Care Coordination and Transitions in Care:
Improving the Information Flow
Exploring One Beacon Communities Experience
Teams Are Reaching Goals Every Time
HealthBridge 2011 Meaningful Use and Health Care Transformation Conference
May 20, 2011
Julie Schilz BSN MBA
Colorado Beacon Consortium
Today’s Discussion
 Brief Description of the Beacon Community
 Overview of Colorado Beacon Consortium
 Linkages to Care Coordination & Care
Transitions
Look through Patient & Family
Eyes for Value
National Quality Strategy 2011
Two Priorities
Safer Care
Eliminate preventable health care-acquired conditions
Care Coordination
Create a delivery system that is less fragmented and more
coordinated, where handoffs are clear, and patients and
clinicians have the information they need to optimize
the patient-clinician partnership
http://www.healthcare.gov/center/reports/nationalqualitystrategy032011.pdf
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Sorting Through the Acronyms
( and methodologies)
MU?
ACOs?
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The Beacon Community Program
Goal: Share best practices that help communities
achieve cost savings and health improvement
17 demonstration communities that will:
–Build and strengthen their HIT infrastructure
and exchange capabilities and showcase the
Meaningful Use of EHRs
–Provide valuable lessons to guide other
communities to achieve measurable
improvement in the quality and efficiency of
health services or public health outcomes
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The Beacons
Southeastern
Minnesota
Central
Indiana
Southeast
Michigan
Western
New York
Bangor
Inland
Northwest
Rhode Island
Utah
Keystone
Colorado
Greater
Cincinnati
San Diego
Hawaii
Southern
Piedmont
Greater Tulsa
Delta Blues
Crescent City
ONC Beacon Community Integrated
Learning Networks
Activities across the CoPs will align to enable high quality, cost
efficiencies, patient-focused health care, and population health
through clinical transformation
Colorado Beacon Consortium
The CBC is a collaboration of health providers and
community agencies in Western Colorado. The
project is led by the following Community
members:
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Colorado Beacon Consortium Region
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Overall Aim
CBC Offerings
Technology Enhancements
 HIE Connectivity
 EMR Interface
 Provider Portal
(simplified sign on)
 Improved Analytics &
Reporting
 Community Registry
 Inter-HIE Connections
Practice Transformation
 Clinical Process
Efficiency
Consultation
 Performance
Improvement Skills
 Practice
Transformation
 Collaboration with REC
Partner for Meaningful
Use
 Financial incentives to
reduce barriers to
participation.
Practice Transformation Program Guiding Principles
IHI Triple Aim
IOM Six Aims
Program Methodology
Care Model
Model for Improvement
Performance Improvement
QIAs and Learning Collaboratives
Timeframe and Goals
One Year with Advisors and Learning Collaboratives
Close the Gap by 50% from Baseline Measures
Improve Value–Team, Evidence Based Guidelines,
Patient-Centered, HIE/HIT
Our Philosophy, Tools & Program
CBC Change Package
 Performance Improvement
Steps for Performance Improvement
•Choose a measure.
•Determine a baseline.
•Evaluate your performance.
•If performance is not what you would like, develop a performance aim.
•Make changes to improve performance.
•Monitor performance over time.
 Practice Transformation
 Based on the Expanded Care Model
 Curriculum
 Pre-Work Curriculum
 Year long transformation with Learning Collaboratives
 Monthly Narrative & Measure Reporting
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Adapted from IHI Breakthrough Series Collaboratives
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Pediatric & Adult Measures
Pediatric
Phase I
 Asthma – Appropriate
Medications for
Persistent Asthma
 Immunizations – Up to
date by age 2
Phase II
 Child Weight
Assessment &
Counseling
Adult
Phase I
 Diabetes (BP & HbA1c)
 IVD (Lipid screen and
control)
 Depression Screening
(Diabetes & IVD)
Phase II
 Adult Weight Assessment
& Counseling
 Breast Cancer Screening
 Tobacco Ask & Counseling
Multi-Disciplinary and HIT/HIE Focus
CBC Practice Transformation Program
Highlights with emphasis on HITs supporting
role
 Team Based Care
 Care Compacts
 Care Coordination/Transitions
Community Referrals using QHN
All Parties Request and Agree:
All Parties Request and Agree:
 A standardized process for creating and responding to referrals is best
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A standardized process for creating and responding to referrals is best
Each office should have a referral contact person
Each office should have a referral contact person
Provide adequate information so both parties can treat the patient!!
Provide adequate information so both parties can treat the patient!!
Use QHN when possible
Use QHN when possible
Use fax as second choice
Use fax as second choice
Use phone calls when in doubt
Use phone calls when in doubt
Primary Care Practices Request the Following from Specialty Practices:
Primary Care Practices Request the Following from Specialty Practices:
 Date and time of the appointment
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Date and time of the appointment
Notification if the patient was a “no show”
Notification if the patient was a “no show”
Copy of transcription from the specialist, use QHN to cc the PCP!!
Copy of transcription from the specialist, use QHN to cc the PCP!!
Outline of the plan of care
Outline of the plan of care
Communication about who will manage the medications
Communication about who will manage the medications
When there are critical issues, pick up the phone and call!
When there are critical issues, pick up the phone and call!
Specialty Practices Request the Following Information:
Request the Following Information:
 Specialty
Patient Practices
name
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Patient
name
Patient
demographics
Patient
demographics
Patient
Insurance
(if known)
Patient
Insurance
(if known)
Diagnosis or symptoms
Diagnosis
or symptoms
Relevant
notes,
lab and radiology results
Relevant
notes,
lablist
and radiology results
Current medications
Current
ICD-9
code,medications
if possible list
ICD-9
code, if possible
Send
in QHN
Send in QHN
How HIT Fits!
-Consistency around registry data capture
-Work flows around Health Information Technology
-Medication reconciliation for Diabetic patients
-Establishing focused care visits
-Transitioning to Meaningful Use Electronic Medical
Record
-Creating Electronic Medical Record templates
-Redefining office protocols around the Beacon chronic
disease measure set
-Implementation of team huddles and daily patient
preparation
-Processes around patient check in/check-out
procedures and scheduling
-Standardizing office standing orders
-Streamlining lab reconciliation processes
What Can You Do By Next Tuesday?
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Teams Are Reaching Goals Every Time