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Steven Kardos, MD, is one of the urologists involved in creating an integrated care model (ICM) for patients with abnormal PSA levels. Led by Yale New Haven Health’s Office of Strategy Management and Clinical Redesign, the ICM project established best care practices for patients with abnormal PSA results, abnormal mammogram results and pediatric asthma, and those receiving screening colonoscopies.

Initiative creates integrated care models to optimize care and patient experience

Imagine that two patients visit urologists who are part of the same health system. Both patients are close in age, with comparable medical histories.

Testing reveals similar, abnormal levels of prostate-specific antigen (PSA), which can sometimes indicate prostate cancer. One patient’s physician recommends a biopsy; the other patient is told to wait two years and return for a recheck, since prostate cancer often progresses slowly.

This type of scenario has occurred nationally and at Yale New Haven Health medical centers. Why would physicians make such different recommendations for follow-up care?

That question prompted Rogerio Lilenbaum, MD, chief medical integration officer of Ambulatory Services for Yale New Haven Health, Northeast Medical Group and Yale Medicine, to engage with Clinical Redesign, in Yale New Haven Health’s Office of Strategy Management.

They led four Integrated Care Model (ICM) initiatives that aimed to establish consistent care pathways – patient care which is directed by evidence-based clinical practice – for four types of patients. These are: children diagnosed with asthma, patients with abnormal PSA levels, patients with abnormal mammograms and those scheduled for screening colonoscopies.

By Feb. 28, these ICMs are scheduled to be implemented in at least one ambulatory practice at four Yale New Haven sites. The ICMs will be in practices managed by Yale Medicine, Northeast Medical Group and Community Medical Group.

The ICM project brought together – for the first time – physicians from these practices. Clinical Redesign teams for each of the four areas also included other clinicians and representatives from Care Coordination, Clinical Integration, Information Technology Services, Patient Experience, Pharmacy and operations.

“Members of these interdisciplinary teams reviewed extensive research and contributed their own experience and expertise to jointly develop these care pathways,” Dr. Lilenbaum said. “These are true best practices that will improve the quality, safety and efficiency of care, and translate into a superior patient experience.”

For example, under the ICMs, patients whose mammograms show possible or probable cancer will have biopsies within seven days (in 2017, these patients waited an average of 17 days). Patients who receive their first abnormal PSA results will be scheduled for follow up with a specialist within 14 to 28 days, vs. waiting months or longer. Pediatric patients in the asthma ICM will require fewer emergency department visits. The new ICM care pathways will be embedded into Epic.

“The ICMs reduce variations in care among different providers and sites,” said Stephanie Amport, Office of Strategy Management. “This helps ensure we’re providing the right care to the right patient at the right time.”