It is well established that uninsured and publicly insured Californians, who generally rely on community clinics and other safety-net providers for their medical care, face significant challenges in gaining timely access to specialty care services. The many factors affecting access include low or no reimbursement, a limited supply of specialists in some geographic areas, and poor communication between primary care providers and specialists. In addition to policy-level efforts to address provider reimbursement and supply, there are significant opportunities to optimize the use of existing specialty resources in the safety net through innovative use of provider resources, technology, and new care models. This could include expanded primary care provider training to manage common presentations, the introduction of new specialty consultation methods such as telemedicine or electronic consultation, or greater use of physician extenders for common procedures or screenings, among other measures. In order to identify strategies that appropriately address specialty care needs, it is essential to clearly understand the typical clinical scenarios that generate referrals within individual specialties and the specific services or tasks that are requested. In June 2008, the California HealthCare Foundation commissioned a series of interviews with experienced primary care providers at community and public hospital clinics to address these questions and to gain greater insight into typical referral processes, identify specific challenges, and gather ideas about how to address access problems. The primary purpose of this project was to clearly describe the most common clinical presentations for safety-net clinics within difficult-to-access specialty services and discuss strategies that could lead to more optimal use of specialty resources. A secondary purpose was to provide a framework for thinking about optimizing specialty resources and initiating discussion among the provider community for developing, testing, and disseminating effective strategies.
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