COUNTY OF ORANGE HEALTH CARE AGENCY

1. Technology and the Uninsured: Increasing Access and Coordinating Care Doing the Impossible—Leveraging Technology to Reduce Costs and Improve the Quality of Care for the Uninsured COUNTY OF ORANGE HEALTH CARE AGENCY Hank Fanberg Manager of Research & Development Dan Castillo,MHA, FACMPE, CHE Program Administrator 2007 National Congress on the Un and Under-Insured

2. To share with you how two different types of healthcare organizations are utilizing technology in their efforts to serve the underserved. What a Provider System is currently doing What a Public Health (Payor) System is currently doing Today’s Objectives

3. We will demonstrate the different technology applications that have been implemented and how they support our respective initiatives. We will share with you the outcomes of our efforts and how leveraging technology has not only made our respective systems more efficient but how it has enhanced the patient’s quality of life. Today’s Objectives (cont.)

4. The Provider Perspective Hank Fanberg – CHRISTUS Health The Public Health (Payor) Perspective Dan Castillo – Orange County Health Care Agency Today’s Objectives (cont.)

5. Our Healing Ministry

6. CHRISTUS Health background Market Statistics re: un and under insureds Programmatic Approach to Care Technology Tools to Accomplish PRESENTATION GUIDE

7. Strengthen current ministries and expand into new locations and services Implement innovative approaches to caring for the whole person Increase access to health care for the poor and underserved through advocacy and other initiatives Make significant contributions to creating healthy communities Create a work environment filled with hope, dignity and mutual respect Our VisionWhat We Are Striving To do.

8. Our Legacy • In 1866, Texas was faced with illness, disease and poverty of staggering proportions. • Galveston Bishop Claude M. Dubuis turned to his native France and issued a plea to Religious Sisters for assistance • Three Sisters answered the Bishop’s call, Mother Blandine, Sister Ange, and Sister Joseph

9. Our Legacy • The Sisters arrived in Galveston in October 1866 and founded the Congregation of the Sisters of Charity of the Incarnate Word. • In 1887 the Sisters opened the state’s first Catholic hospital in Galveston, Charity Hospital. • Mother Madeline, Sister Agnes and Sister Pierre traveled from Galveston to San Antonio in 1869 • Within months, the Sisters established Santa Rosa Infirmary in San Antonio.

11. 40 hospitals and other health care ministries in more than 70 communities Dozens of other health services in Texas, Louisiana, Arkansas, Utah, Oklahoma and Mexico Approximately 27,000 employees More than 8,000 staffed beds Facts and Figures - Today Cont’d

12. Uninsured in Texas and Louisiana – Demographics • Texas leads nation in uninsured; Louisiana is third (2005) • Majority are: - Working families with low and moderate incomes - Young adults age 19-34 - Disproportionately Hispanic and African-American - Legal, US residents • Health care coverage is not available from employer or is unaffordable Sources: Health Policy Institute; The Access Project

13. Uninsured and Underinsured in Texas and Louisiana, 2005

14. CHRISTUS Direction From To Focus on high cost, ER-based charity care to treat illnesses that Could have been prevented. Comprehensive strategies to address the symptoms and underlying causes of health problems. Proprietary approaches to planning and implementation. Community collaboratives that mobilize and build upon existing community assets.

15. Three Pronged Approach • Manage Care • Identify high risk patients • Manage Lifestyle • Navigate the System • Provide Access to Care • Identify/establish medical homes • Identify/develop other building blocks Uninsured Population • Manage Acute Care • Develop clinical pathways/ supply chain management • Implement strategic pricing • Implement communication plan

16. Current Building Blocks Enrollment Medical Home Wellness & Prevention Disease Management Pharmaceuticals Access Care Management Diagnostic Service Referrals System Durable Medical Goods

17. Comprehensive Integrated Care Enrollment Medical Home Admission Wellness & Prevention Disease Management Prepare for treatment & discharge Mental Health Dental Health Community Collaboration Care Management Diagnostic Service Medical or surgical treatment Expanded Insurance Coverage Pharmaceuticals Access Project & Information Management Discharge to home and/or aftercare Referrals System Durable Medical Goods

18. Technology: variety of tools that fit the need Touch: Community Health Workers Success Requires Tech and Touch

19. People who are residents of underserved communities who are uniquely knowledgeable about their neighbors’ needs Care Managers by many different names Health Promoter Family Health Care Advisor Natural Caregiver Promotora Resource Mother Community Health Workers

20. A study of 77 chronically ill clients during the first 6 months of intervention by CHWs Utilization Impact 52 of 77 had no ED visits or admissions 49 ED visits by 25 patients 28 admissions by 20 patients Financial Impact (6 months) $123,329 in net savings for ED & Acute Care Costs of $35,152 Return on investment (ROI) $3.80 per $1 invested in the Kleberg CHW program CHRISTUS Spohn Kleberg – Preliminary Results (12-06)

21. 22 year old Caucasian female Diabetic ED as primary care site Admitted to ICU ~ 6 weeks for acidkerotosis Community Health Worker + Home Monitoring No admissions 11 months 3 ED visits $215,000 cost avoidance Patient Specific Results

22. Home Monitoring Device

23. Clinical Systems Communications Systems Financial Systems What Technology building Blocks Are Needed?

24. Map the technology to the Need

25. Clinical Systems Shared electronic medial record Community Wide Master Patient Index Vital sign monitoring device in the home Communications Systems Secure network for accessing and sharing Web based access and applications Financial Systems Eligibility verification Strong Authentication Positive patient identification and verification What Technology building Blocks Are Needed?

26. CDA document-based network EHR V-EHR PHR Patient Portal Physician Portal Health Record Bank • All transform to CDA • View the complete record • No loss in computable semantics EMR HL7|^v2 data PM-paper HL7|^v2 text text HL7|^v2 chart LIS text DICOM paper NCPDP RIS/dictation eRx/paper

27. HIE Infrastructure

28. Divert inappropriate care from ED By using home monitoring devices and Community Health Workers for support Provide a medical home with electronic linkages to entire care team Virtual PHR using grid technology Establish a community wide referral network Web site, in early development Collect de-identified data for analytics Not yet robust enough Identified the major components to implement and integrate – much more work to be done OUTCOMES TO DATE AND FUTURE NEEDS

29. Evaluating social networking model (i.e. Face Book) for sharing and notifications Standardizing terminology across multiple systems Integrating eligibility and financial systems with clinic systems Continue to develop the virtual EMR Continue to improve communication and collaboration tools Continue to automate as much as possible Still Building Infrastructure

30. The Need drives the technology Not the other way around Technology by itself is insufficient But it is necessary Underlying Foundation is the Medical Home Requires sharing of information Summary

31. Doing the Impossible—Leveraging Technology to Reduce Costs and Improve the Quality of Care for the Uninsured 2007 National Congress on the Un and Under-Insured Dan Castillo, Medical Services Initiative Administrator

32. About Orange County MSI • Orange County’s state mandated indigent program • Serves as the County’s safety net program for the underserved • Operates without the benefit of a County controlled healthcare delivery system • Public-private partnership • No County-Employed Physicians • No County-Run Hospital system • Annual enrollment of 25,000 patients • $87 million annual budget

33. By the Numbers • 22 hospitals reporting admit and discharge data • Over 10,000 ER admits electronically reported • Over 3,000 hospital stay notifications • 14 Community Clinics connected • Over 200 ER Physicians connected • Over 200 Primary Care Physicians connected • Over 500 Pharmacies connected

34. By the Numbers (cont.) • Over 5,000 eligibility checks per month by provider network • Over 10,000 ER Queries in 12 Months • Over 2,000 ER Physician notes submitted • Over 700e-Referrals to Community Clinics

35. e-fficiencies Result in Cost Savings • Reduction of inappropriate ER utilization by 11% over the last quarter • Hospital cost savings per re-admitted patient is $2,000 • Duplicate prescription cost savings per patient per year is $600 (avoidable) • Diagnostic and ancillary cost savings is $130 per patient per year • Improved quality of care: • PRICELE$$

36. The Bottom Line…Improving Care • Medical Home linkage (over 12,000 patients assigned) • Reduction in prescription errors • Increased continuity of care • Increased access to timely care • Improved outcomes • Increased patient satisfaction

37. Manual enrollment process with “paper” record keeping More likely to wait over 45 days for eligibility determination Limited medical home linkage Less likely to have a regular source of care Lack of clinical information at the point of care More likely to report they have not received needed care The Dark Ages

38. Standardized paperless enrollment 30% reduction in eligibility staff Patient eligibility wait times decreased to less than 30 days Balancing Stakeholder ROI with quality patient care Enhanced Physician and Clinic reimbursement through P4P Increased ability to monitor and manage program costs Addressed through Case Management enrollment, patient outreach, and consultation with Medical Homes. Health IT Renaissance

39. The four pillars to our technology initiative:1. Electronic Eligibility Determination & Enrollment2. Hospital Census Notification and Tracking3. ER Connect4. Clinic ConnectWith these technologies, MSI is the most technologically progressive Safety Net Program in the State. “Need” Drove Technology

40. A streamlined and automated web-based enrollment and eligibility determination System. An immediate and automated way to screen and enroll applicants online Workflow approach promoting efficiencies in management oversight and processor accountability Electronic Eligibility & Determination

41. Hospital Census Notification & Tracking • Collects daily census data electronically from hospital scheduled batch runs • Uploads data automatically and provides the user with a current daily census report in a web-based environment • Tracks and displays “Level of Care” and “Length of Stay” information • Case Management linkage

42. ER Connect • Provides usable patient data at the “point of care” • Facilitates communication between ER physicians • Tracks patient’s utilization activity • Reduces consumption of the community’s scarce healthcare resources

43. ER Connect – Patient History Tab

44. ER Connect – Prescriptions Tab

45. Clinic Connect • It’s an innovative, technology-based, data communication platform, facilitating the use of available patient information. • It allows Clinic Providers to access patient information with the goal of enhancing the health services both “at the point of care” and for ongoing care management purposes. • It’s a patient flow management tool for those patients referred into the clinic.

46. Clinic Connect – Patient Referral Worklist

47. Clinic Connect – Patient Summary

48. Clinic Connect – Patient Encounter Documented

49. MSI Technology Schema Medical Home Medical Home e-Referral Prescriptions Referrals Lab Results Eligibility Emergency Room Data Accessed by ERs Claims History Hospital Activity Case Management Fiscal Intermediary

50. End-user was included from the beginning Community clinics and ED physicians created it! Early adoption by the hospital association Proven return on investment Reduction in redundant procedures and prescriptions Reduction in delays and costs associated with enrollment Efficiency savings to us and our partnering hospitals from avoided tests Increased patient safety Better continuity of care Improved provider reimbursement Critical Success Factors