eCaring Inc.
November 19, 2015
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Agenda
Introduction
Goal of Pilot
Tier Piloting
Activity to Pilot
Role of eCaring in the pilot
Standards and Technologies Under Consideration
Logistics
Ecosystem
Defining Success
Resources/References
Pilot Team
Name
Role
Email
Robert Herzog
CEO
Robert@ecaring.com
Pamela Hall
COO
Pamela@ecaring.com
Stuart Hunt
CTO
stuart@ecaring.com
Kathleen Harkins
VP of Business Development
kharkins@ecaring.com
Jane Fields
VP Care Management & Sr. Advisor
Jane@ecaring.com
Sara Dijak
Director of Client Implementation
Sara@ecaring.com
Introduction to eCaring
• A unique patient-centered reporting and care management system
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eCaring is easy to use and enables home care workers, caregivers and patients to report real time health care
information from the home, capturing previously inaccessible unstructured human touchpoint data
Data is basis for actionable alerts that enable early interventions that minimize problem severity across the
care continuum
• Proven results with payers, plans, hospitals and providers
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40% reduction in ED and hospital visits; 60% reduction in CHF readmissions
Average savings of $4,000 per patient annually
Substantial reporting of quality-related metrics – over 70 data points per patient per month
Enhances care management and coordination
Improves quality and patient satisfaction
• eCaring support and services
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Generates real time, actionable home health care data, creates a longitudinal patient-centered record, collects
easily shared cloud-based information that supports quality and population health initiatives
• eCaring and eLTSS activities
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eCaring enables the creation, exchange and reuse of patient-centered records by health care and communitybased service providers, payers and the beneficiaries they serve
eCaring uses Verizon cellular network to provide internet connectivity to underserved populations, for real
time data flow that is accessible through the cloud
Robust analytics customized for collecting information, such as; quality, timeliness, critical disease state data
Real-time Actionable Data from the Home
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Business Drivers
• Connects systems and organizations within the healthcare ecosystem
• Aligned with major CMS goals of reducing preventable hospital and ED visits and
readmissions, and programs such as DSRIP, Financial Alignment model for dualeligibles, Value-Based Payment Initiatives
• Enables beneficiaries to remain in their homes
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Keeps people out of the hospital
Enhances service and care plan adherence
Captures quality metrics and improves patient satisfaction
• Lowers costs, improves quality for payers, plans and providers
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Supports shift from fee for service to capitated rates, bundled payments and VBP
Ongoing tracking of quality metrics to optimize patient engagement and satisfaction
New source of major health care data from the home, easily sharable among care teams
• Supports federal initiatives such as:
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National Quality Strategy: “Improve the health of the US population by supporting proven interventions to address behavioral,
social and environmental determinates of health in addition to providing quality care”.
IMPACT ACT’s requirement for person centered care, connecting disparate system
Meaningful Use requirement for Interoperability to create communication for care coordination between caregivers, beneficiaries
and care management teams. Also providing robust analytics for population health initiatives, engaging patients and family,
improving safety, efficiency and health disparities.
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User Story 2
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Workflow:
Capturing Data from the Home
Meet Ruth:
She has a caregiver, Stephanie, and Care Manager, Meredith
• Care Manager creates a customized service plan for Ruth into eCaring
• Caregiver works with the patient and enters functional status, ADL and other
care plan elements daily, including
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Medication adherence
Psychological state
Vital signs
Critical behaviors and activities
Health
And much more
Two way note system
HIPAA Compliant
Caregiver Stephanie arrives at Ruth’s house for her regular work shift and notices Ruth
seems a little confused.
Stephanie uses her eCaring tablet to enter confused.
An alert is immediately generated and sent to her care manager Meredith.
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Workflow:
Care Management for Early Interventions
Alert is sent directly to Meredith in real time, placed at top of her Care Management dashboard for
urgent response
Meredith reviews Ruth’s health history within eCaring and calls Ruth
Caregiver speaks on behalf of Ruth and explains that she has worked with Ruth for 3 years and today
Ruth cannot remember her name.
Historical response was to go to ED
Care Manager sends nurse to Ruth’s home who
completes lab work and discovers she has a
Urinary Tract Infection (UTI)
Care Manager contacts PCP, who orders
Antibiotics
Outcome:
Ruth’s UTI was caught early through eCaring and care coordination. She was
treated in her home and avoided hospitalization.
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eCaring Program Partner Results
70
Quality Data Points PMPM
Key quality metrics used in
Quality Rating System
529
2-3
Observations PMPM
Alerts PMPM
Extensive actionable data
Easily manageable
>$4,000 Cost Savings Annually
Which Tier are you piloting?
• eCaring currently works within scope of Tiers I and II
• eCaring can if required be interoperable through API’s into
other EHRs, and Care Management Systems
• eCaring works with multiple stakeholders, all of whom have
different workflows
• eCaring meets all providers where they are within their
development process
What are you intending to pilot
• eCaring fits into the following pilot plans:
– Create Plan
– Access, View, Review Plan
– Update Plan
• eCaring can meet all Pilot sub-domain requirements
– The following sub-domains are particularly relevant for eCaring:
– Health, Wellness and Rights:
» Health
» Medications
» ADL/IADL/Functional Status
» Psychological Well-Being
– Cross-Cutting Sub-Domains:
» Units of service
» Priorities
» Issues
» Interventions
What role do you play in the pilot
eCaring is a unique provider of real time actionable home care
information from the patient’s home. As such it can support several
eLTSS roles, including:
• CB-LTSS Provider
– eCaring can provide a person-centered eLTSS record to support the needs of the beneficiary
as they receive support and services in the community. The record will enable information to
be exchanged electronically across multiple CB-LTSS settings such as adult day care,
beneficiary homes, group homes, and assisted living
• Beneficiary System
– The information captured within eCaring records supports the beneficiary and care teams in
making decisions about the types of care and services required, while improving the
coordination of health and social services.
• LTSS/Case Management Information
– eCaring provides a significant new source of health care data that is vital to genuine
comprehensive care management, and enables communicating this data among the
beneficiary’s Care Manager and service providers
– eCaring enables the creation, exchange and reuse of person-centered records by health care
and community based service providers and the individuals they serve.
Standards Under Consideration:
• eCaring has the infrastructure in place to work with Pilot
providers at their current level of development and progress to
the Tier level they seek to achieve:
• Tier 1
– Help service providers establish a customized service plan for beneficiaries
• Tier 2
– Electronically share the plan and improve communication and care coordination between the
beneficiary and service providers
• Tier 3
– Support interoperability by integrating with EHRs, care management systems, and other
critical communication tools
Pilot Logistics:
• Timeline
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Kick off: December 2015
Identification of Partners/Providers- January 2016
Completion of RTM: March 2016
Completion of Pilots: June 2016
• Solving challenges:
– Easy to use for patients, caregivers, home care workers and care managers, regardless of
English or computer literacy
– Available in multiple languages for non-English speaking beneficiaries
– Provides Internet connectivity for underserved populations – low income, rural, dual eligible,
etc. – through Verizon partnership
– Improves care management workflow with alerts that triage resources
– Avoids alert fatigue by filtering for actionable alerts
– analytics for ongoing performance reviews and assessing and sharing best practices
• Challenges:
– No standards in place for interoperability
– Service plans differ by organization
Pilot Ecosystem
• Current and potential partners/providers
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Medicaid managed care and Medicare Advantage
MLTC and Home Health Agencies
CMS’s Financial Alignment Initiatives
Hospitals, Health networks and ACO’s
Verizon
Samsung
• eCaring’s partners/providers use systems including:
– EHR (Epic, Cerner, etc…)
– Care Management Platforms
– Time reporting documentation (HHA Exchange, SanData, etc…)
• eCaring uses the following systems during operations:
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SOTI remote device management
HIPAA compliance
Coded in Ruby on Rails
Servers are running on Heroku
Amazon S3 to store data
Database is PostgreSQL managed by Heroku
How do you define success
• Pilot
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Reducing ED and hospital visits and readmissions
Lowering patient costs while enhancing quality
Engaging beneficiaries and their advocates
Improving care team workflow
Keeping beneficiaries at home
Adoption by patients, care givers and care managers
Translating data entered from the home into actionable information for care managers
• Beyond pilot
– Collecting quality indicators that can be used to improve STAR, Quality, and Patient
Satisfaction scores
– Integrating data from eCaring to the eLTSS record to accelerate quality, population health and
research initiatives
– Utilizing eCaring tablet and connectivity to connect to ancillary services in the home such as:
education and support, transportation, DME, prescription refills, Meals on Wheels
Select Clients and Partners
www.eCaring.com | 18
Additional Resources
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The eCaring Website
eCaring Case Studies
News
Blog
eCaring Video
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