Transforming Care: Lessons & Practical Tools from Beacon-Part 2

1. Transforming Care: Lessons & Practical Tools from Beacon-Part 2

2. Greater Cincinnati Beacon Collaboration (GCBC)

3. The Transformation Equation MU (EHR+HIE) Transformed Care Patient Centered Care Point of Care Info Value Based Purchasing Change Readiness

4. 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

6. ED/Admission Technology Data Elements of ED/Admission Alert

7. ED/Admission Alert

8. Patient RegistryPopulation 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

9. Improve Care-Improve Cost, Quality, andPopulation Health Disease Registry-Diabetes & Asthma-Population Management

10. Transforming Care: Lessons & Practical Tools from Beacon

11. 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

12. 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

13. 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.

14. PHO Practice Network • Beacon-related QI goals: • 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.

15. PHO Asthma Initiative

16. 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

17. 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

18. 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

20. 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.

21. 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

22. Asthma Care Summary

23. Asthma Care Summary

24. 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

25. 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

28. 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

29. Effective Care TransitionsED 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.

30. 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.

31. 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.

32. Alerts Sourcing From Hospitals Beyond CCHMC

33. ED/Alert Report

34. ED/Alert Report Viewing

35. 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.

36. CCHMC-PHO: Alerts Intervention Bundle Practice Notification of Admissions and ED/Urgent Care Visit Alert • 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) RCA Web-based Decision Aid Asthma decision support tool (linked to national guidelines) RCA Review information and discern reasons for recent ED/urgent care visit or admission Pre-Visit Planning Determine follow-up and changes to treatment/plan of care based on findings Access/Productive Visit Follow-up visit/outreach to patient/family

37. RCA Interview Script

38. 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.

39. 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

40. Questions • Beacon web page • www.healthbridge.org/beacon • Social Media • Twitter: http://twitter.com/healthbridgehio • Facebook: http://www.facebook.com/pages/Cincinnati-OH/HealthBridge/128672340540952 • LinkedIn: http://www.linkedin.com/company/healthbridge_3 • YouTube: http://www.youtube.com/user/HealthBridgeHIE Thank You……….