AMCH PPS. Clinical & Quality Affairs Committee. March 30, 2016

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1 AMCH PPS Clinical & Quality Affairs Committee March 30, 2016

2 AMCH PPS: Clinical & Quality Affairs (CQA) Committee Presentation Objectives: Clinical Integration Strategy Accenture Project Implementation Updates

3 Insight Driven Health Albany Medical Center Hospital DSRIP Clinical Integration Strategy CQAC March 30, 2016 Copyright 2016 Accenture All Rights Reserved. Accenture, its logo, and High Performance Delivered are trademarks of Accenture. Copyright 2016 Accenture All Rights Reserved. Accenture, its logo, and High Performance Delivered are trademarks of Accenture. 3

Project Status 3/21/16 3/25/16 Draft for discussion Accomplishments this period: (from 3/21/16 3/25/16) Scheduled and conducted all site visits Received data / document request responses and began

5 Project Status 3/21/16 3/25/16 Draft for discussion Accomplishments this period: (from 3/21/16 3/25/16) Scheduled and conducted all site visits Received data / document request responses and began analysis Determined current state assessment based on site visits Defined future-state CI workgroup agendas, dates, and key activities Developed draft Care Coordination Model (CCM) Held Current State Validation meeting on 3/22/16 to review the assessment and confirm findings Reviewed future state straw model with Dr. Manj and Tara for initial approval Key activities for next period: (from 3/28/16 4/1/16) Finalize future-state CI workgroup participants Finalize future-state straw models and send to workgroup participants as a pre-read Hold Future State Workgroup #1 on 3/31/16 (4hrs, 8:30am-12:30pm) Develop material for Workgroup #2 to be held on 4/7/16 Continue to finalize Care Coordination Model (CCM) Key Project Milestone Progress: Issues & Risks: Risk / Issue Risk: Need to identify workgroup participants by this week (week of 3/28/16) Resolution / Mitigation Work with Steering Committee to identify and confirm participant commitments We are here mid-week 6 Copyright 2016 Accenture All Rights Reserved. Accenture, its logo, and High Performance Delivered are trademarks of Accenture. 5

7 Current State Assessment Objectives Draft for discussion The CSA will inform the future state CI Strategy and CCM Develop an understanding of affiliates current state Care Coordination (CC) functions / processes / protocols: o Hospital admission management o Discharge (D/C) planning o Transition of Care (ToC) (e.g., ED, inpatient, outpatient providers) o Readmission management o Barriers to care o Communication o High risk patient management o Roles / responsibilities (e.g., infrastructure, staffing ratio, hours of coverage) o Technology enablers Identify gaps / leading practices and create a unified understanding of current capabilities related to Clinical Integration (CI) Summarize and validate findings to serve as inputs for the future state CI processes, implementation approach and plan Copyright 2016 Accenture All Rights Reserved. Accenture, its logo, and High Performance Delivered are trademarks of Accenture. 7

8 Current State Assessment Scope / Approach Illustration of Activities Draft for discussion AMCH conducted a CSA utilizing interviews / focus groups / shadowing staff and analyzing data / documents 20 Conducted 2 webinars with Affiliates Sent care management/ care 109 to introduce project goals and coordination documentation and data expectations request to Affiliates on 2/29 Affiliates Documents Reviewed DSRIP requirements and CM leading practices; analyzed interview / observation notes 81 Interviewees Launched observations / interviews / focus groups on 3/8 across 14 of the Affiliates Reviewed / analyzed Affiliates documents and hospital admission / discharge data Reviewed preliminary findings / recommendations with Clinical Integration Leadership Conducted Current State Validation webinar session with select participants All leading to... Completed Current State Assessment (CSA) and preparation for future state Clinical Integration Care Coordination Model (CCM) Copyright 2016 Accenture All Rights Reserved. Accenture, its logo, and High Performance Delivered are trademarks of Accenture. 8

9 Current State Assessment Key PPS Strengths Draft for discussion Several areas of strength were identified that could be leveraged for the CCM / future state design Admissions & Assessments D/C Planning & Transitions of Care Readmissions & High Risk Patient Management Barriers to Care Acute ED Social Worker available 24/7 to focus on aligning complex / high-risk patients with services Standardized acute Case Mgmt / Social Work assessments for high risk readmissions and D/C planning minute acute interdisciplinary huddle to review D/C today Acute care setting shares patient D/C list with OP clinics Acute utilization of Vocera software allows patients to play-back of D/C dictations Acute charge nurses conduct D/C follow up calls within 48 hours OP Referral coordinator schedules follow-up appts. in reserved appt. slots, retrieves patients medical records, and follows up to ensure compliance OP liaisons embedded in acute care settings improve D/C planning and post-acute care transition Acute Extended Stay weekly review meeting for all patients LOS >5 days; attendance includes representatives from finance, legal, psych, case management, hospitalists, and social work OP physician practice staffs 2 case managers and 1 social worker 5 days / week OP Physicians complete risk assessment and assigns Case Mgrs to all high risk patients Acute care setting s Financial Counselors assist patients with navigating Medicaid Community Based Organization / OP Clinics staff employees who serve in patient navigation function Copyright 2016 Accenture All Rights Reserved. Accenture, its logo, and High Performance Delivered are trademarks of Accenture. 9

Current State Assessment Summary by Key Themes Draft for discussion Key themes / challenges were identified from the observations / interviews across the affiliates and provide insights for the

10 Current State Assessment Summary by Key Themes Draft for discussion Key themes / challenges were identified from the observations / interviews across the affiliates and provide insights for the future state CC opportunities Key Themes Behavioral Health Challenges Increasingly complex population combined with lack of resources and fragmented care Inconsistent Communication across the Care Continuum Inconsistent communications across levels of care was an issue for nearly every affiliate Fragmented CC functions / processes For most sites, CC functions are dependent on expertise of staff rather than standard processes Limited Data Exchanged Affiliates use a multitude of systems, the use of Hixny as an HIE remains highly variable Limited Availability for Placements / Services Limited options and extreme wait times for patients needing care / services is a pronounced issue across sites Social Barriers to Care Social barriers often prevent patients from taking basic steps for health prevention and disease management Copyright 2016 Accenture All Rights Reserved. Accenture, its logo, and High Performance Delivered are trademarks of Accenture. 10

Current State Assessment Current CC / ToC Functions Draft for discussion Based on observations of current Care Coordination and Transitions of Care functions indicates there are areas of consistent

11 Current State Assessment Current CC / ToC Functions Draft for discussion Based on observations of current Care Coordination and Transitions of Care functions indicates there are areas of consistent practice and opportunities for standardization and improvement Affiliate ID High Risk Patients Standard CM Ass-essment Alert for Readmit Align PCP BH Management Patient Navigator Make Post D/C Calls Make Post D/C Appts. Make Reminder Calls Hospital Primary Care Primary Care Hospital Primary Care Hospital Primary Care Primary Care Primary Care CBO CBO CBO CBO CBO Legend: Yes / Regularly Applied No / Not in Limited / Source: Practice Inconsistent 1. Tier 1 PPS stakeholders during data requests / interviews / focus groups, from 3/8/16 thru 3/17/16 Copyright 2016 Accenture All Rights Reserved. Accenture, its logo, and High Performance Delivered are trademarks of Accenture. 11

12 Current State Assessment Summary Draft for discussion Site Visit affiliates have significant gaps in evening / weekend / vacation coverage with limited Patient Navigation support Staffing / Coverage Status Current Coverage Evening Coverage Significant gaps 2 of 15 affiliates provide on-call evening coverage beyond working hours Weekend/ Vacation Lack of weekend / vacation 1/3 of the affiliates lack weekend/ vacation coverage Behavioral Health Variable BH CC services 3 of 5 BH affiliates have Case Management services Patient Navigation Limited PN functions 3 of 15 affiliates use Patient Navigator services ED Limited ED CM Only 1 hospital offers evening / weekend coverage (SW) Case Load Variation by role Dependent on extended role i.e. UM, the services provided and if there are Social Worker and Patient Navigation roles / support Implications for Future State Enhance existing ED infrastructure (staffing & coverage) to support CC functions effectively Leverage interdisciplinary care team, inclusive of Patient Navigators, all working at top of their license; current model is expensive Establish co-location or coordination models for BH and Primary Care Integration; shortage of BH resources is a concern and alternative models need to be considered Copyright 2016 Accenture All Rights Reserved. Accenture, its logo, and High Performance Delivered are trademarks of Accenture. 12

Opportunities Continuum Focus CI Requirements: Define /

data sharing Optimize available technology enablers to

coverage to support 7 day services Draft for discussion

the continuum Substance Abuse Clinic Housing Services

Inpatient Rehab Courthouse Ambulance Department of

Outpatient Behavioral Health Social Services Outpatient

Services Copyright 2016 Accenture All Rights Reserved.

14 Opportunities Continuum Focus CI Requirements: Define / establish standards for CM functions / processes and data sharing Optimize available technology enablers to support CC Define clear CC roles / functions and coverage to support 7 day services Draft for discussion AMCH DSRIP PPS supports 3 ecosystems with a focus on the continuum Substance Abuse Clinic Housing Services MCO Pharmacy Skilled Nursing Facility Physician Clinic Inpatient Rehab Courthouse Ambulance Department of Corrections Patients / Service User Hospital Home Outpatient Behavioral Health Social Services Outpatient Rehab Urgent Care Center Home Care Transportation Services Copyright 2016 Accenture All Rights Reserved. Accenture, its logo, and High Performance Delivered are trademarks of Accenture. 14

Opportunities Risk Reduction and Care Coordination for All Patients Draft for discussion Assessing all patients and using analytics to calculate risk score allows for proactive management across the

15 Opportunities Risk Reduction and Care Coordination for All Patients Draft for discussion Assessing all patients and using analytics to calculate risk score allows for proactive management across the care continuum Previous models focus on interventions for high risk populations only Expanding the model to include interventions and follow up for moderate and low risk populations, in order to: Enhance post discharge support Prevent the patients becoming a higher risk for readmission Copyright 2016 Accenture All Rights Reserved. Accenture, its logo, and High Performance Delivered are trademarks of Accenture. 15

16 Opportunities Current State vs. Future State Functions and Outcomes Draft for discussion While there are many existing CM practices to leverage, the future state CCM and CI Strategy will enable the full PPS to optimize CC for better outcomes Current State Future State Processes Development of CCM and CM Functions / Processes Define / establish standards for CM / CC functions / processes and data sharing across the care continuum Leverage interdisciplinary care teams utilizing PN with increased coverage and access for weekends / evenings Enhance data sharing and leverage available technology enablers to faciliate communication Future Clinical Integration Expected Outcomes Avoidable ED visits / use % of admissions Avoidable readmissions Cost in ED / inpatient / PC / BH Frequency of ambulatory / preventive visits Alignment to PCP Patient satisfaction Capture of HCAHPS Care Transition across PPS Pts. with new / updated CM plan / self mgmt. goals ED pts. with follow-up appt. with PCP Copyright 2016 Accenture All Rights Reserved. Accenture, its logo, and High Performance Delivered are trademarks of Accenture. 16

17 Opportunities Strategies and Enablers Draft for discussion The CI strategy will focus on establishing standard functions, processes, communication protocols and technology enablers Current State Development of CCM and Future CM Functions / Processes Future Clinical Integration Admissions & Assessments D/C Planning & Transitions of Care Readmissions & High Risk Patient Management Barriers to Care & Patient Navigation Complete initial review within 24 hrs. Utilize criteria-based tool to assign pts. appropriate acute LOC Coverage 7 days / week, all entry points Target LOS / disposition identified at admission D/C plan initiated upon admission Concurrent reviews completed every 48 hrs. Align patients with Primary Care Physician Timely D/C summary to post-acute provider(s) Warm hand-offs to next LOC Proactive outlier management Use of high risk stratification tool Schedule PCP follow-up appointments Follow-up phone call within 48 hrs. of D/C Med Rec at D/C Develop care continuum plan Establish leveraged care teams, including patient navigator roles Assist care team with non-clinical tasks Ensure smooth coordination of logistical, financial and social services Technology Enablers ED triage alerts Standard process for incorporating Hixny data EMR quick view displays Target LOS date / disposition Information exchange and access of D/C summary and care plans Assessments and plans regularly contributed to Hixny Single transfer alert schema Risk score sharing Readmission alerts configured in EMRs EMR quick view indicates risk level for all patients Barriers to care documented in assessments Assessments contributed to Hixny Copyright 2016 Accenture All Rights Reserved. Accenture, its logo, and High Performance Delivered are trademarks of Accenture. 17

18 Opportunities Next Steps Draft for discussion The next step to enhance CC and CI across the PPS is the future state design of the CI strategy and CC functions /processes standards Mobilization Current State Assessment Future State Design Training Jan/Feb Mar 1 Mar 28 May 6 May 31 Define CI project scope Identify Site Visit Affiliates Kick-off Webinar for Site Visit Affiliates Gain understanding of current state of care coordination, CM, processes, data, and staffing Collect relevant data and documentation Conduct analysis Develop high-level key findings and recommendations Affiliates validate individual findings Design and refine CI processes/functions for discharge and ToC Convene work group of stakeholders and Subject Matter Advisors to validate and refine the CI functions / process standards Define education criteria and implementation / training plan Conduct training on future state for hospital staff and affiliate partners Key Completed In progress Not yet started June 30 th, 2016: Milestone due date; all activities completed, documented and reported to DOH Copyright 2016 Accenture All Rights Reserved. Accenture, its logo, and High Performance Delivered are trademarks of Accenture. 18

20 Focus Areas Future State Workgroup Focus Areas by Session Draft for discussion Workgroup sessions will cover in scope Care Coordination functions / elements and processes Session 1 3/31 Session 2 4/7 Session 3 4/14 Session 4 4/21 Session 5 4/28 Review Current State & Set Obj. ED, Observation and Acute Admission Protocols and Assessments ED / hospital admission function / elements / handoffs / info sharing CM assessments / risk identification Readmission and Transition of Care Planning Readmission mgmt. / elements / interventions ToC / D/C planning Discharge to Post Acute, Home and Primary Care Process flows: D/C to home D/C to / OP / clinics/ Home Health Primary Care Post Acute Care (SNF, Rehab, other facility) Each functional focus area discussion will include the following (what / when): 1. Elements / interventions 2. Recommended timeframes to complete activities 3. Required data to support communication sharing and when to share / send 4. Potential recommendations for the who 5. Focus on ToC and CC in community settings between primary care and behavioral health where applicable Patient Navigation Barriers to Care Patient navigation functions /elements Barriers to Care management functions Alignment of All Processes Complete any outstanding processes Validate there are no gaps in the end to end patient management Copyright 2016 Accenture All Rights Reserved. Accenture, its logo, and High Performance Delivered are trademarks of Accenture. 20

21 April March Future State Workgroup Proposed Schedule Draft for discussion Future state workgroup sessions will begin Thursday 3/31 Monday Tuesday Wednesday Thursday Friday Send pre-read to workgroup #1 EOD Send pre-read to workgroup #2 EOD Send pre-read to workgroup #3 EOD Send pre-read to workgroup #4 EOD Send pre-read to workgroup #5 EOD Workgroup Session #1 (8:30am-12:30pm) Workgroup Session #2 (8:30am-12:30pm) Workgroup Session #3 (8:30am-12:30pm) Workgroup Session #4 (8:30am-12:30pm) Workgroup Session #5 (8:30am-12:30pm) Feedback collected and adjustments made Feedback collected and adjustments made Feedback collected and adjustments made Feedback collected and adjustments made Feedback collected and final material developed Copyright 2016 Accenture All Rights Reserved. Accenture, its logo, and High Performance Delivered are trademarks of Accenture. 21

22 AMCH PPS: Project Sequence - Update Project name Project ID Start date SC 1. Integrated Delivery Systems 2.a.i Nov/Dec ED Care Triage 2.b.iii Nov/Dec Patient Engagement PAM & CFA 2.d.i Nov/Dec Asthma Evidence-Based Guidelines 3.b.iii Dec 2015/Jan Cardiovascular - Hypertension 2.a.iii Dec 2015/Feb Integration of PC & BH Part I (Models 1 & 3) 3.a.i Jan 2016/Feb Health Home At-Risk Intervention Program 3.b.i Jan 2016/Feb BH Community Crisis Stabilization 3.a.ii Jan 2016/Feb Integration of BH & PC Part II (Model 2) 3.a.i Jan 2016/Mar Medical Village SNF 2.a.v Apr 2016/Mar Tobacco Cessation 4.b.i Jun Cancer Screening 4.b.ii Jun 2016

23 23 2.a.iii Health Home At-Risk Intervention Project Objective: Expanded access to community primary care services (PCMH 2011 Level III certified sites) and develop integrated care teams to meet the individual needs of higher risk patients who do not currently qualify for NYS Health Home services. Co-Chairs: Kallanna Manjunath & Stephanie Lao Key updates: Introductory webinar held on Feb 19 th Strong interest among our HH care management downstream organizations First Sub-committee meeting held on March 29 th Sub-committee approved roles and responsibilities document Next steps: Educational session on Health Homes Finalize the components of project care plan Explore utilization of EMR systems for patient identification

24 2.b.iii ED Care Triage Project Objective: To develop a care coordination/care transition program that will assist patients to link with a PCP To provide supportive assistance to transitioning members to the least restrictive environment Chair: Denis Pauze MD Key Updates: ED Care Triage Subcommittee meeting held on March 7 th Discussion of current ED triage process and narcotic prescription guidelines Workflow for Patient Navigators Meeting with EmUrgent Care Leadership on March 4 th ED Diversion and Crisis Stabilization Project Meeting in Hudson on February 29 th Presentation to the CMH ED department on March 23 rd. Next Steps: Next ED Care Triage Subcommittee meeting on Monday, April 4 th at 10am Review new CDC guidelines on opiate Rx Discuss current patient navigation approach across PPS 24

25 3.a.i Integration of Primary Care and Behavioral Health Services The initial 3.a.i sub-committee meeting was held on 3/24/2016. Co-Chairs: Keith Stack, Executive Director of The Addictions Care Center of Albany Brendon Smith, PhD of AMCH PPS We proposed a structure of two distinct workgroups, one for projects based in primary care sites, and one for projects based in behavioral health sites. We proposed that the workgroups meet monthly to support project implementation, and that the full sub-committee meet quarterly for performance reporting review. Members were tasked with reviewing documents related to DY1 Q4 deliverables, sub-committee roles and responsibilities, and project specifics.

26 3.a.ii Behavioral Health Community Crisis Stabilization Services The initial 3.a.ii sub-committee meeting will be held on 3/31/2016. Co-Chairs: TBD Brendon Smith, PhD of AMCH PPS The subcommittee is comprised of experienced behavioral health and community crisis providers, key stakeholders, and content-area experts from across the PPS. The subcommittee will meet on a monthly basis to support project implementation.

27 3.b.i - Evidence-Based Strategies for Disease Management in High Risk/Affected Populations (Adults Only) Project Objective: To support implementation of evidence-based best practices for disease management in medical practice for adults with cardiovascular conditions. Co-Chairs: Joseph Wayne, MD & Tara Foster, MS, RN Key updates: Subcommittee meeting held on Friday, March 25 th Identification of co-chair; Distribution of participant list; Review of draft Subcommittee Charter; Review of Project Summary and performance measures; Identification of opportunities for rapid cycle improvement Next steps: 27 Future subcommittee meetings proposed for 1 st Friday, 8-9am, starting May 6. Identify required data elements to be captured in EMR and discuss creation registries Discuss feasibility of standardization of self-management tool across PPS and review available tools

28 3.d.iii: Implementation of Evidence Based Medicine Guidelines for Asthma Management Project Objective: Ensure access for all patients with asthma to care consistent with evidence-based medicine guidelines for asthma management. Co-Chairs: Ron Dick, MD & Shannon McWilliam, MPH Key updates: Subcommittee meeting held on Monday, March 28 th Identification of co-chair; Distribution of participant list; Review of draft Subcommittee Charter; Review of Project Summary and performance measures; Identification of opportunities for rapid cycle improvement Next steps: Future subcommittee meetings proposed for 2 nd Friday of the month. Review available Asthma Action Plans and discuss widespread adoption Discuss the feasibility of developing a common AAP for use across PPS Identify required data elements to be captured in EMR and discuss creation registries 28

Albany Medical Center. AMCH PPS Clinical & Quality Affairs Committee

Albany Medical Center. AMCH PPS Clinical & Quality Affairs Committee Albany Medical Center AMCH PPS Clinical & Quality Affairs Committee Kallanna Manjunath MD, FAAP, CPE Tara Foster, MS, RN Mingie Kang, MPH Mark Quail, MEd Brendon Smith, PhD Susan Kopp MBA, BSN, RN January