HHC Connectx HHC’s Community Provider Services Promoting Continuity of Care

1. HHC Connectx HHC’s Community Provider ServicesPromoting Continuity of Care Irene Kaufmann Sr. Assistant Vice President NYC Health and Hospitals Corporation May 2010

2. NYC Health and Hospital Corporation Overview

3. The New York City Health and Hospitals Corporation Facilities HHC consists of different networks across New York City

4. The New York City Health and Hospitals Corporation • The largest municipal hospital system in the country, serving 1.3 million patients annually • Consists of eleven acute care hospitals, six diagnostic and treatment centers, four nursing homes, a home health agency and more than 80 community-based health clinics • Metroplus, HHC’s managed care plan, covers 400,000 lives, 40% of which have community providers as PCPs • 5,000 affiliated but independent community providers • A workforce of 39,000 physicians, nurses, and healthcare professionals who advocate and promote a modern, innovative, and customer-focused vision of public health • The provider of comprehensive quality health services to all, equally and in an atmosphere of humane care, dignity, and respect, without regard for their ability to pay

5. The Continuity Issue

6. New Push for Continuity and Coordination of Care The value of care coordination among different providers of care has been demonstrated and is likely to be a priority in the health policy landscape • The automated transfer of clinical information among different health providers has demonstrated (Health Affairs, January 19, 2005): • Significant reductions in healthcare expenditures • Safer and higher quality healthcare • Fewer redundancies, medical errors, and administrative time saved • Nonexistent referral processes spread inefficiency, waste and dissatisfaction throughout the health care system (American Academy of Family Physicians, 2002) due to: • Unnecessary health services and duplicative tests as patients try to navigate the system themselves to get needed care • Increased administrative burden due to lack of communication of clinical information (e.g., telephone calls and inquiries, inefficient and inconsistent clinical exchange, tracking down clinical information, duplicative entry, etc.) • New York State Medicaid will promote and reward the ability to exchange clinical information between providers of care through such programs as the PCMH Incentive Program and HEAL NY grants.

7. The HHC Baseline Experience • Community providers were expected but not required to refer patients to their risk hospital • HHC hospital-based providers did not know their community network providers • HHC hospitals did not have a formal and standardized process for receiving referrals from community • There were no metrics or methods for measuring referral activity

8. Providers Across HHC’s Networks Speak About the Challenges of Building the Continuum • Patients will be turned-off by big hospital environment and their experience will reflect poorly on my practice • Access to services complicated by hospital’s bureaucracy and limited capacity • Consults and information difficult to obtain • Referred patients will not return • Our community physicians are not credentialed by our hospitals Community patients will use up hospital limited resources • Community practitioners will • Send their uninsured • Overutilize services • Send their sickest Community-Based Physicians Hospital Based Physicians

9. Providers Recommend Some Basic Requirements for Achieving Care Coordination and Continuity Systems that respect the primary care provider - patient relationship Reliable connection and communication between primary and other providers of care System for tracking results and patients Willingness to change workflows Willingness to partner with providers from other settings, practices, facilities and care systems

10. Making Provider Issues Our Service Challenge The foundation for continuity and coordination of care is partnership between participating providers Provider Defined Issues Become HHC Connectx Goals Improve continuity by building a system that recognizes patients community-based pcp’s Link patients and their community-based providers is not protected Process for accepting specialty care referrals and for forwarding consult reports/results is absent Design a referral process that enhances coordination between community providers and HHC hospitals An unidentified referring physician base and no formal channel for communication Build productive relationships between providers to improve care coordination

11. Building the Bridge

12. From Hospital Closed Shop to a Partnership Environment Engaged the front-line staff to designs the system and the tools for exchanging clinical information Ensured that internal and external communications articulate the responsibilities and the benefits of partnership Identified and engaged social networks as process and partnership stakeholders Invited the voice of the customer as planning and spread partners Developed the referral management process as an agreement between partners in care Our results 13

13. Centralized referral & consultation services linking community providers to hospital based specialists Coordinated access to specialty and diagnostic services Transactional excellence and outstanding customer services System for tracking patient information and physician referral activity Provider Relations Specialists familiar with community provider needs and ability to troubleshoot problems Dedicated Provider Recruitment & Retention Services Face-to-Face Visits for on-site training and coordination support Front-Line Redesigns the Community Referral System Providers and Patients Established the Guiding Principles Referral Management Provider Relations • Efficient – lean solutions • Customer needs and satisfiers drive system changes Operational excellence and effective communication became best practice for fostering partnerships

14. Front-Line Also Design the IT Referral Management Solution Community providers can forward consultation requests and receive reports on-line quickly & confidentially

15. The Referral Agreement • I agree to submit the following information to the hospital’s Community Referral Office either electronically (through HHCAdvantage), by fax, or by mail: • Statement indicating request for consultation • The reason for the consultation • List of any current or past pertinent medications. • Tests and results that have been done so far. • What I would like the treating provider at the hospital to do. Referring Provider Commitment • The hospital will transmit back, either electronically (through HHCAdvantage), by fax, or by mail, the following: • A consultation report in response to the consultation request • What was done for the patient and the results. • Answers to the referring provider’s questions in the consult request • Follow-up recommendations for the referring provider and educational notes as appropriate. Hospital Providers Commitment Promotes clearly stated, efficient, and standardized consultation requests, reports, and discharge summaries

16. Framework for Implementation and Spread

17. The Value Proposition • Administrative Benefits • Decreases administrative burden on clinical and administrative staff (e.g., telephone calls, Xerox/fax, filing and retrieval of records), reducing duplicative entry of patient information • Reduces medical and transcription errors resulting from duplicative entry and illegible documents • Reduces unnecessary clinical services, cycle time spent on trying to ascertain reason for patient visit, and repetitive tests/evaluations • Clinical Benefits • Provides HHC clinician with historical information, medications, and pertinent test results to make the most informed clinical decisions • Helps community provider better manage patients’ care by having online access to consultation reports and diagnostic test results • Enables clinical staff more time on direct patient care expediting assessment and evaluation process • Promotes clearly stated, efficient, and standardized consultation requests, reports, and discharge summaries

18. HHC Connectx Work Groups Facilitate Spread Weworked with the HHC and community provider “social system” to facilitate “spread” and create “spread agents” in each HHC hospital network • Leadership Work Group –CEO’s and Medical Directors • Operations and Implementation Team -Managers • Metrics and Financial Performance Workgroup –Finance and Managed Care • Community Physician Advisory Group • Communications Team – representatives from the workgroups IHI SPREAD MODEL

19. communication tools were used to share new ideas, best practices, help “make the case”, and sustain focus Communications Strategy Intranet Site “What are they saying?” featuring interview with key HHC leaders and Community Providers regarding specific program goals Derrick Bailey, Kings County Hospital presenting his storyboard Website HHC Connectx Launches HHCAdvantage to Community Physicians Connectx workshops Workshops

20. Structuring Spread through Training Materials and Tools Training Materials for Facility and Community Provider Were Created Tools to Manage Outreach and Rollout Process Were Developed Tool to help facilities prioritize their provider practices HHC Connectx Enrollment Form to formally enroll provider in HHC Network Assessment Form to evaluate whether practice sites meet requirements for HHCAdvantage Central Electronic Document Repository Was Designed HHCAdvantage Training Visit Form for trainers to document visit, issues, and required follow-up

21. HHC’s Community Physicians Honored at 2009 Doctor’s Day Celebration

22. Our Results

23. Community-Based Provider Network Our Community Provider network is robust with all eleven HHC hospitals having actively referring community-based providers Community-Based Providers Network in 2008 Metroplus 2009 number is from Jan 2010 whereas Healthfirst 2009 number is from Feb. 2010.

24. Community-Based Provider Network HHCAdvantage has been rolled out to 2,133 community based-providers as of December 2009 608 practices have been trained on HHCAdvantage as of December 2009 Elmhurst and Queens were not included in the 2008 count because providers were on legacy system, CHNAdvantage, in 2008

25. HHC Connectx: Referral Volume Our referral offices processed a total of 66,799 and 100,194 referrals in 2008 and 2009, respectively using HHCAdvantage Total Percentage of Online Referrals by Month in 2008 and 2009 HHCAdvantage was introduced during the beginning of 2008; the total percent of referrals online has steadily increased (online rate of 33% in 2008 and 46% in 2009, respectively)

26. Enhancing Coordination of Care: Response Times to Community Providers Quick response times enable providers to address patients’ needs in a timely manner, efficiently act on consultation reports/clinical results, and help to reduce no-show rates at our hospitals As our referral volume increased, our referral response time became faster; during the six month period from Jan. to Jun. ’09, the average referral response time was 2.2 days Average Time to Schedule an Appointment Volume of Appointments Scheduled Data does not include Elmhurst or Queens since they are in process of transitioning from legacy system (CHNAdvantage)

27. Percentage of Visits with Clinical Reports Returned to Referring Provider Report Response rate: The average percentage of community-referred visits with clinical reports returned to the referring provider over the six-month period was 86% Number of Visits with Reports Sent Data does not include Elmhurst or Queens since they are in process of transitioning from legacy system (CHNAdvantage)

28. Lessons Learned

29. Winning Engagement and Making Change • Providing services that have value • Respecting needs of patients and the concerns of community and hospital providers • Let customer needs and satisfiers drive system changes • Engaging the front-line in the design and development process • Establishing a framework for partnership