Featured Practice: Cookeville, TN Medical Neighborhood — Focus on High Value Referrals

This week we are featuring an exciting community wide medical neighborhood collaboration — 9 practices that have been diligently working the past year to increase high value referrals for their shared patients. Taking time to build relationships and lay the groundwork for efficient referrals contributes to many of our TCPI goals, including reduced ED visits and unplanned hospitalizations, providing person-centered, whole-person care, and enhancing continuity. 

There is nothing worse, for both patients and providers, than receiving a referral but wasting time coming to the appointment without any documentation or understanding about what the patient needs. Closing referrals gaps takes coordination and effort both within and between participating practices, but the outcomes will be worth it.  

Many of our TCPI practices in Cookeville, Tennessee, are taking steps to do this. Upper Cumberland Family Physicians, OB/GYN Associates, Cookeville Gynecology, and Cookeville Medical Clinic, along with a handful of practices outside TCPI, convened in early 2019 to identify underlying barriers that prevent care coordination. Many issues surfaced that could be addressed through focused quality and process improvement initiatives: incomplete record sharing between practices, repeat testing, limited communications about scheduling, incomplete referral letters, and the need to better inform patients about referral processes, among others. 

There was consensus on the greatest barriers: for specialists, not receiving patient records at the time of the appointment; for primary care providers, not receiving the referral letter back in a timely manner. 

The practices agreed the first step was for each individual practice to get their house in order — all resolved to create process maps, identify and analyze their referral gaps, and detail their referral policies and procedures. 

With the help of TCPI, a shared data collection tool was created and practices are now collecting baseline data on referral phone calls. Additionally, they’ve created a shared contact database for area referral coordinators and will reconvene soon to examine the data. You can read more about this Cookeville Medical Neighborhood and their efforts to close the referral loop here

High value care coordination won’t happen overnight– indeed, there are many steps: getting your house in order, establishing referral and consultation criteria to get what you need and ensure others get what they need– including, of course, patients. It requires tight data management and establishing care coordination agreements. For more information and tools to accelerate these QI initiatives, we recommend theAmerican College of Physicians’ High Value Care Coordination toolkit.        

The views expressed in this story are those of the authors and do not necessarily represent the official views of Upper Cumberland Family Physicians, OB/GYN Associates, Cookeville Gynecology, Cookeville Medical Clinic or the American College of Physicians. Additionally, this work was funded by the U.S. Department of Health and Human Services – Centers for Medicare and Medicaid Services’ Transforming Clinical Practice Initiative, under grant number 1CMS331549-03-00. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.


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