Enhancing Care Coordination for Chronic Illness Patients: Patient Advocate Program

1. Open Door Family Medical Centers Care Coordination and Information Exchange Presentation October 2010

2. Began in 1972 as a free clinic. Now serves almost 37,000 users, reported over 169,000 visits in the 2009 UDS Operates 10 sites 4 health centers in Northern Westchester County 5 school based health centers in Port Chester, NY 1 mobile dental van Employees 268 individuals, 60 licensed providers Implemented an EMR and integrated practice management system in 2007 Recognized by NCQA as a Level III Patient Centered Medical Home – December 2009 HIMSS Davies Award – 2010 Joint Commission accredited Open Door Family Medical Centers

3. Open Door Family Medical Center Clinic sites Ossining, Mount Kisco, Sleepy Hollow, and Port Chester Open Door's dedicated team of doctors, nurse practitioners, dentists , and clinical support staff seek to provide excellent care in collaboration with our patients, involving their families and the broader community in the effort.

4. Chronic Illness in America • More than 125 million Americans suffer from one or more chronic illnesses and 40 million limited by them. • Despite annual spending of nearly $1 trillion and significant advances in care, one-half or more of patients still don’t receive appropriate care. • Gaps in quality care lead to thousands of avoidable deaths each year. • Best practices could avoid an estimated 41 million sick days and more than $11 billion annually in lost productivity. • Patients and families increasingly recognize the defects in their care.

5. Changing Outcomes Requires Fundamental Practice Change • Reviews of interventions in several conditions show that effective practice changes are similar across conditions. • Integrated changes with components directed at: • influencing physician behavior, • better use of non-physician team members, (Pt Advocates) • enhancements to information systems, • Safe and efficient information exchange, • plannedencounters (Planned visits) • modern self-management support, and • care management for high risk patients

6. Patient Advocate Program • Patient Advocates are a group of professionals, coming from different experiences, professions and cultural backgrounds, all having the common purpose to expand and share their knowledge to serve the community. • The goal of the patient advocate program is to improve the care and clinical outcomes for patients with chronic disease. • A patient Advocate functions as an extension of the health care team: • Coordinates services and follow-up on requested referrals • Manages medical information and data to ensure planning, action, and follow up. • Provides education and self-management support • Facilities and assist with Concrete Services • (Medicaid Eligibility, Financial Assistance, Charity Funds opportunities)

7. Patient Advocates at Open Door • We employ 8 Patient Advocates and one Supervisor at our 4 main sites. • Each works in a medical or women’s health unit supporting 3-4 clinical providers. • Appointments are made both in advance and on the same day. • Providers can refer at the time of the visit and advocates review daily schedules for appropriate intervention. • All together our Patient Advocates see ~ 1000 visits per month.

8. Patient Advocate EMR Template

9. Patient Advocate EMR Flow Sheet

10. The Patient Advocate Role in Information Exchange • Advocates document in a progress note using templates. • The note is easily accessible to the provider and the entire patient care team. • Referrals are tracked in the EMR. • The advocates provide the specialist with the medical summary information – • reason for the referral, • current problem list, • Medication list • Last visit information

11. Using the EMR Referral System Appointment information must be documented in the referral

12. Re-scheduling a Referral Appointment

13. The Referral Tracking Process Where do we need to improve

14. Advocates reach out to specialists by phone/email to obtain results by fax or mail. Providers can log into affiliated hospital’s EMR to obtain consult reports and ER visit info. Medical records staff receives consults or test results through EMR Fax In-Box or USPS mail and attaches them to the order, then assigns the order to the provider for review and follow-up Advocates use the registry reports to identify patients who need follow-up and/or reminders BridgeIT report writing tool is used to identify missing information and improve data integrity Closing the Loop

15. Example BridgeIT Report:Referral Status for Diabetic Patients

16. We are still doing some tasks manually through paper / fax / scanning. We need better ways to track down missing results from outside referrals We need better communication with patients to know when and where they went for care outside Open Door. We need to have more control of the EMR processes and the ability to prevent data entry errors Our Challenges - Where we need to improve

17. Plans to implement Patient Portal to connect with our patients P2P (Peer to Peer) EMR connection between providers. Open Door has collaborated with ThincRHIO in designing and beginning health information electronic exchange with health providers in the Hudson Valley Open Door has worked with CHCANYS and HCNNY in improving the functional use and reporting abilities of the EHR and practice management system. Open Door has collaborated with HITCH focusing on diabetic care across the health care continuum; the transitions in care when specialists and hospitalization is needed. Technology and Collaboration

18. The EHR has changed how we operate – information is readily available, legible and allows for more transparency. Meaningfully using the data allows us to learn about the patients and the community we are caring for. The technology allows us to engage more with our patients and provide them with their information about their health. Reporting tools and structured data allows us to identify areas that need improvement to improve care to our patients and ultimately the community. The technology is a tool for our Patient Centered Medical Home, meaningful use and care coordination efforts. Summary – Technology and EHR

19. Technology, Meaningful Use, Care Coordination & Medical Home Important for: Quality Care Incentive Reimbursements Prestige Recognition

20. Together, we can keep our promise to those we serve and in doing so, strengthen and expand the Open Door brand. Building stronger, healthier communities… One patient at a time