The Michigan Primary Care Transformation (MiPCT) Project

1. The Michigan Primary Care Transformation (MiPCT) Project Transition of Care Using an EMR (Epic) Diane McLeod BSN,RN, CCP

2. Disclosure • I have no conflict of interest to declare • I do not have any relevant financial relationships with any commercial interests

3. Objective • Describe IT tools which facilitate clinician communication across the continuum for optimal patient care

4. Sparrow Health System • Using EPIC EMR • Ambulatory has been live since Aug 2010 • Inpatient has been live since Dec 2012

5. Transition of Care (TOC) - Pre-EMR • Care Facilitators had to rely on paper discharge summaries, ED reports or patient self reporting • Inconsistent receipt of reports • 50% of the time we did not know that the patient had been admitted • Missed TOC opportunities

6. Non-Epic facilities • TOC for non-Epic facilities still on paper • D/C summaries scanned into the chart

7. TOC with Hospital on EMR • Easily identify MiPCT patients • PCP and Care Facilitator receive notification in “real time” of patient admission/ED visit andfollow the inpatient/ED course • Allows Care Facilitator to coordinate with inpatient care managers PRIOR to discharge • Able to run reports and monitor in real time: • Inpatient stay/ED visits • Elective surgery/Procedures • Sparrow Urgent Care clinic

8. Identify MiPCT patients • How do we determine if the patient is on our MiPCT list?

9. MiPCT Problem • Created “MiPCT Eligible” problem using a dummy code • Clearly visible on the problem list • Can create an overview indicating when the case was opened and complex or moderate level • IT automated monthly import of MiPCT problem

10. How is “Real Time” notification possible?

11. Care Team navigator section In-basket alert received when the patient is admitted to a Sparrow inpatient unit

12. Caseload Tracking

13. Chief Complaint • Chief complaint section of navigator - facilitates tracking of discrete data • Ambulatory Complex OR Moderate Care Management • Distinguish from Inpatient Case Management • Problem list – adding problem “MiPCT Eligible” • Episode create/link

14. Epic Reports • Each Care Facilitator has a report formatted for their clinics/providers. • Run the report several times a week to identify patients appropriate for care management services • Displays: MRN/Name/DOB/Age/Gender Admit/Discharge date/Department Admission Reason/DX

15. Episode • Initial contact create a MiPCT episode • Follow up visits link today’s note to the episode • Able to see all care facilitator activity/notes in one defined printable report • Deactivate episode when patient discharged from care facilitator caseload

16. Follow Documentation If the patient is at a Sparrow facility we can monitor documentation in “real time”

17. Advantage of “real time” alerts • Allows care facilitators to monitor the progress ofinpatient or ED in “real time” • Notes, orders, imaging and lab results readily available • Able to communicate with inpatient/ED providers or care managers PRIOR to discharge • Increased coordination of care and TOC

18. ED/Inpatient Documentation

19. Communication • Send in-basket messages to Sparrow PCP/Specialists • Send in-basket reminders to yourself and future date them, i.e. “call the patient for a status report” • Patient portal: MySparrow • Secure email from/to patient • Patient flow sheet glucose and blood pressure • Route documentation

20. In-basket/MySparrow message

21. Route your documentation

22. EMR Improves Documentation • Legible • Easy to retrieve • Use Epic tools to chart faster

23. Ambulatory CF Documentation • I hate hand writing out my notes! • Not so fond ofhaving to type out EVERY word either • Sparrow utilized Epic’s smart tool options and created new/return patient note templates • Self-management care plans

26. Case Study • Provided for your information to demonstrate how an EMR improves TOC • Bolding indicates outcome or information directly related to use of EMR

27. Complex Case Study • Problem List – “MiPCT Eligible” provider saw and referred patient • PCP requested I work with 91 y/o male due to HgbA1c of 9.1 (last result 7.8) • Called patient to introduce myself. Said he was not feeing “so good” • Glucose in the past 3 days had been in the 400’s • Facilitated CM and PCP visit now as I could see providers schedule

28. Findings • Glucose in clinic was 425 • Lantus vial empty – he thought he had at least one week of insulin left • Novolog: giving incorrectly only at breakfast • Glucose testing: only fasting • HOH: often cannot hear the phone • Lives alone: no life line/did not carry cell phone

29. Actions • Facilitated PCP visit that day • Determined he had previously been seen by Sparrow Endocrine specialty • Electronic communication with Sparrow Endocrine. Coordinate care and receive suggested insulin dose changes • Facilitated sooner Endocrine follow up apt • Communicated with patients son - Demographics • Home care referral

30. Actions – cont’d • Son agrees to family home care insulin teaching • I Accompanied patient and son to Endocrine appointment the following week • Weekly calls to patient and son • Patient chose to continue to live independently • Son visited patient at least every other day and called twice a day

31. Follow up All was going well for a while……….

32. Two Months Later • Accompanied patient and son to Endocrine apt • Glucose running in the 500’s (I had just called patient 3 days ago –was told levels were 200) • Insulin vial empty again! • Insulin dose increased and patient sent home with new dose and monitoring instructions • Another home care referral • Family re-educated importance of medication safety

33. The EMR Advantage for TOC • Next day I received an electronic alert - patient had been seen at Sparrow ED • Able to follow up immediately with family and facilitate a PCP visit • Home care updated • Patient was firm that he wanted to continue to live alone independently • The family did explore alternative living options and had a plan in place

34. Fast forward ONE MONTH LATER…

35. Epic Electronic Alert Received • Patient currently in the ED - hypoglycemia • Notes indicated the plan was to send patient home • Facilitated doctor –to-doctor call and discussed “the rest of the story” • Patient was admitted to monitor hypo/hyperglycemia episodes and address safety concerns • Social work involved • In-patient CM communication

36. Currently • Patient continues to live at home alone • Son checks on him twice a day: before and after work • Patient now carries cell phone with him • Home care has just discharged him

37. Diane McLeod BSN, RN CCPCare Facilitatorsmg west 517-622-2788smg potterville 517-645-0000Diane.McLeod@Sparrow.org