Transforming Care: Lessons & Practical Tools from Beacon-Part 2 1 Greater Cincinnati Beacon Collaboration (GCBC) Beacon Goal • Provide funding to communities to strengthen health IT infrastructure and exchange capabilities • Achieve measurable improvements in health care quality, safety, efficiency, and population health Funding $13.75 million award to Cincinnati Cincinnati Project Demographic • • • • 200+ Adult PCPs 35,000 patients with Diabetes 300+ Pediatricians 30,000 patients with Pediatric Asthma • 21 Regional Hospitals Awarded September 1, 2010 30 month initiative The Transformation Equation MU (EHR+HIE) Patient Centered Care Point of Care Info Change Readiness Value Based Purchasing Transformed Care Beacon Health IT Interventions ED/Admission Alerts • Electronic Alerts triggered on registration at ED or hospitalization> Alert sent through HealthBridge> Primary Care Physician>Practice interventions • Real time notification of utilizations • ED alerts become a clinical decision support tool for care coordination • With the goal of reducing readmissions and subsequent ED visits by enhancing the delivery of better coordinated, preventive care in the primary care setting 4 HealthBridge ED Alert Architecture 1 2 Patient Hospital Visit The patient goes to the hospital and is admitted to the ED. 3 HealthBridge Integration HealthBridge receives the ADT and matches on the patient. If the patient is part of a subject group, an alert will be created from one of the four options (A, B, C, D). HealthBridge Hospital Practice receives preferred alert from HealthBridge and calls patient for a follow-up visit. Practice A B ADT Alert Aggregator ALERT C Admission D Clinical Messaging Practice Follow-up ED/Admission Technology Data Elements of ED/Admission Alert Data Element Last Name First Name Birth date Admit Date/Time HL7 Field PID.5.1 PID.5.2 PID.7.1 PV1.44 Facility Visit Type MSH.4 PV1.2 Description Patient’s last name Patient’s first name Date of birth for patient Date and time patient was admitted to hospital Hospital where patient was admitted Patient class type associated with the hospital visit E-Emergency Department visit Diagnosis Code Diagnosis Description/Chief Complaint MRN Phone Number DG1.3 DG1.4 I-Inpatient admission Diagnosis Code Diagnosis Description MSH.10 PID.13 Medical Record Number Patient’s home phone number ED/Admission Alert Patient Registry Population Health Management and Analytics Population health management Data aggregation from the EMR Customizable quality measures and alerts Patient outreach and engagement to address care gaps Provider benchmarking to track performance Care management and predictive risk modeling Quality reporting to payers and other stakeholders Improve Care-Improve Cost, Quality, and Population Health Disease Registry-Diabetes & Asthma-Population Management 9 CCHMC Pediatric Primary Care Practices • 3 Cincinnati based sites • Pediatric Primary Care Center (PPC) • Hopple Street Health Center (HPC) • Fairfield Primary Care (FPC) • • • • • 35,000 active patients across the 3 sites 5400 active asthma patients ages 2-17 Predominantly Medicaid insured or uninsured 10-15% of patients require an interpreter Resident/medical student training sites CCHMC Asthma Population Health Initiative • Asthma Improvement Collaborative began in 2007, now a CCHMC Strategic Improvement Priority • Goal: 20% reduction of asthma related admissions and ED visits for children ages 2-17 with Medicaid insurance in Hamilton County • Beacon: Implementing Health Information Technology tools to further impact care through integration with clinical care PHO Practice Network • 40 independent primary care practices • • • across 8 county primary service area caring for 200,000 children (predominantly commercially-insured). 14,000 children with asthma. Asthma initiative began in 2004. Pre-existing web-based asthma registry. PHO Practice Network Beacon-related QI goals: 1. 2. 3. 4. 5. Eighty percent (80%) of PHO asthma at-risk population is rated as “well controlled” by both the physician and the patient family. Eighty percent (80%)of eligible PHO asthma at-risk population receives seasonal influenza vaccines during the 2012/2013 flu season. Commercially insured PHO asthma admission rate will be sixty percent (60%) lower among participant group verses comparison group by December 2012. Commercially insured PHO asthma ED/UC visit rate will be forty-five percent (45%) lower among participant group versus comparison group by December 2012. Commercially insured PHO 30 day asthma readmission rate will be reduced by fifteen percent (15%) by December 2012 Beacon-related QI initiatives: • • Regional alerts + intervention bundle. Electronic asthma decision support tool. PHO Asthma Initiative CCHMC General and Community Pediatric Beacon Initiatives • • • • Expansion of Care Coordination WellCentive Registry Implementation Implementation of Regional Alerts Reliable use and spread of: • Asthma Specific Electronic History and Physical • Asthma Risk Assessment tool Care Coordination Model 4 Asthma Care Coordinators • 2 PPC, 1 HPC, 1 FPC 1 Care Coordinator Support Criteria for enrollment: • One of more admissions for asthma in last year • Two or more ED visits for asthma in the last year Bundle of Interventions Care Coordination Bundle Bundle of Interventions • • • • • • Risk Assessment (CARAT) Self Management Assessment Asthma Control Test MDI skills training Notification of Managed Care Leverage resources/reduce barriers based on risk assessment • i.e.-Referral to Home Health Pathway, Legal Aid, Managed Care- transportation, DME • Create a multi-user shared care plan • Pharmacy Delivery Service Criteria: Ages 2-17 Hamilton & Butler Co Medicaid PPC, HPC, FPC 1-3 admissions &/or 2-4 ED in preceding 12 months Intake Only: Excluded Subjective assessment that family will not engage in CC past initial intake. SM = Pre-contemplation Complex care, pt is managed elsewhere Enrollment Algorithm for Care Coordination Alert identifies HR patient eligible for CC intake Intake Intake Only: Low Risk No further action planned, CC available as needed in future. CARAT, SM, & ACT Referrals placed if needed (HHC, Asthma Center, ChildHeLP, SW, Pharmacy delivery, etc.) Intake Only: Inactive Enrollment attempted – at least 3 attempts within 3 months, with no additional utilization Insurance or transfer of care Alert notifies CC of “failure” & initiates f/u tracking process If pt has subsequent failure, complete intake as a “new” patient Graduation Pt reaches 365 failure-free Care Coordination days If pt has subsequent failure(s), complete “new” intake If future contact is made > 3 mos and pt has not had subsequent failure(s), can move to enrolled Active SM = Contemplation through Action Low Risk SM = Maintenance Continued contact every 6 months Pt reaches 270 days w/o failure (~ 9 months) Enrolled Subsequent contact & additional CC bundle items completed SM > Pre-contemplation Inactive Private Insurance for 1 yr Transfer of care Unable to contact within 6 consecutive months If future contact is made and family is engaged, re-enroll patient (If not engaged – complete new intake) Alert initiates potential for pt to be “reactivated” in CC Care Coordination Results • 335 children ever enrolled in Care Coordination • 114 children graduated from Care Coordination ( no admission or ED visit for asthma in last year) • 19 children with subsequent failure after graduation • Time between failures up from baseline of 173 days to current of 263 days ( max achieved 325 days) • Failure rate/1000 days enrolled decreased from baseline of 5.5 to 2.9. Registry Implementation WellCentive – Significant customization for pediatric asthma – Multiple tests using VOIP for flu vaccination for all 3 sites – Different scripts for phone call – Limited efficacy- timing/functionality issues – Use of gaps in care reports to do letter outreach for patients without ACT score – About 10-15% return rate, low yield, but low cost – Asthma Care Summary • Tested at HPC, spread to FPC • Just beginning implementation at PPC Asthma Care Summary Asthma Care Summary Regional Alerts for Gen Peds • Pre-existing alerts from CCHMC via ADT messages • Currently receive alerts via HealthBridge Clinical Messaging system for CCHMC and non-CCHMC alerts • Much more facile to use singular system • Matching on patient panel allows us to know it is our patient • Minimizes limits of alert being driven by chief complaint field; can compare with patient information in EPIC • Better capture of ED visits for asthma Goals for Regional Alerts • Ensure follow-up with the medical home after the ED visit or admission within an appropriate time frame • Identify additional children eligible for care coordination due to events outside CCHMC • 13% of asthma alerts were from non- CCHMC sources Please call/page for questions Contact Information: Desk: 636-7994 Hadley Sauers Pager: 736-4525 Where to find letters? GPC: LTR Fu Asthma Appt Unable to Reach GPC: LTR Asthma Three No Show Appt Fu PPC Inpatient/ED Healthbridge/CCHMC Alerts A patient is admitted for asthma Hadley creates a phone note in EPIC regarding the admission & routes it to the “PPC Triage pool” (if appt is not already made) *NOTE: If utilization is not asthma related, document & route note to the “PPC Asthma F/U Pool” *NOTE: PPC Triage RN calls pt to access recent utilization. If utilization is due to asthma then schedule f/u appt Regional Alert # is disconnected on attempt Nurse sends letter, document & leave note on “PPC Triage Pool” for remainder of (1) week (after d/c) * NOTE: Even if # is disconnected, attempts should still be made w/in the wk after pt is d/c PPC Triage RN calls pt to schedule follow-up appt **(RN should try to reach pt while still in-house) Triage should make at least 3 attempts to schedule asthma f/u appt within ONE week from d/c *NOTE: Asthma f/u appt needs to be made within 1 wk of d/c (4-8 days) If f/u IS scheduled Note is routed to “PPC Asthma f/u pool” for Hadley to track If 3 unsuccessful attempts have been made to schedule asthma f/u appt within 1 WEEK Nurse sends letter & routes phone note to “PPC Asthma F/U Pool” (template for letter in EPIC) DO NOT SIGN THE NOTE! If pt no-shows appt, note routed back to While pt is still in-house or after pt has been d/c If the pt shows for the appt note is closed (by Hadley) If the patient shows Ifthe theappt patient shows forthe note is If shows Ifpatient the patient shows If pt no-shows appt, note routed back to triage desktop & process begins again 80% 40% Desired Direction 1/01/12 (n=05) 1/08/12 (n=06) 1/15/12 (n=09) 1/22/12 (n=06) 1/29/12 (n=07) 2/05/12 (n=08) 2/12/12 (n=06) 2/19/12 (n=06) 2/26/12 (n=03) 3/04/12 (n=04) 3/11/12 (n=05) 3/18/12 (n=10) 3/25/12 (n=08) 4/01/12 (n=05) 4/08/12 (n=12) 4/15/12 (n=12) 4/22/12 (n=06) 4/29/12 (n=11) 5/06/12 (n=10) 5/13/12 (n=06) 5/20/12 (n=02) 5/27/12 (n=01) 6/03/12 (n=00) 6/10/12 (n=03) 6/17/12 (n=03) 6/24/12 (n=03) 7/01/12 (n=01) 7/08/12 (n=09) 7/15/12 (n=04) 7/22/12 (n=04) 7/29/12 (n=02) 8/05/12 (n=07) 8/12/12 (n=03) 8/19/12 (n=05) 8/26/12 (n=07) 9/02/12 (n=12) 9/09/12 (n=11) 9/16/12 (n=08) 9/23/12 (n=10) 9/30/12 (n=06) 10/07/12 (n=09) 10/14/12 (n=09) 10/21/12 (n=12) 10/28/12 (n=04) 11/04/12 (n=09) 11/11/12 (n=05) 11/18/12 (n=07) 11/25/12 (n=06) 12/02/12 (n=04) 12/09/12 (n=11) 12/16/12 (n=06) 12/23/12 (n=02) 12/30/12 (n=04) 1/06/13 (n=01) 1/13/13 (n=05) 1/20/13 (n=02) 1/27/13 (n=03) 2/03/13 (n=02) 2/10/13 (n=02) 2/17/13 (n=03) 2/24/13 (n=04) 3/03/13 (n=03) 3/10/13 (n=12) 3/17/13 (n=06) 3/24/13 (n=04) 3/31/13 (n=06) 4/07/13 (n=05) % complete 100% 30-day Asthma Admission Follow-Up Rate (PPC, HPC, FPC) ↑ 30 day early f/u check begins Regional Alerts Added ↓ 30-day Admission follow-up PPC Admin Pool 60% 20% 0% weeks Admission follow-up Control Limits Thanks to the Gen Peds Team • Hadley Sauers, Project Specialist • Brandy Wiener, Lauren Poling, Jamie Mahaffey, Jennifer Hughes- Asthma Care Coordinators • Kelly Stack, Care Coordinator Support • Tracy Huentelman/Kristin Line- Beacon Program Managers • Primary Care Triage Nurses • Providers and Staff in our Primary Care Sites • CCHMC IT- Jason Napora, Bryan Martin , Julie Navarre, and Kate Langworthy Effective Care Transitions ED Admission to Primary Care Transitions in care between in-patient to out-patient have shown significant patient safety issues and deficiencies in quality of care: • Medication discrepancies • Lack of Lab result follow-up • Family misunderstanding and lack of involvement in POC Lack of effective communication is a key contributor to ineffective care transitions. • Direct communication between primary care hospitals and MDs. • Availability of discharge summary and or lack of important information at time of follow-up visit. • Lack of follow-up. • Lack of designated Medical Home to support coordination of the patient care across settings. Current Focus and Goals • Improve quality of ED/Admission Alert report and develop method for timely viewing by primary care practices (network-wide). Goal: 80% of reports are viewed by the practice within 24 hrs. • Increase occurrence of follow-up visit post-utilization. (network-wide population of focus is Asthma). Goal: 80% of patients will have follow-up visit post-utilization. • Understand and address factors contributing to the ED/Admission. (Pilot practices) Goal: 75% of time the RCA process provided additional insight about the underlying factors of the recent utilization. • To enhance the effectiveness of follow-up visit supported by pre-visit planning, assessment of medication effectiveness, follow-up on outstanding lab results and involvement/review of plan of care with family. (Pilot practices) Goal: 75% of providers reporting value of the process. ED/Admission Alert Report • Currently receiving alerts via HealthBridge information exchange matched to PHO asthma registry population which provides incremental data to existing alerts received from CCHMC. • Single document “action oriented” report of ED and inpatient utilizations. • Links to existing patient registry. Alerts Sourcing From Hospitals Beyond CCHMC ED/Alert Report ED/Alert Report Viewing Alert Response Bundle • RCA – Practice level review completed to determine all factors contributing to the ED/Urgent Care or Admission. • Web-based asthma decision aid – Practice completion of a web-based decision support tool (linked to NHLBI guidelines) to support effective medication regimen. • Pre-visit planning – Practice member review of findings and development of plan for the follow-up visit. • Access – Practice confirmation and/or outreach to families to schedule follow-up visit. • Productive follow visit – Implementation of plan for the visit. CCHMC-PHO: Alerts Intervention Bundle Alert Practice Notification of Admissions and ED/Urgent Care Visit RCA Review relevant information within 14 days of ED/urgent care visit or admission: • Outreach to family members • Medical record • Specialist summary/consult notes • Discharge summary (ED/urgent care visit, admission) • Recent test results (e.g., spirometry) Web-based Decision Aid Asthma decision support tool (linked to national guidelines) RCA Pre-Visit Planning Access/Productive Visit Review information and discern reasons for recent ED/urgent care visit or admission Determine follow-up and changes to treatment/plan of care based on findings Follow-up visit/outreach to patient/family RCA Interview Script Key Learnings • Embedding ICD-9 code in alert report is more valuable than chief complaint. • Reliable use of tools to support a “deep dive” requires practice redesign. • Integrating clinical decision support tools with EMR and registries is key. • Collaborating with inpatient and ED colleagues to complete the response bundle at “time of greatest impact”. • Practice challenges to prospectively identify which patients would benefit most from response bundle. Thanks to the PHO Team • Carl Donisi, Director Clinical Operations • Pilot Community Primary Care Pediatric Practices • • • • • • • • • ESD Pediatric Group Children’s Health Care, P.C. Mid-City Pediatrics, Inc. Pediatrics of Florence Anderson Hills Pediatrics, Inc. Pediatric Associates, PSC The Whole Child Pediatrics Landen Lake Pediatrics, P.C. Pediatric Associates of Cincinnati, Inc. • PHO Quality Improvement Team: Susmita Das, Claudette Coleman, Kendra Wiegand, Huiping Li, Ellen Schafer Questions Beacon web page • www.healthbridge.org/beacon Social Media • • • • Twitter: http://twitter.com/healthbridgehio Facebook: http://www.facebook.com/pages/CincinnatiOH/HealthBridge/128672340540952 LinkedIn: http://www.linkedin.com/company/healthbridge_3 YouTube: http://www.youtube.com/user/HealthBridgeHIE Thank You……….