CNY Cares PHM System: Advancing Transformation
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1 CNY Cares PHM System: Advancing Transformation
2 Agenda 2 Community Integration By The Numbers Community Modules Partner Integration/Implementation Progress and Success How can PHM help your organization Discussion
3 Community Integration 3 By the Numbers Integrations 43 Unique Source Systems Currently Integrating 36 Partner Organizations Hospital, PC, BH, HH,HSO 24 Newly Incentivized Integration Partners PC,BH,HSO 60 Possible Partner Integrations 73 Total Partner Organization to be enabled in Q on Claims Data By the Numbers Measures 24 DSRIP Measures DSRIP Related Performance Management 3 Custom Measures DSRIP Related Performance Management 27 VBP Measures Measure Provided to Allow Partners to prepare for VBP contracting
4 Community Integration Modules 4 Performance Manager Available to All Integration Partners Available to All Partners with Claims Attribution 73 Total Partners Care Manager Available to All Partners Community Care Plan CBO & HSO Programming Engagement Manager Available to Integration Partners Real time care coordination and outreach 60 Possible Partners by program completion
5 Community Integration: Scaling Source Go Lives Partner Go Lives Total Sources
6 Community Integration Milestone Progress % 90.00% 26.83% 17.07% 80.00% 70.00% 56.10% 51.22% 12.20% 41.46% 60.00% 82.93% 85.37% 19.51% 50.00% % % 40.00% 30.00% 19.51% 12.20% 53.66% 70.73% 58.54% 20.00% 36.59% 10.00% 17.07% 14.63% 24.39% 0.00% Kickoff Project Discovery Gaps Closures Connectivity Mapping Integration Virtual Chart Review Content Validation Training Remaining In progress Complete 6
7 Community Integration: Partner Timeline Partner/EMR Estimated Completion Date Note/Act Complete Auburn McKesson Complete (Dec 17) Complete Auburn Medent Complete (Dec 17) Complete MVHS All Scripts MVHS McKesson MVHS Centricity MVHS Greenway MVHS AS/400 Family Care Medical Group Medent East Hill Medent CHS Medent Oswego Family Physicians Medent Claims Oneida Meditech Connext Care Oneida Medent Sitrin Medent Sep 18 Nov 18 Nov 18 Nov 18 Nov 18 Integration Compete: MVHS & IBM Working through content validation tickets (Oct 18) Integration Compete: IBM and Medent Verifying data for one measures (Oct 18) Integration Compete: Content Validation with IBM (Nov 18) Data integrated, QA Started working towards sign off Data integrated, QA Started working towards sign off Data integrated, QA Started working towards sign off Data integrated, QA Started working towards sign off
8 Community Integration: Partner Timeline Partner/EMR Estimated Completion Date Note Liberty Medent Nov 18 Data integrated working towards sign off Lewis County General Meditech Dec 18 Data mapped working towards sign off 1 month behind Lewis County General Meditech Amb Dec 18 Data mapped working towards sign off 1 month behind Planned Parenthood Mohawk Hudson Dec 18 Data integrated, QA Started working towards sign off Loretto True Chart Dec 18 Currently Integrating Oswego Meditech Feb 19 Mapping review being scheduled Meditech Upgrade Physician Care PC Feb 19 Mapping review being scheduled Meditech Upgrade SCHC Nextgen Feb 19 SCHC Creating views to limit BH/SUD Data Crouse/Community Sorian Feb 19 Operational & SUD prior to mapping ARISE Nersmart Feb 19 Mapping Phase Kinney Drugs Feb 19 Mapping Phase Rome Medent Mar 19 Data Being Integrated Rome McKesson Mar 19 Mapping Phase Community Memorial Medent Mar 19 Data Being Integrated Crouse Medent Mar 19 Data Being Integrated Liberty DocAssist Mar 19 Data Validation
9 Community Integration: Partner Timeline Partner/EMR Estimated Completion Date Note Upstate Epic TBD Upstate on hold until at least Jan 2019 SJHHC Epic TBD SJHHC evaluating Data Use Agreement before sending live data, test data has been mapped Sitrin PointClick Care Apr 19 Working with PCC Fingerlake Community Health ecw Apr 19 Data Connectivity in Progress RPCN ecw Apr 19 Mapping to begin Circare Homegrown CM Desktop Jul 19 Pre Mapping Circare Qualifacts Jul 19 Pre Mapping CNYHHN GSI Jul 19 Initial extractions being processed Helio Netsmart Jul 19 Working with IBM to Architecture The Neighborhood Center Jul 19 Initial extractions being processed Menorah Park Sigma Care Sep 19 Not Started St. Camillus PointClick Care Sep 19 Working with PCC Upstate CP Credible Sep 19 Working with Credible EMR
10 How Can Watson Help: Performance Manager 10 Data Governance Aggregation and standardization of data will allow to see documentation inefficiencies in your own data Patient List Generation Registries allow your organization to find custom patient cohorts using all community data VBP Readiness Measures, Metrics and Registry using all community data will allow your organization to have superior insight when negotiating VBP contracts Care Opportunities Community patient chart, measures and registries will actively identify patients in need of care, or avoid redundant Care
11 How Can Watson Help: Engagement Manager 11 Care Coordination Use all community data with IBM protocols to perform automatic protocol based outreach on patients in need of care or intervention. Breast Cancer Screen, Cervical Care Screen, Diabetes, Depression, Cholesterol, Annual Wellness Custom Campaigns Use campaign function to target patients of Organization, or Clinic specific initiatives Flu Shot Reminders, School Physical Reminders, Registry based campaigns Practice Efficiency All outreach performed is custom to your organization, with your brand Outreach is performance your preferred cadence
12 How Can Watson Help: Watson Care Manager 12 Custom Care Management CNYCC will work with partners to put their assessments and programs into Watson Care Manager. Community Care Plan As organizations adopt Care Manage, you will be able to collaborate on care within one system and view the shared care plan. Effective Capture of Social Determinants of Health All participating partners can document on SDH on patients which can lead to more effective care planning. SDH can be used with clinical data to drive new insight into community. Community Referrals Care manager and community portal can provide effective community based referral process.
13 Discussion: What else can Watson do for you? Performance Manager Are there performance initiatives that do not fit into the categories discussed? Medicare? Private Payer? Internal? 13 Engagement Manager What type of routine outreach does your organization normally perform? Is it automated? Does it meet all your needs? Are there protocols or groups of patients you have trouble identifying? Care Manager In what ways does can a community care plan benefit your organization and your patients/clients? Does your organization have the ability to document care plans? How would a community care plan save you time?
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