed its doors)

Fairfax                          (The same list of specialties as for Medicaid — gynecology, rheumatology, endocrinology, most of the surgical subspecialties, neurology)

No:

Decatur                        (all specialists take their fair share; very seldom is there any problem.  However, rheumatology limits referrals to one or two a day)

Kaiser LA

Lexington

No (Phase 2 Responses):

Huntsville                      (have no direct knowledge of such)

Ventura

*NPCB P2 (SD II.2.9a (new)) If the answer to either NPCB P2 II.2.7 or NPCB P2 II.2.8 is yes, do you attempt to mitigate the problem of finding referral specialists for a given specialty by the following: Attempting to manage patients to the highest degree of competence of the residency program’s faculty and residents? Yes __ No __

Yes:

Dayton Community

Miami Valley

Mercer

Natividad

Klamath Falls

Lehigh Valley

Mercy Toledo

Tyler

Las Vegas

Fresno

Springfield

Glasgow

OHSU Portland

Yes (Phase 2 Responses):

Sparrow

Huntsville

Long Beach

U Penn

Crozer-Keystone

Jefferson

McKeesport

Shadyside

Johnstown

Altoona

St Margaret

Fairfax                                      (and perhaps beyond, but with the participation of subspecialists in the care process)

Not applicable (Phase 2 Responses):

Ventura

*SD II.2.9b (new) If the answer to either SD II.2.7 or SD II.2.8 is yes, do you attempt to mitigate the problem of finding referral specialists for a given specialty by the following: Developing specialty clinics within the residency program in which referral specialists are invited to assist? Yes __ No __

Yes:

Natividad                     (To some extent with dermatologist and with a pulmonary specialist)

Klamath Falls

Lehigh Valley                (We do it with psychiatry.  Additionally, the internal medicine residency clinic has specialty medicine clinics that we use)

Mercy Toledo              (A dermatology clinic is staffed by a family medicine faculty member with specialty competence; the hospital provides specialty clinics in which residency patients can be seen)

Fresno                          (For example, clinics for hepatitis C and diabetes)

OHSU Portland

Yes (Phase 2 Responses):

Long Beach                  (We try to do this from time to time, not always with success)

Crozer-Keystone          (We offer a dermatology clinic)

McKeesport                 (To an extent; we have surgical, gynecological and allergy)

Johnstown                    (We have a pediatric cardiac clinic, in which a pediatric cardiologist participates; we previously had a dermatology clinic, but cannot find a dermatologist to participate now)

St Margaret

Fairfax                          (The hospital sponsors a few clinics in general surgery, OB, GYN, pediatrics which we access, but availability is very limited)

No:

Dayton Community    (We’ve talked about this, but we have not developed the concept)

Miami Valley

Mercer

Tyler

Las Vegas

Springfield

Glasgow

No (Phase 2 Responses):

Sparrow

Huntsville

U Penn

Jefferson

Oahu

Shadyside

Altoona

Not Applicable (Phase 2 Responses):

Ventura

*SD II.2.9c (new) If the answer to either SD II.2.7 or SD II.2.8 is yes, do you attempt to mitigate the problem of finding referral specialists for a given specialty by the following: Other mechanisms for securing referral specialty services? Yes __ No __ Describe:

Yes:

Dayton Community       (In Dayton, we have the “Reach Out” program to get specialists to take patients)

Miami Valley                (We send them out of area to Cincinnati)

Mercer                         (We work within a responsive public system, so, using public hospital resources, we do cope)

Las Vegas                    (We hospitalize them so that they can obtain access to specialists; this is not possible here an the outpatient setting)

Springfield                    (Some of our patients may be transferred to Capital Community, an FQHC that has access to some community physician specialists)

Glasgow                       (Telemedicine)

Yes (Phase 2 Responses):

Sparrow                       (Begging; we are trying to set up a multidisciplinary group practice in the community, where specialists would agree to take care of anyone referred to them, with a community support system to help finance that)

Huntsville                      (Referral to University of Alabama medical school campus in Birmingham)

Long Beach                  (Our Westside CHC relationship with Harbor/UCLA Medical Center is the better way to do this)

Crozer-Keystone          (We employ specialists in our health system, who have to take the Medicaid insured covered by our system)

Jefferson                       (We have relationships with city health centers that have specialists connected with them)

McKeesport                 (We involve specialists in teaching residents, who see the patients as part of the education process; this achieves the support of the specialists)

Shadyside                     (We have relationships with the dental school and with UPMC’s program that provides a level charity care for those who do not qualify for public assistance)

Johnstown                    (Begging)

Altoona                        (We personally call colleagues and beg)

Fairfax

No:

Lehigh Valley

Mercy Toledo

Fresno

OSHU Portland            (Starting in July 2005, we will have additional onsite clinics for dermatology, ENT, urology and orthopaedics.  Most of these will be in an FQHC setting, so specialists can refer their own Medicaid patients)

No (Phase 2 Responses):

U Penn

Oahu

St Margaret

Other comments:

Natividad                     (Prayer)

Klamath Falls               (Invoking guilt in the specialists who refuse to cooperate)

Tyler                            (Prayer and harassment)

Not applicable (Phase 2 Responses):

Ventura

*NPCB P2 II.2.10 (SD II.2.10 (SD II.5.3)) In what ways do the specialty services that your family medicine center provides, including those provided in special clinics, promote access to these services from disenfranchised or vulnerable populations?

Modesto                      (These are the only specialty services available to these disenfranchised populations.  No other specialty services exist in Stanislaus County to service them.  We also provide those services to bordering counties (Merced, Tuolumne, Calaveras and Mariposa))

Saints                           (We provide first tier continuity, and promote access to                                                 dermatologists where their services are needed)

Indiana U Methodist     (We have one-stop shopping in a convenient location; x-ray and lab are on-site, so are mental health services)

Whittier                        (A moderate percentage of our patients would not have access to these services at all.  The particularly vulnerable are unemployed women, such as housewives between ages 40-65 with no children.  The best they can get are very limited public health services and cancer screening.  Our women’s health clinic has been very beneficial.  Also adolescents and young adults with dermatologic problems are unlikely to get services elsewhere)

Pomona                        (We have chosen the specialty clinics in the areas (sports medicine, gynecology, colposcopy and orthopedics) where Medi-Cal does not pay well.  We cover disenfranchised populations, such as cerebral palsy patients needing PAP smears, because others do not want to do it.  Most of our adult medicine people are on Medicare which pays well, so we do not do specialty clinics to serve that population)

Arrowhead                   (We have sent out mailers and brochures to target indigent populations, listing the services we provide from which they can benefit)

Loma Linda                  (In the sports medicine rotation we interact with students from low income high schools in the area.  Sac Norton clinic has 50% uninsured patients, a significant source of the medically indigent; Victoria School’s students are children whose families are mostly uninsured, many from families who do not speak either English or Spanish; the school clinic is the only place that their families have where they can drop in for care)

Stockton                      (We have a health care van that goes out; we coordinate with the local transit system; we operate two outlying clinics)

Louisville                      (Basically, we have an open door to the disenfranchised; in addition, outreach clinics, the GLO, Hope, and TAPS programs reach out to the isolated and disenfranchised; our WINGS program is an HIV/AIDS program that receives Title III and Title IV funding)

MCE Birmingham         (The specialty services at Cooper Green Hospital, the county hospital, may require a six to eight month wait; our colposcopy, dermatological procedures and OB care is provided without the need to refer to these specialty services.  We do home visits and nursing care.  We do two to three nights at the Empire Clinic in a Methodist Church annex in a volunteer free clinic basis.  Our residency’s participation in the Empire Clinic doubled the free clinic’s service capacity)

Glendale                       (Persons from vulnerable patients comment on how well they like the specialty services provided in their “medical home”; we provide services that they normally wouldn’t have access to; many specialists will not see Medicaid etc. in their offices, but will provide services at our clinics)

Dayton Community       (If we did not provide these services, the patients would end up in inappropriate ER use, or would fall through the cracks)

Miami Valley                (We have open appointments for patients.  We admit six patients a day to the hospital.  A lot of the admissions are people who have put off care.  We split admissions of unattached patients with Internal Medicine, with them doing about ten patients and us about six)

Decatur                        (Most of the time, patients are taken care of; if the residency program was not here, that might not be the case)

Mercer                         (Because we refer our paying patients to specialists, when we also refer non-paying patients to them, they feel obliged, they feel obliged to see them; being part of the community’s medical school, teaching relationships with specialists help also)

Natividad                     (If the residency disappeared, over a few months, patients would be absorbed slowly into other public sector practices – practices that are not set up to handle more patients, so they would be slow in ramping up; the ability of other public sector practices to absorb the patients would be compromised: some specialized services would be lost)

Klamath Falls               (We break down barriers to getting the services, because once they become our patients, we can arrange referrals through personal contacts)

Lehigh Valley                (They can get into our clinics regardless of insurance status, so they can get the range of services; plus we have community linkages to assist the process)

Mercy Toledo              (After a visit to the emergency room, these patients would have nowhere else to go)

Kaiser LA                    (We do not turn away disenfranchised patients, even if they are “out of plan”; this increases access)

Tyler                            (Partly due to the hospital’s master plan, our clinics are becoming the referral center for the hospital’s indigent patients, whether they are new or established patients)

Las Vegas                    (We provide low cost community sports physicals and conduct a low risk OB clinic)

Fresno                          (They permit people to get these services; increases capacity and lower barriers)

Springfield                    (We are the only people who do colposcopies, obstetrics and ultrasound for Medicaid and the indigent; who provide their hospital care)

Glasgow                       (We are open and turn no one away on ability to pay; we are the patient’s advocate, caring for them here, assisting them in specialty referrals or referrals to the tertiary care facility)

Lexington                     (We see referrals from Salvation Army free clinics; we provide entry to primary care and specialty care from our local state prison contract for coordination of referral services)

OHSU Portland            (We get cost-based reimbursement at our Richmond FQHC site)

Phase 2 Responses:

Sparrow                       (Our Family Health Centers participate with any and all insurance that the Sparrow health system accepts (include Medicaid and Medicare); we have an all-Medicaid Community Services Clinic with 130 deliveries a year)

Huntsville                      (Director is too new to the program to be able to respond to this question)

Ventura                        (We as the county health system provides Ventura County’s safety net care; we coordinate referral to specialists if needed)

Long Beach                  (We provide the medical home for the chronic disease patients we follow, keeping them out of emergency rooms)

U Penn                         (In no way; default social services do exist)

Crozer-Keystone          (We take all comers on all insurances; although we receive most of our patients by word-of-mouth, ERs and other hospitals refer the disenfranchised to us)

Jefferson                       (We have open access appointments; most specialists that work with Thomas Jefferson University will provide services to any of our patients with insurance)

Long Beach                  (They come here; they feel comfortable with us for primary care; they can get referrals here, and specialists who provide care here get paid for it)

Oahu                            (We provide services that are accessible to such populations; we have a grant to cover medical services to the uninsured.  The major diagnostic labs have some discounts available for uninsured patients; we absorb the costs of EKGs for such populations.  We participate in state family grants for women of child- bearing age, and we put appropriate patients on this grant.  We do a lot of work with underserved populations in Micronesia, so have outreach programs that take place at much greater distances from our site than virtually all other residency programs.)

Shadyside                     (We have relationships with cerebral palsy services; we market ourselves at community events.  We keep in touch with medical assistance offices, particularly for pre-natal patients, runaway kids and persons at domestic violence shelters.)

Johnstown                    (We provide them with the care that they need)

Altoona                        (We manage clinical situations all other doctors in the community refer to a specialist or emergency department right away)

St Margaret                  (Our services substantially enhance the patient’s ability to be seen by referral specialists.  If we did not provide this service, most people would stay at home and say they could not afford it)

Fairfax                          (Our program’s impact on access for these populations is minimal)

Last Updated (26 May 2006 22:01)