Transforming Care: Lessons & Practical
Tools from Beacon-Part 2
1
Greater Cincinnati Beacon Collaboration
(GCBC)
Beacon Goal
• Provide funding to communities to
strengthen health IT
infrastructure and exchange
capabilities
• Achieve measurable improvements
in health care quality, safety,
efficiency, and population health
Funding
$13.75 million award to Cincinnati
Cincinnati Project Demographic
•
•
•
•
200+ Adult PCPs
35,000 patients with Diabetes
300+ Pediatricians
30,000 patients with Pediatric
Asthma
• 21 Regional Hospitals
Awarded
September 1, 2010
30 month initiative
The Transformation Equation
MU
(EHR+HIE)
Patient
Centered
Care
Point of
Care Info
Change Readiness
Value
Based
Purchasing
Transformed
Care
Beacon Health IT Interventions
ED/Admission Alerts
•
Electronic Alerts triggered on registration at ED or
hospitalization> Alert sent through HealthBridge> Primary Care
Physician>Practice interventions
• Real time notification of utilizations
• ED alerts become a clinical decision support
tool for care coordination
• With the goal of reducing readmissions and subsequent ED visits
by enhancing the delivery of better coordinated, preventive care in
the primary care setting
4
HealthBridge ED Alert Architecture
1
2
Patient Hospital Visit
The patient goes to the
hospital and is admitted to
the ED.
3
HealthBridge Integration
HealthBridge receives the ADT and matches on the
patient. If the patient is part of a subject group, an
alert will be created from one of the four options
(A, B, C, D).
HealthBridge
Hospital
Practice receives preferred alert
from HealthBridge and calls
patient for a follow-up visit.
Practice
A
B
ADT
Alert Aggregator
ALERT
C
Admission
D
Clinical Messaging
Practice Follow-up
ED/Admission Technology
Data Elements of ED/Admission Alert
Data Element
Last Name
First Name
Birth date
Admit Date/Time
HL7 Field
PID.5.1
PID.5.2
PID.7.1
PV1.44
Facility
Visit Type
MSH.4
PV1.2
Description
Patient’s last name
Patient’s first name
Date of birth for patient
Date and time patient was admitted to
hospital
Hospital where patient was admitted
Patient class type associated with the
hospital visit
E-Emergency Department visit
Diagnosis Code
Diagnosis Description/Chief
Complaint
MRN
Phone Number
DG1.3
DG1.4
I-Inpatient admission
Diagnosis Code
Diagnosis Description
MSH.10
PID.13
Medical Record Number
Patient’s home phone number
ED/Admission Alert
Patient Registry
Population Health Management and Analytics
Population health management
Data aggregation from the EMR
Customizable quality measures and alerts
Patient outreach and engagement to address care gaps
Provider benchmarking to track performance
Care management and predictive risk modeling
Quality reporting to payers and other stakeholders
Improve Care-Improve Cost, Quality, and
Population Health
Disease Registry-Diabetes & Asthma-Population Management
9
CCHMC Pediatric Primary
Care Practices
• 3 Cincinnati based sites
• Pediatric Primary Care Center (PPC)
• Hopple Street Health Center (HPC)
• Fairfield Primary Care (FPC)
•
•
•
•
•
35,000 active patients across the 3 sites
5400 active asthma patients ages 2-17
Predominantly Medicaid insured or uninsured
10-15% of patients require an interpreter
Resident/medical student training sites
CCHMC Asthma Population
Health Initiative
• Asthma Improvement Collaborative began in 2007,
now a CCHMC Strategic Improvement Priority
• Goal: 20% reduction of asthma related admissions
and ED visits for children ages 2-17 with Medicaid
insurance in Hamilton County
• Beacon: Implementing Health Information Technology
tools to further impact care through integration with
clinical care
PHO Practice Network
• 40 independent primary care practices
•
•
•
across 8 county primary service area
caring for 200,000 children (predominantly
commercially-insured).
14,000 children with asthma.
Asthma initiative began in 2004.
Pre-existing web-based asthma registry.
PHO Practice Network
Beacon-related QI goals:
1.
2.
3.
4.
5.
Eighty percent (80%) of PHO asthma at-risk population is rated as “well
controlled” by both the physician and the patient family.
Eighty percent (80%)of eligible PHO asthma at-risk population receives
seasonal influenza vaccines during the 2012/2013 flu season.
Commercially insured PHO asthma admission rate will be sixty percent
(60%) lower among participant group verses comparison group by
December 2012.
Commercially insured PHO asthma ED/UC visit rate will be forty-five
percent (45%) lower among participant group versus comparison group by
December 2012.
Commercially insured PHO 30 day asthma readmission rate will be
reduced by fifteen percent (15%) by December 2012
Beacon-related QI initiatives:
•
•
Regional alerts + intervention bundle.
Electronic asthma decision support tool.
PHO Asthma Initiative
CCHMC General and Community
Pediatric Beacon Initiatives
•
•
•
•
Expansion of Care Coordination
WellCentive Registry Implementation
Implementation of Regional Alerts
Reliable use and spread of:
• Asthma Specific Electronic History and Physical
• Asthma Risk Assessment tool
Care Coordination Model
4 Asthma Care Coordinators
• 2 PPC, 1 HPC, 1 FPC
1 Care Coordinator Support
Criteria for enrollment:
• One of more admissions for asthma in last year
• Two or more ED visits for asthma in the last year
Bundle of Interventions
Care Coordination Bundle
Bundle of Interventions
•
•
•
•
•
•
Risk Assessment (CARAT)
Self Management Assessment
Asthma Control Test
MDI skills training
Notification of Managed Care
Leverage resources/reduce barriers based on risk
assessment
• i.e.-Referral to Home Health Pathway, Legal Aid,
Managed Care- transportation, DME
• Create a multi-user shared care plan
• Pharmacy Delivery Service




Criteria:
Ages 2-17
Hamilton & Butler Co Medicaid
PPC, HPC, FPC
1-3 admissions &/or 2-4 ED in
preceding 12 months
Intake Only: Excluded
 Subjective assessment
that family will not
engage in CC past initial
intake.
 SM = Pre-contemplation
 Complex care, pt is
managed elsewhere
Enrollment Algorithm for Care Coordination
 Alert identifies HR
patient eligible for
CC intake
Intake


Intake Only: Low Risk
 No further action
planned, CC available
as needed in future.
CARAT, SM, & ACT
Referrals placed if needed (HHC, Asthma Center,
ChildHeLP, SW, Pharmacy delivery, etc.)
Intake Only: Inactive
 Enrollment attempted – at
least 3 attempts within 3
months, with no additional
utilization
 Insurance or transfer of
care
 Alert notifies CC of
“failure” & initiates
f/u tracking process
If pt has subsequent failure,
complete intake as a “new”
patient
Graduation
 Pt reaches 365
failure-free Care
Coordination
days
If pt has subsequent
failure(s), complete
“new” intake
If future contact
is made > 3 mos
and pt has not
had subsequent
failure(s), can
move to enrolled
Active
 SM = Contemplation through
Action
Low Risk
 SM = Maintenance
 Continued contact every 6
months
 Pt reaches 270 days w/o
failure (~ 9 months)
Enrolled
 Subsequent contact & additional CC
bundle items completed
 SM > Pre-contemplation
Inactive
 Private Insurance for 1 yr
 Transfer of care
 Unable to contact within
6 consecutive months
If future contact is made and family
is engaged, re-enroll patient
(If not engaged – complete new
intake)
Alert initiates potential
for pt to be
“reactivated” in CC
Care Coordination Results
• 335 children ever enrolled in Care Coordination
• 114 children graduated from Care Coordination (
no admission or ED visit for asthma in last year)
• 19 children with subsequent failure after
graduation
• Time between failures up from baseline of 173
days to current of 263 days ( max achieved 325
days)
• Failure rate/1000 days enrolled decreased from
baseline of 5.5 to 2.9.
Registry Implementation
WellCentive
– Significant customization for pediatric asthma
– Multiple tests using VOIP for flu vaccination for all 3 sites
– Different scripts for phone call
– Limited efficacy- timing/functionality issues
– Use of gaps in care reports to do letter outreach for patients
without ACT score
– About 10-15% return rate, low yield, but low cost
– Asthma Care Summary
• Tested at HPC, spread to FPC
• Just beginning implementation at PPC
Asthma Care Summary
Asthma Care Summary
Regional Alerts for Gen Peds
• Pre-existing alerts from CCHMC via ADT messages
• Currently receive alerts via HealthBridge Clinical
Messaging system for CCHMC and non-CCHMC
alerts
• Much more facile to use singular system
• Matching on patient panel allows us to know it is
our patient
• Minimizes limits of alert being driven by chief complaint
field; can compare with patient information in EPIC
• Better capture of ED visits for asthma
Goals for Regional Alerts
• Ensure follow-up with the medical home after
the ED visit or admission within an appropriate
time frame
• Identify additional children eligible for care
coordination due to events outside CCHMC
• 13% of asthma alerts were from non- CCHMC
sources
Please call/page for questions
Contact Information:
Desk: 636-7994
Hadley Sauers Pager: 736-4525
Where to find letters?
GPC: LTR Fu Asthma Appt Unable to Reach
GPC: LTR Asthma Three No Show Appt Fu
PPC Inpatient/ED Healthbridge/CCHMC Alerts
A patient is admitted for asthma
Hadley creates a phone note in EPIC
regarding the admission & routes it
to the “PPC Triage pool” (if appt is
not already made)
*NOTE: If utilization is not
asthma related, document &
route note to the “PPC
Asthma F/U Pool”
*NOTE: PPC Triage RN calls pt
to access recent utilization. If
utilization is due to asthma then
schedule f/u appt
Regional
Alert
# is
disconnected
on attempt
Nurse sends letter, document &
leave note on “PPC Triage Pool” for
remainder of (1) week (after d/c)
* NOTE: Even if # is
disconnected, attempts
should still be made w/in
the wk after pt is d/c
PPC Triage RN calls pt to schedule
follow-up appt **(RN should try to
reach pt while still in-house)
Triage should make at least 3
attempts to schedule asthma f/u
appt within ONE week from d/c
*NOTE: Asthma f/u
appt needs to be
made within 1 wk of
d/c (4-8 days)
If f/u IS
scheduled
Note is routed to “PPC
Asthma f/u pool” for
Hadley to track
If 3 unsuccessful attempts
have been made to
schedule asthma f/u appt
within 1 WEEK
Nurse sends letter & routes
phone note to “PPC Asthma
F/U Pool” (template for
letter in EPIC)
DO NOT SIGN THE NOTE!
If pt no-shows appt,
note routed back to
While pt is still
in-house or after
pt has been d/c
If the pt shows
for the appt
note is closed
(by Hadley)
If the patient shows
Ifthe
theappt
patient
shows
forthe
note
is
If
shows
Ifpatient
the patient
shows
If pt no-shows appt,
note routed back to
triage desktop &
process begins again
80%
40%
Desired
Direction
1/01/12 (n=05)
1/08/12 (n=06)
1/15/12 (n=09)
1/22/12 (n=06)
1/29/12 (n=07)
2/05/12 (n=08)
2/12/12 (n=06)
2/19/12 (n=06)
2/26/12 (n=03)
3/04/12 (n=04)
3/11/12 (n=05)
3/18/12 (n=10)
3/25/12 (n=08)
4/01/12 (n=05)
4/08/12 (n=12)
4/15/12 (n=12)
4/22/12 (n=06)
4/29/12 (n=11)
5/06/12 (n=10)
5/13/12 (n=06)
5/20/12 (n=02)
5/27/12 (n=01)
6/03/12 (n=00)
6/10/12 (n=03)
6/17/12 (n=03)
6/24/12 (n=03)
7/01/12 (n=01)
7/08/12 (n=09)
7/15/12 (n=04)
7/22/12 (n=04)
7/29/12 (n=02)
8/05/12 (n=07)
8/12/12 (n=03)
8/19/12 (n=05)
8/26/12 (n=07)
9/02/12 (n=12)
9/09/12 (n=11)
9/16/12 (n=08)
9/23/12 (n=10)
9/30/12 (n=06)
10/07/12 (n=09)
10/14/12 (n=09)
10/21/12 (n=12)
10/28/12 (n=04)
11/04/12 (n=09)
11/11/12 (n=05)
11/18/12 (n=07)
11/25/12 (n=06)
12/02/12 (n=04)
12/09/12 (n=11)
12/16/12 (n=06)
12/23/12 (n=02)
12/30/12 (n=04)
1/06/13 (n=01)
1/13/13 (n=05)
1/20/13 (n=02)
1/27/13 (n=03)
2/03/13 (n=02)
2/10/13 (n=02)
2/17/13 (n=03)
2/24/13 (n=04)
3/03/13 (n=03)
3/10/13 (n=12)
3/17/13 (n=06)
3/24/13 (n=04)
3/31/13 (n=06)
4/07/13 (n=05)
% complete
100%
30-day Asthma Admission Follow-Up Rate (PPC, HPC, FPC)
↑
30 day early
f/u check begins
Regional Alerts
Added
↓
30-day Admission follow-up
PPC
Admin
Pool
60%
20%
0%
weeks
Admission follow-up
Control Limits
Thanks to the Gen Peds Team
• Hadley Sauers, Project Specialist
• Brandy Wiener, Lauren Poling, Jamie Mahaffey,
Jennifer Hughes- Asthma Care Coordinators
• Kelly Stack, Care Coordinator Support
• Tracy Huentelman/Kristin Line- Beacon Program
Managers
• Primary Care Triage Nurses
• Providers and Staff in our Primary Care Sites
• CCHMC IT- Jason Napora, Bryan Martin , Julie
Navarre, and Kate Langworthy
Effective Care Transitions
ED Admission to Primary Care
Transitions in care between in-patient to out-patient have shown
significant patient safety issues and deficiencies in quality of care:
• Medication discrepancies
• Lack of Lab result follow-up
• Family misunderstanding and lack of involvement in POC
Lack of effective communication is a key contributor to ineffective
care transitions.
• Direct communication between primary care hospitals and MDs.
• Availability of discharge summary and or lack of important
information at time of follow-up visit.
• Lack of follow-up.
• Lack of designated Medical Home to support coordination of the
patient care across settings.
Current Focus and Goals
• Improve quality of ED/Admission Alert report and develop method for
timely viewing by primary care practices (network-wide).
Goal: 80% of reports are viewed by the practice within 24 hrs.
• Increase occurrence of follow-up visit post-utilization. (network-wide
population of focus is Asthma).
Goal: 80% of patients will have follow-up visit post-utilization.
• Understand and address factors contributing to the ED/Admission.
(Pilot practices)
Goal: 75% of time the RCA process provided additional insight
about the underlying factors of the recent utilization.
• To enhance the effectiveness of follow-up visit supported by pre-visit
planning, assessment of medication effectiveness, follow-up on
outstanding lab results and involvement/review of plan of care with
family. (Pilot practices)
Goal: 75% of providers reporting value of the process.
ED/Admission Alert Report
• Currently receiving alerts via HealthBridge information
exchange matched to PHO asthma registry population
which provides incremental data to existing alerts
received from CCHMC.
• Single document “action oriented” report of ED and
inpatient utilizations.
• Links to existing patient registry.
Alerts Sourcing From
Hospitals Beyond CCHMC
ED/Alert Report
ED/Alert Report Viewing
Alert Response Bundle
• RCA – Practice level review completed to determine all
factors contributing to the ED/Urgent Care or Admission.
• Web-based asthma decision aid – Practice completion of a
web-based decision support tool (linked to NHLBI guidelines)
to support effective medication regimen.
• Pre-visit planning – Practice member review of findings and
development of plan for the follow-up visit.
• Access – Practice confirmation and/or outreach to families to
schedule follow-up visit.
• Productive follow visit – Implementation of plan for the visit.
CCHMC-PHO: Alerts Intervention Bundle
Alert
Practice Notification of Admissions and ED/Urgent Care Visit
RCA
Review relevant information within 14 days of ED/urgent care visit
or admission:
• Outreach to family members
• Medical record
• Specialist summary/consult notes
• Discharge summary (ED/urgent care visit, admission)
• Recent test results (e.g., spirometry)
Web-based Decision Aid
Asthma decision support tool (linked to national guidelines)
RCA
Pre-Visit Planning
Access/Productive Visit
Review information and discern reasons for recent ED/urgent care
visit or admission
Determine follow-up and changes to treatment/plan of care based on
findings
Follow-up visit/outreach to patient/family
RCA Interview Script
Key Learnings
• Embedding ICD-9 code in alert report is more valuable than
chief complaint.
• Reliable use of tools to support a “deep dive” requires practice
redesign.
• Integrating clinical decision support tools with EMR and
registries is key.
• Collaborating with inpatient and ED colleagues to complete
the response bundle at “time of greatest impact”.
• Practice challenges to prospectively identify which patients
would benefit most from response bundle.
Thanks to the PHO Team
• Carl Donisi, Director Clinical Operations
• Pilot Community Primary Care Pediatric Practices
•
•
•
•
•
•
•
•
•
ESD Pediatric Group
Children’s Health Care, P.C.
Mid-City Pediatrics, Inc.
Pediatrics of Florence
Anderson Hills Pediatrics, Inc.
Pediatric Associates, PSC
The Whole Child Pediatrics
Landen Lake Pediatrics, P.C.
Pediatric Associates of Cincinnati, Inc.
• PHO Quality Improvement Team: Susmita Das, Claudette Coleman,
Kendra Wiegand, Huiping Li, Ellen Schafer
Questions
Beacon web page
•
www.healthbridge.org/beacon
Social Media
•
•
•
•
Twitter: http://twitter.com/healthbridgehio
Facebook: http://www.facebook.com/pages/CincinnatiOH/HealthBridge/128672340540952
LinkedIn: http://www.linkedin.com/company/healthbridge_3
YouTube: http://www.youtube.com/user/HealthBridgeHIE
Thank You……….