Health Choice Network

1. PRESTIGE Hosting EHR BHR EOHR HCiOS BI Centralized IT RCM CMMHC PCMH Health Choice Network Eliminating Health Disparities Forum - June 18, 2013

2. Health Choice Network • A network of Community Health Centers & Community Mental Health Centers – focused on providing technology and care management services to improve the health status of the underserved. • 501c3 / Not for profit organization based in Miami, FL • 12 States • 36 Member Centers • 653K Patients Integrated Analytics Focused Patient

3. Our Footprint

4. CHC Patient Demographics • 20.2 Million Patients • 93% below 200% Poverty • 72% below 100% Poverty • 62% Racial Ethnic minorities • 39% Medicaid • 36% Uninsured Integrated Analytics Focused Patient

5. Health Choice Network • Supporting our member Centers through: • Health Information Technology • 2. Collaboration • Care Management Integrated Analytics Focused Patient

6. Data Integration Systems Managed Care MCAID/MCARE ACO School Health Askesis BH Dentrix Intergy

7. Our 2012 data snapshot 155 Dental Providers 563 Meaningful Use Providers 653K Patients Seen 2012 1.9M e-Rx Sent 124K Dental Radiographs 1.8M e-Labs Results Received 61 Fulltime IT Resources

8. HCN Clinical Development Adult Preventative Care HEDIS 2013 EHR Template HCN Clinical EHR Templates & Forms (400+) HCN Clinical Flow sheets

10. Health Choice Network • Supporting our member Centers through: • Health Information Technology • Collaboration • Clinical / Grants/Partnership • Care Management Integrated Analytics Focused Patient

11. Health Choice Network • Supporting our member Centers through: • Health Information Technology • Collaboration • Care Management • Prestige Health Choice – A capitated Medicaid plan • Medicaid/Managed Care • Health Connect in Our Schools - HCiOS • Care Management Medical Home Center Integrated Analytics Focused Patient

12. The Birth of the Care Management Medical Home Center • GE Foundation Developing Health™ Program • Requirements • Effective, sustainable community health center interventions • Leverage resources across a network of health centers • Miami-Dade County focus • Patient-centered • Improve health outcomes of Diabetic patients by 10% each year • Advanced clinical informatics • Innovative and Evidence-based Integrated Analytics Focused Patient

13. The Care Management Medical Home Center • An innovative diabetes care management initiative • Developed by HCNFL and 7 Member FQHCs with GE Foundation Developing Health™ • Utilizes Care Coordinators at HCN and in FQHCs • Empowers care teams • Engages patients to self manage • With the goal of improving care outcomes in a cost efficient and sustainable fashion Integrated Analytics Focused Patient

14. Flow Diagram for CMMHC Centralized Care Coordinators CHC Care Coordinators PATIENT 1 LPN Care Coordinator at each of 7 participating CHCs 1RN 2LPNs 2 Health Care Techs Patient Care Teams

15. E.H.R Patient Roster Flow diagram for CMMHC CHC Patient Care Teams Centralized Care Coords CHC Care Coords Contact patient 7 days prior to appointment Appointment reminder Appointment obstacles identified Review care gaps Educate on Diabetes care, Apptmt Expectations Assess progress with self management goals Reinforce provider’s guidance TAG THE PATIENT Communicate with Center Care Coordinators Organize Shared Medical Appointments Facilitate Diabetes Group Education Sessions Train CHC Care Teams Analyze and Share Data Implementation of additional innovations Disseminate information to CHC Care Teams Huddle 1-2xs per day Address care gaps Order tests to be done before visit Complete referrals prior to visit Obtain hospital or specialist info before visit Ensure no patient leaves with pending care gaps Integrated Analytics Focused Patient

16. Centralized Care Coordinators at Work Integrated Analytics Focused Patient

17. Use of IT in CMMHC • Electronic Health Record supports patient engagement • Roster identifying patients with scheduled appointments – Reminder, self care follow-up, due/outstanding tests/screenings, appointment preparation • Performance management using Patient Registries • Aggregated data describing demographics, test/screening activity and results, HbA1c status and change over time • All patients with diabetes, CMMHC model experience • Amalga views guide analysis of patient population • Planned care view of upcoming appointments • Diabetes view of missed care opportunities – Appointments, screening/tests Integrated Analytics Focused Patient

18. Performance Data

19. High Risk Diabetics 24%

20. High Risk Diabetics 28%

21. SUCCESS FACTORS Use of Technology State of art Data and care documentation Leadership CMOs Program Leadership • CHC Coordinators • Focused • Knowledgeable of center operations and barrier navigation • Limited competing priorities with central oversight • Centralized Team • Dedicated, Committed, Well trained • Low turnover rate • Minimal variation in services • Real time communication with CHCs Integrated Analytics Focused Patient

22. Questions? More Information? Kevin Kearns President / CEO kkearns@hcnetwork.org THANK YOU!!!