Indiana Rural Health Association Annual Conference August 7, 2013

1. Building an HIE Network and Virtual Community to Improve Quality of CareAn IN HIE-enabled Model for Coordinated Transitions of Care Indiana Rural Health Association Annual Conference August 7, 2013

2. Meet the Panel • Tom Liddell VP Information Systems, South Bend Medical Foundation • Tim Roberts, MHA, CHCIO-e CEO, Michiana Health Information Network • Steven Witz, PhD, MPH Director, Purdue University Regenstrief Center for Healthcare Engineering

3. Transitions in Patient Care Jeopardized patient safety Reduced care quality Increased service utilization Decreased patient experience Emphasis in value-based purchasing Transitional Care Defined as a set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care in the same location. Coleman and Boult, 2003

4. Improving Translational Care • Identify the types of transitions patients experience • Which transitions are associated with care concerns? • Improved intra-organization communications

5. Types of Patient Transitions

6. Mapping Intra-Organizational Transitions Analytics TIME

7. Ambulatory to Organization Transitions

8. Intra-Organization Transitions

9. Intra-Organizational Transitions: Rural Hospital – Post Acute Care Organizations 0.36% 6% 13% 1%

10. The Core Mission of HIE • 100% of patient data in the hands of the provider at the time of care. • HIE is a solid foundation for coordinated care and smooth transitions.

11. MHIN Transitions in Care Project Goals • Survey area SNFs and LTCs to understand existing care coordination challenges and barriers to accessing information. • Leverage HIE infrastructure to exchange information between transferring and receiving provider in time to allow the receiving provider to effectively care for the patient. • Pilot Transitions in Care projects in Northern Indiana • Measure outcomes to demonstrate value to expand project

12. MHIN Transitions in Care Plan Primary Care/ Recent Specialists Admit Discharge 1 Acute Care Facility Extended Care Facility 3 2 Admit Discharge Home/ Real Services • Utilizing the following solutions: • Community Data Repository (longitudinal storage of clinical data) • The Direct Project (MHIN Direct Messaging/ HISP Services) • ADT Alerts (Notifications to primary care providers) • KeyHIE Transform (MDS CCD Tool)

13. KeyHIE Transform CCD Transmission

14. Measuring the Impact • The effect of new communication • Reduction in preventable acute care Readmissions • Improvement in medication communication and reduction in errors • Reduction in Adverse Drug Events • Reduction in acute care length of stay • Improved patient experience and quality of life • Measure through pre and post pilot survey of patients and families • Patient management improvements • Measure through patient/ staff surveys • Chronic disease management improvement and medication compliance • Measure through patient/ staff surveys

15. Learn More • Program Manager Contact: Hannah Kingkingh@mhin.com (574) 968-1004

16. Thank you. Questions?