Over 200 ambulatory sites

Transcription

1 Welcome to

2 five inpatient hospitals: Tisch Hospital Rusk Rehabilitation NYU Langone Orthopedic Hospital NYU Langone Hospital - Brooklyn Hassenfeld Childrens Hospital with locations in New York City s five boroughs Long Island New Jersey Westchester, Putnam, and Dutchess counties affiliation with Winthrop University Hospital Over 200 ambulatory sites

3 Clinical Care Modern Healthcare THE JOINT NATIONAL QUALITY APPROVAL COMMISSION Modern Healthcare Top Hospital Ranked #1 & #2 Third Year in a Row for Overall Patient Safety & Quality 140 Physicians Listed in New York Magazine s Best Doctors Gold Seal of Approval by the Joint Commission for Commitment to High Quality Care Magnet Recognized Hospital for Excellence in Nursing Most Wired Hospital

4 #1 in licensing revenue among U.S. universities A Top 11 U.S. News & World Report s Best Medical School $189 million in new NIH funding for 2016 RESEARCH 435 research faculty Among the fastest growing NIH portfolios in the U.S. 4,187 peer reviewed publications as of 2016

5 Education 175 Years of Training Physicians and Scientists 5,000 Voluntary, full and part-time faculty 80 MD/PhD students 75+ Residency and Fellowship Training Programs 3 -year medical degree program 233 PhD Students

6 we ve achieved Based On Ability To Leverage and govern health data and analytics Stage 7 Execute computer order entry and electronic documentation Measure and analyze patient engagement Demonstrate advanced implementation and augmentation of EHR Healthcare Information and Management Systems Society (HIMSS) Analytics Electronic Medical Records (EHR) Adoption Model Stage 7 Award. only 4% of over 5,000 hospitals evaluated are Stage 7 Stage 7 Non-Stage 7

7 Top 20 in the Nation with 12 nationally ranked and 8 high performing specialties

8 VBM Pathways Frank Volpicelli, MD Chief of Medicine, NYU Langone Hospital Brooklyn Clinical Lead Value Based Management Jonathan Austrian, MD Medical Director, Inpatient Clinical Informatics, NYU Langone Health

9 In 2014, our Inpatient Medicare Loss was increasing % Increase in Medicare Loss Since 2010 Inpatient & Outpatient Inpatient Only 250% 200% 210% 150% 166% 100% 50% 0% FY10 FY11 FY12 FY13 FY14 (6-month annualized)

10 Plus, other hospitals were better at managing their costs 80% Inpatient Medicare Cost per Discharge (WI & CMI Adj.) % Increase since 2008 NYU AMC 1 AMC 2 AMC 3 AMC 4 AMC 5 AMC 6 60% 62% 40% 20% 0% -20% 8% 6% 6% -4% -6% -6%

11 Value Quality Based Value = Management Cost

12 2 Years of Savings from VBM and Health IT Collaboration Daily Labs Blood IV Acetaminophen Pathways

13 2 Years of Savings from VBM and Health IT Collaboration Daily Labs Blood IV Acetaminophen Pathways $2,968, $2,897, $2,241, $12,925,172.00

14 2 Years of Savings from VBM and Health IT Collaboration Daily Labs Blood IV Acetaminophen Pathways $2,968, $2,897, $2,241, $12,925, Total Savings $21,033,358.30

15 2 Years of Savings from VBM and Health IT Collaboration Daily Labs Blood IV Acetaminophen Pathways $2,968, $2,897, $2,241, $12,925, Total Savings $21,033,358.30

16 Baseline Pathway Data Pneumonia Heart Failure Colon Surgery O/E 1.17 O/E 1.16 O/E 0.8

17 Pathways Implementation Org Chart Business Sponsors Dr. Fritz Francois Dr. Paresh Shah Business Day-to-Day Lead Dr. Frank Volpicelli MCIT Clinical Systems Sponsor Nancy Beale RN Kay Dickason RN MCIT Clinical Systems Day-to-Day Lead Cheryl Long Project Physician Dr. Jonathan Austrian Project Manager Richard Lew Congestive Heart Failure Pneumonia Colon Resection Nursing Informatics Champions Michele Costa Phyllis Murray Care Manager / Social Work Champion Ana Mola Nursing Informatics Champions Michael Emory Katie Schmidt Care Manager / Social Work Champion Yuliya Grechukhin Nursing Informatics Champions Gary Liu Kimberly Kenney Care Manager / Social Work Champion Stephen Markley Epic Orders Hardev Randhawa Vincent Yuen Epic ClinDoc Vicky Javier (Lead) Lani Albania Glen DiBenedetto Mark Durbin Nursing Champion Lizanne Velapoldi Nursing Champion Elizabeth Capobianco Nursing Champion Margaret Frank-Bader Jessica Hsu Epic Trainer Janet Zarecor Credentialed Trainer Pharmacy Champion Roda Plakogiannis Pharmacy Champion Marco Scipione Pharmacy Champion Caitlin Aberle Clarity Reporting Clarity Reporting Resource Provider Champion / Team Lead Dr. Stu Katz Provider Champion / Team Lead Nancy Amoroso Vinh Pham Provider Champion / Team Lead Mitchell Bernstein Jason Fisher Reporting Workbench Hardev Randhawa Lani Albania Project Manager Kathleen Green Project Manager Meredyth Lacombe Project Manager Christina Distefano Epic Technical Support Andrew Munfakh

18 Leadership Team Business Sponsors Dr. Fritz Francois Dr. Paresh Shah Business Day-to-Day Lead Dr. Frank Volpicelli MCIT Clinical Systems Sponsor Nancy Beale RN Kay Dickason RN MCIT Clinical Systems Day-to-Day Lead Cheryl Long Project Physician Dr. Jonathan Austrian Project Manager Richard Lew Congestive Heart Failure Pneumonia Colon Resection Nursing Informatics Champions Michele Costa Phyllis Murray Care Manager / Social Work Champion Ana Mola Nursing Informatics Champions Michael Emory Katie Schmidt Care Manager / Social Work Champion Yuliya Grechukhin Nursing Informatics Champions Gary Liu Kimberly Kenney Care Manager / Social Work Champion Stephen Markley Epic Orders Hardev Randhawa Vincent Yuen Epic ClinDoc Vicky Javier (Lead) Lani Albania Glen DiBenedetto Mark Durbin Nursing Champion Lizanne Velapoldi Nursing Champion Elizabeth Capobianco Nursing Champion Margaret Frank-Bader Jessica Hsu Epic Trainer Janet Zarecor Credentialed Trainer Pharmacy Champion Roda Plakogiannis Pharmacy Champion Marco Scipione Pharmacy Champion Caitlin Aberle Clarity Reporting Clarity Reporting Resource Provider Champion / Team Lead Dr. Stu Katz Provider Champion / Team Lead Nancy Amoroso Vinh Pham Provider Champion / Team Lead Mitchell Bernstein Jason Fisher Reporting Workbench Hardev Randhawa Lani Albania Project Manager Kathleen Green Project Manager Meredyth Lacombe Project Manager Christina Distefano Epic Technical Support Andrew Munfakh

19 Business Sponsors Dr. Fritz Francois Dr. Paresh Shah MCIT Clinical Systems Sponsor Kay Dickason Project Physician Dr. Jonathan Austrian Business Day-to-Day Lead Dr. Frank Volpicelli Congestive Heart Failure Pneumonia Colon Resection MCIT Clinical Systems Day-to-Day Lead Cheryl Long Project Manager Richard Lew Dedicated clinical operations team working in conjunction with health IT Nursing Informatics Champions Michele Costa Phyllis Murray Care Manager / Social Work Champion Ana Mola Nursing Champion Lizanne Velapoldi Nursing Informatics Champions Michael Emory Katie Schmidt Care Manager / Social Work Champion Yuliya Grechukhin Nursing Champion Elizabeth Capobianco Nursing Informatics Champions Gary Liu Kimberly Kenney Care Manager / Social Work Champion Stephen Markley Nursing Champion Margaret Frank-Bader Jessica Hsu Epic Orders Hardev Randhawa Vincent Yuen Epic ClinDoc Vicky Javier (Lead) Lani Albania Glen DiBenedetto Mark Durbin Epic Trainer Janet Zarecor Credentialed Trainer Pharmacy Champion Roda Plakogiannis Pharmacy Champion Marco Scipione Pharmacy Champion Caitlin Aberle Clarity Reporting Clarity Reporting Resource Provider Champion / Team Lead Dr. Stu Katz Provider Champion / Team Lead Nancy Amoroso Vinh Pham Provider Champion / Team Lead Mitchell Bernstein Jason Fisher Reporting Workbench Hardev Randhawa Lani Albania Project Manager Kathleen Green Project Manager Meredyth Lacombe Project Manager Christina Distefano Epic Technical Support Andrew Munfakh

20 Business Sponsors Dr. Fritz Francois Dr. Paresh Shah MCIT Clinical Systems Sponsor Nancy Beale RN Kay Dickason RN Project Physician Dr. Jonathan Austrian Nursing Informatics Champions Michele Costa Phyllis Murray Care Manager / Social Work Champion Ana Mola Business Day-to-Day Lead Dr. Frank Volpicelli Congestive Heart Failure Pneumonia Colon Resection Nursing Informatics Champions Michael Emory Katie Schmidt Care Manager / Social Work Champion Yuliya Grechukhin Nursing Informatics Champions Gary Liu Kimberly Kenney Care Manager / Social Work Champion Stephen Markley MCIT Clinical Systems Day-to-Day Lead Cheryl Long Epic Orders Hardev Randhawa Vincent Yuen Epic ClinDoc Vicky Javier (Lead) Lani Albania Glen DiBenedetto Mark Durbin Project Manager Richard Lew Dedicated health IT team working in conjunction with operational leadership Nursing Champion Lizanne Velapoldi Nursing Champion Elizabeth Capobianco Nursing Champion Margaret Frank-Bader Jessica Hsu Epic Trainer Janet Zarecor Credentialed Trainer Pharmacy Champion Roda Plakogiannis Pharmacy Champion Marco Scipione Pharmacy Champion Caitlin Aberle Clarity Reporting Clarity Reporting Resource Provider Champion / Team Lead Dr. Stu Katz Provider Champion / Team Lead Nancy Amoroso Vinh Pham Provider Champion / Team Lead Mitchell Bernstein Jason Fisher Reporting Workbench Hardev Randhawa Lani Albania Project Manager Kathleen Green Project Manager Meredyth Lacombe Project Manager Christina Distefano Epic Technical Support Andrew Munfakh

21 Formal project charter with crossinstitutional buy-in

22 Document approval with cross-departmental stakeholder buy-in

23 Timeline of Clinical Engagement to Support Epic Clinical Pathways Clinical Content and Design Oct 1 - Nov 28 Epic Build Dec 1 - Dec 29 Build Validation by Operations and Epic Build Adjustments Dec 30 - Jan 20 Clinical Engagement Nov 19 Feb 18 End User and SuperUser Training Production Preparation Feb 4 Feb 18 Feb 18 Mar 5

24 Workflow Development Decision strategy IT Intervention Selection Process a. b. c. Guiding Principles

25 Start with Barriers Guiding Principles Interdisciplinary Keep it simple Consistency amongst Pathways

26 Pathway Step 1 Step 2 Step 3 Orders Outcomes Variances Orders Outcomes Variances Orders Outcomes Variances

27 Template to organize Pathway content

28 Developing the Pathway

29 Developing the Pathway

30 Developing the Pathway

31 Developing the Pathway

32 Pathways Workflow Applies Pathway for Eligible Patient Signs Orders for First Step Step Complete? YES Pathway Complete? YES Complete Pathway NO NO Provider Care Team Provide Care Document Outcomes + Variances Sign Order for Subsequent Steps

33 Pathways Workflow Applies Pathway for Eligible Patient Signs Orders for First Step Step Complete? YES Pathway Complete? YES Complete Pathway NO NO Provider Care Team Provide Care Document Outcomes and Variances Sign Order for Subsequent Steps

34 Pathways Workflow Applies Pathway for Eligible Patient Signs Orders for First Step Step Complete? YES Pathway Complete? YES Complete Pathway NO NO Provider Care Team Provide Care Document Outcomes + Variances Sign Order for Subsequent Steps

35 Pathways Workflow Applies Pathway for Eligible Patient Signs Orders for First Step Step Complete? YES Pathway Complete? YES Complete Pathway NO NO Provider Care Team Provide Care Document Outcomes + Variances Sign Order for Subsequent Steps

36 Pathways Workflow Applies Pathway for Eligible Patient Signs Orders for First Step Step Complete? YES Pathway Complete? YES Complete Pathway NO NO Provider Care Team Provide Care Document Outcomes + Variances Sign Order for Subsequent Steps

37 Pathways Workflow Applies Pathway for Eligible Patient Signs Orders for First Step Step Complete? YES Pathway Complete? YES Complete Pathway NO NO Provider Care Team Provide Care Document Outcomes + Variances Sign Order for Subsequent Steps

38 Pathways Workflow Applies Pathway for Eligible Patient Signs Orders for First Step Step Complete? YES Pathway Complete? YES Complete Pathway NO NO Provider Care Team Provide Care Document Outcomes and Variances Sign Order for Subsequent Steps

39 Pathways Workflow Discontinue Pathway Applies Pathway for Eligible Patient Signs Orders for First Step Step Complete? YES Pathway Complete? YES Complete Pathway NO NO Provider Care Team Provide Care Document Outcomes + Variances Sign Order for Subsequent Steps

40 Converting Paper into an Electronic Pathway

41 Pathway Begins

42 Inclusion / Exclusion Criteria

43 Pathway Orders

44 Outcomes

45 Variance

46 Status of Pathway Step

47 Pathway Dashboard

48 Change Management & Implementation

49 Content Changes Continuous Process Improvement Functionality Changes Functionality Changes

50 Suggested Outcome Values

51 Aggregated Heart Failure Data

52 Predictive Analytics

53 $ Realized Value

54 O:E Observed / Expected Length of Stay Pneumonia Baseline Q3 FY15 Q4 FY15 Q1 FY16 Q2 FY16 Q3 FY16 Q4 FY16 Q1 FY17 Q2 FY17 Pneumonia

55 Percentage Decrease 10 % Decrease in Variable Direct Cost per Case Pneumonia Baseline Q3 FY15 Q4 FY15 Q1 FY16 Q2 FY16 Q3 FY16 Q4 FY16 Q1 FY17 Q2 FY17 Pneumonia

56 O:E 0.85 Observed / Expected Length of Stay Colon Baseline Q3 FY15 Q4 FY15 Q1 FY16 Q2 FY16 Q3 FY16 Q4 FY16 Q1 FY17 Q2 FY17 Colon

57 Percentage Decrease 10 5 % Decrease in Variable Direct Cost per Case Colon Baseline Q3 FY15 Q4 FY15 Q1 FY16 Q2 FY16 Q3 FY16 Q4 FY16 Q1 FY17 Q2 FY17 Colon

58 O:E 1.25 Observed / Expected Length of Stay Heart Failure Baseline Q3 FY15 Q4 FY15 Q1 FY16 Q2 FY16 Q3 FY16 Q4 FY16 Q1 FY17 Q2 FY17 Heart Failure

59 Percentage Decrease 10 % Decrease in Variable Direct Cost per Case Heart Failure Baseline Q3 FY15 Q4 FY15 Q1 FY16 Q2 FY16 Q3 FY16 Q4 FY16 Q1 FY17 Q2 FY17 Heart Failure

60 Epic Clinical Pathways Pre and Post Implementation

61 Quarterly Savings for Pathway Cases Colon $2,579, Heart Failure $3,951,855 Pneumonia $6,394, Q3 FY15 Q4 FY15 Q1 FY16 Q2 FY16 Q3 FY16 Q4 FY16 Q1 FY17 Q2 FY17 Colon Heart Failure Pneumonia Total Savings $12,925,172

62 691 Project Team Hours Costs $79,465

63 Lessons Learned Pathway analytics drive change Project management handoff key Pathways need to be lean. Electronic pathways demonstrate value

64 Thank You

65 Paperless Registration Dana Ostrow Senior Director of Clinical Systems, NYU Langone Health Gabriela Grygus, MBA, RHIA Senior Director, Health Information Management, NYU Langone Health

66 In the past, our registration process involved lots of paper.

67 In 2014, we had over 1.25 million paper registration documents signed and scanned into Epic.

68 Average registration time with PAPER took 10 minutes

69 3,897,690 pieces of paper were used, costing over $428,745.90

70 That s about 527 trees.

71 Registration And we spent over $93,986 annually on scanning services before paperless registration.

72

73 We mapped the Digital Patient Experience to better understand the needs of our patients across the continuum of care beginning end

74 In the first half of 2017, over 1.3 million documents were digitally signed.

75 Paperless Implementation Org Chart Operational Steering Committee Andrew Rubin Business Sponsor Steven Weiner Business Owner MCIT Steering Committee Nancy Beale Suresh Srinivasan James Song Suzanne Howard MCIT Partners MCIT/Clinical Systems Owner Operational Partners Dana Ostrow Project Management MCIT/Clinical Systems Application Leads Nathan Gollogly Ann Cote OnBase Elizabeth Brutti - EpicCare Mary Ann Cox Epic ADT/Cadence Joe Shelmet - Hardware Vendor Partners Hyland Stacey Less PM Marypat Schrantz Tom Buehner Tony Turner Susan de Cathelineau Samsung Timothy Gillis Steven Hamilton Ben Simmons Desktop/Hardware/Wireless Jamie Lynch Sammy Lee Rob Dennison Fabian Clarke Matt Zago Matt Horany Ian Gonsalves Application/Training Team Maureen Hickey - EpicCare Vertil Gourgues - OnBase Alex Mathew ADT Javier Ramos ADT Marie Laguerre - Training

76 September 2014 Discovery process for tool selection began Design + Implementation Timeline

77 enable positive experience for both employee and patient Guiding Principles for Tool Selection integrate with Epic work seamlessly with other registration technologies such as Patient Secure offer a flexible platform that would allow for more than just paperless registration leverage existing partnerships if possible

78 We counted clicks to ensure that the registrar was in fact able to work faster. We timed patients to ensure that registration was in fact quicker.

79 Topaz ecapture Access Welcome Kiosk Patient can see/ complete form independently Form is interactive We considered a wide variety of platforms and their capabilities Error checking on the form Data Captured Discretely Signature Embedded on Saved Form Can be used for Questionnaires? Can be used for Clinical Consents

80 We tested devices and platforms and found that some didn t meet our needs.

81 Design + Implementation Timeline September 2014 Discovery process for tool selection began October November 2014 Initial development in coordination with Epic, Samsung and Hyland

82 We chose to develop a paperless platform with these partners.

83 The QR Code what makes our paperless platform dynamic.

84 Paperless Registration Workflow Patient Presents at Registration Desk Patient completes prepopulated form on Tablet Patient Registrar Registrar begins the Check-In / Admission in Epic Registrar validates forms for the registration packet and creates barcode in Epic Registrar Scans barcode using Tablet Tablet is returned and Registrar confirms all forms have been received in Epic Epic / FOS / Unity eforms Forms saved to OnBase and then linked to Epic

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88 Testing Bi-monthly Iterative testing with each release for a week, including integrated end to end testing Usability with staff Usability with patients Trials with multiple types of tablets and styluses

89 Change Management Devices are enrolled in Airwatch, which allows us to manage them remotely Updates can be pushed to devices through Airwatch Airwatch Secure Launcher is installed on the devices which allows us to lock down the home screen of the device to the Paperless application

90 Infection Control

91 Paperless Registration Timeline

92 Design + Implementation Timeline September 2014 Discovery process for tool selection began October November 2014 Initial development in coordination with Epic, Samsung and Hyland February 2015 First Go-Live at NYU Langones Center for Womens Health

93 First Test Site NYU Health: Center for Women s Health 23 providers

94 Design + Implementation Timeline September 2014 Discovery process for tool selection began October November 2014 Initial development in coordination with Epic, Samsung and Hyland February 2015 First Go-Live at NYU Langones Center for Womens Health June 2015 Rolled out to large ambulatory location Huntington Medical Center ensuring enterprise readiness

95 Design + Implementation Timeline September 2014 Discovery process for tool selection began October November 2014 Initial development in coordination with Epic, Samsung and Hyland February 2015 First Go-Live at NYU Langones Center for Womens Health June 2015 Rolled out to large ambulatory location Huntington Medical Center ensuring enterprise readiness December 2015 Paperless registration rolled out to 95% of enterprise

96 Continuous Improvement MyChart ID creation in registration Multilanguage capabilities Research Consents

97 Patient Encounters Using Paperless Registration Patient Encounters Q Q Q Q Q Q Q Q Q Q2 2017

98 Average registration time with TABLET 5 minutes

99 Documents Digitally Signed Since Launch of Paperless Initiatives Signed Documents Q Q Q Q Q Q Q Q Q Q Digitally Signed Documents

100 Time Saved by Patients Quarterly in Minutes Minutes Saved by Patients Over 1 million PATIENT minutes saved Q Q Q Q Q Q Q Q Q Q2 2017

101 60000 Monthly MyChart Activation Since Paperless Registration Launch New My Chart Activations Patients

102 Not using paper saved us nearly $450,000 a year.

103 Time Saved by the Registrars 5,613,115 minutes saved 93,552 hours saved 3,898 weeks saved 51.4 years saved

104 Soft savings of $1.7 million in FTE costs

105 Tablet Replacement budget - $30,000 Software Maintenance - $30,000 Annual Costs FTEs to Support- ½ an FTE in steady state. Additional support as needed for roll outs and forms in other languages Desktop FTEs to Support- ½ an FTE in steady state across all locations

106 Lessons Learned - Ensure that documents format correctly on tablet and are not merely copies of paper documents - Ensure that signature requests on electronic forms are in the appropriate place - Turn on certain interfacing early enough to allow all pieces of the platform to function properly at go-live - Create an FAQ document for go-live to easily address common questions - Find secure locations for use of tablets to ensure that they are not taken - Do not assume that registrars already have full understanding of the registration process before implementation

107 Next Steps In 2016 we signed more then 125,000 surgical/ procedural clinical consents. By the first quarter of 2018 we will be fully digital with all consents.

108 Questions

109 Total Joint Arthroplasty Bundled Payment Care Initiative Kathleen Mullaly, MSN, RN Senior Director MCIT, Care Delivery Transformation, NYU Langone Health Lily Pazand Director, Managed Care Payment Reform Analytics, NYU Langone Health

110 Clinically Integrated Network Risk Programs CARE Bundled Payment for Care Improvement (BPCI) NYUPN Commercial Shared Savings Medicaid IPA United Delivery System Reform Incentive Payment (DSRIP)

111 Clinically Integrated Network Risk Programs CARE Bundled Payment for Care Improvement (BPCI) NYUPN Medicaid IPA United Delivery System Reform Incentive Payment (DSRIP)

112 Bundle Payment Strategy What We Considered What We Selected Clinical Opportunity Strong clinical leadership Defined, discrete clinical episodes Relatively predictable Financial Opportunity High volume Procedure-based Attractive to Medicare Total Joint Replacement Major joint replacement of the lower extremity 800 Medicare cases annually 31 physicians; 55% employed / 45% voluntary Spinal Surgery Spinal fusion (non-cervical) 235 Medicare cases annually 18 physicians; 56% employed / 44% voluntary Cardiovascular Surgery Cardiac valve 260 Medicare cases annually 8 physicians, 100% employed

113 Cost Drivers Across Episode of Care Internal Cost Reductions 90-day Episode Spend Reductions Levers to reduce internal hospital cost: Reduce LOS Reduce implant, supply, and/or drug costs Reduce OR time Levers to reduce 90-day episode spend: Reduce readmissions Alter discharge patterns (home-based vs. facility-based care) Decrease utilization (e.g. consults, ancillary tests Reduce SNF LOS

114 Baseline Metrics Total Joint Replacement Initial Post-acute Setting 90 Day Readmission Rate AVG 90-Day Episode Payment Inpatient Rehab 15% $40,095 Skilled Nursing Facility 18% $43,466 Home Health 10% $23,462 Outpatient Therapy 18% $27,267

115 Total Joint Replacement Pathway Org Chart Total Joint Replacement Pathway

116 Total Joint Replacement Pathway Development Governance Bundled Payment Initiative Steering Committee Total Joint Care Pathway Committee Pre-hospital Team Inpatient Team Post Acute Team Epic Workflow MCIT Reporting Implementation

117 Total Joint Replacement Pathway Implementation Structure and Leads Total Joint Care Pathway Committee TJR Pathway Implementation Team Physician / Res.: Slover Surgical Care Coordinators: Frattini / Slover Case Management / Social Work / Clinical Care Coordinator Roesch / Presa Inpatient Comeau / Bovery Physical Therapy / Occupational Therapy Corcoran / Tafurt Post Acute: Goldberg / Mullaly

118 Clinical Management Throughout the Pathway Standardization Systematization and standardizing are the foundations of good operational routines that can be measured and facilitate improvements, outcomes, and ever-greater efficiency. Advantages of Standardization 1. Increases efficiency 2. Improves ability to monitor and study individual factors 3. Improves communication 4. Allows for identification of outliers or modifiable factors

119 Patient Navigation Patient / Coach Nurse Care Coordinator Pre-admission Hospital + Inpatient 90-Day Post-Acute Period Inpatient Rehab Skilled Nursing Facilities Home Health Agencies Surgeon Pre-Admission Testing Surgeon Outpatient Services Surgeon Follow- Up Visits Hospital Communication Modes: Electronic EMR: My Chart EMR Light: For providers without EMR Telephonic Fax For providers without EMR or limited internet connectivity

120 Physicians Epic OpTime Scheduling System DRG Predictive Model Patients MyChart History Questionnaire Physician Dashboard Medicare Claims Data Bundled Payment Registry Risk stratification to identify patients at risk for readmission Schedule NYULMC occupational therapy home visit for high-risk patients Clinical Episode Documentation, including readmissions to outside hospitals (Outreach/ Telephone Encounter) EDW Clinical Care Coordinators Physician and Surgical Coordinator Care Team Test Results Messaging Conditions Educational Materials/ Videos BPCI Episode Technical Work SNF Partners HIE / Web Portal Population Analytics Home Health Partners

121 Reporting and Monitoring Tools Pre-Care Outcomes Improvement DRG Predictor Reporting Care Coordinator Dashboard High Risk Readmission Identifier

122 DRG Predictor - Scheduled procedure report kicks off outreach efforts pre-surgery Surgery Date Pre- Testing Date Patient Name Patient Age on Surgery Date Surgeon Name Procedure Home Phone Address Birth Date Patient PCP Name PCP Office Phone Num Schedule Status 10/15/2013 5/8/2013 Patient Surgeon 1 ROBOTIC MITRAL VALVE ANNULOPLASTY Phone 1 1 DOB 1 PCP 1 PCP 1 Scheduled 10/15/ /1/2013 Patient Surgeon 2 REVISION FUSION SPINAL POSTERIOR Phone 2 2 DOB 2 PCP 2 PCP 2 Scheduled 10/15/ /2/2013 Patient Surgeon 3 REPLACEMENT HIP TOTAL Phone 3 3 DOB 3 PCP 3 PCP 3 Scheduled 10/15/ /4/2013 Patient Surgeon 4 REPLACEMENT KNEE TOTAL Phone 4 4 DOB 4 PCP 4 PCP 4 Scheduled 10/15/ /4/2013 Patient Surgeon 5 REPLACEMENT HIP TOTAL Phone 5 5 DOB 5 PCP 5 PCP 5 Scheduled

123 FYI Flags identify patients in the EMR

124 BPCI Epic Patient Identification / Registry Data in Epic Epic Registry Dashboard

125 EMR Care Coordination Tools and Patient Registries

126 Clinical Care Coordinator Preadmission Assessment

127 Readmission Risk Predictor Tool

128 Patient Communication Tool NYU Langone Health MyChart

129 Inpatient Workflow + Order Sets During-Care Outcomes Improvement Order Sets Epic Dashboard Reporting

130 Inpatient Goal Order Sets + Standard Workflow Analgesic Pathway POD Standard: Pre-op Standard Celebrex until day of surgery Continue opioids if there is pre-op use Intra-op Standard Routine surgeon wound infiltration with cocktail Wound cocktail to be determined by the surgical team 250mg ropivacaine with epinephrine Ketorolac Intra-op Anesthetic GETA Epidural CSE Spinal Peripheral catheter (femoral, etc.) PACU/POD#0 Standard EPCA or peripheral nerve catheter with +/- IV PCA APAP 1g IV upon PACU arrival and q6h ATC Ketorolac 30 mg IV q8h ATC Lyrica 50 mg bid Continue opioids if there is pre-op use

131 Analgesic Workflow

132 VTE Prophylaxis Workflow

133 Acceptable According to Workflow

134 Actual Patient Info for Comparison

135 Daily Inpatient Census Report

136 Homecare Workflow Post-Care Outcomes Improvement Care Coordinator Post-Acute Documentation Transitional Care Document Analytics

137 Real-Time Readmission, ED, Urgent Care Visit Report

138 Post Discharge Flow Sheet

139 Post Acute Care Provider Contact

140 Post Acute Care Provider Contact

141 3 Post Acute Goal Improved Outcomes and Patient Experience NYULMC Post-Acute Partners Developed in collaboration with Partners Standard Post Acute Pathways Focus on bi-directional exchange of information Twice weekly updates on high risk patients Interdisciplinary weekly call PAC Report card 7 Quarterly PAC Committee Meeting 6 8

142 Two Home Care Pathways Standard Pathway Enhanced Support Pathway Criteria for Homecare VNSNY/TJR Enhanced Support Pathway Pilot Criteria Single Joint replacement Caregiver able to participate in therapy prior to DC Stairs before discharge / No more that 1 flight in home If private home bed/bath cant be longer than a flight of stairs Eligible for SNF / Complex Needs Established risk profile to assist in determining appropriate disposition Focus on bi-directional electronic exchange of information

143 Transitional Care Document Post-Care Outcomes Improvement Transfer Document Follow-up Form Continuity of Care Document

144 Components of Transitional Care Communication Tool Transfer Document Delivered at Discharge Follow-Up Form Delivered Weekly o o o o o o o o o o o o o o Demographics Type of surgery and date Care pathway Readmission risk Clinical Status Functional Status Patient Preferences / Comments Social History Knowledge Deficit Follow-up Appointments Hospital Contact Info VS/Smoking Status Education +CCD Clinical Status Pain VTE pro Surgical Wound Pressure Ulcer UTI Fever Diet Any new medications added Change in clinical condition Evaluated by MD/NP Functional Status Number of PT/OT visits week Ambulation Stairs Transfers Falls Discharge Status Anticipated Discharge Date Barriers to Discharge Patient on Target for Discharge

145 Transitional Care Communication Workflow Patient is Ready for Discharge NYULMC EMR Lite NYULMC HIE VNSNY Homegrown EHR VNSNY nurse visits patient at home NYU Clinical Care Coordinator readies documentation NYU clinician logs into system & completes Post Acute Transfer Form Facilitates exchange of information between NYU and VNSNY systems Information received at VNSNY/Clinician notified Provider logs into system and accesses Post Acute Transfer Form and CCD

146 Transitional Care Communication Tool Implementation Timeline Weekly Meeting with PAC partners to develop pathways understand information critical to transition Meetings with PAC partners to develop workflow Risk-Bearing Phase 2 Period begins Testing NYU-VNSNY Live with Risk Bearing Phase 2 Bundle Payment for Care Improvement Initiative EMR-EMR transfer with VNSNY Jan Mar 1, Mar. - Nov 2012 Dec 2012 Jan, 2013 April. 1 st, 2013 Oct. 1 st, 2013 Mar, 2014 Sept, Internal/external review of potential system solutions Testing solution Began training with VNSNY and NYU teams both individually and together Made updates based on feedback from teams Live with manual transitional care communication tool Transitional Care Communication tool electronically sent to NYULMC HIE

147 We have exchanged over 7,000 forms with VNSNY

148 Bundle Payment Weekly Dashboard

149 Weekly Dashboard Physician Level Reporting # Patients Discharged ALOS Rehab Facility Skilled Nursing Facility Discharge Disposition Total Facility- Based Care Home Health Care Svc Home/ Self Care Total Home- Based Care 90-Day Readmission Rate - Closed Episodes Only 1 # Readmissions (Closed Episodes Only) # Patients (Closed Episodes Only) 90-Day Readmission Rate (Closed Episodes Only) Primary Joint of the Lower Extremity % 37% 44% 53% 3% 56% % HJD % 35% 41% 56% 3% 59% % DRG Primary Joint w MCC % 35% 53% 47% 0% 47% % Physician % 50% 75% 25% 0% 25% 0 0 0% Physician % 25% 50% 50% 0% 50% 0 0 0% Physician % 50% 50% 50% 0% 50% 0 0 0% Physician % 50% 50% 50% 0% 50% 0 1 0% Physician % 100% 100% 0% 0% 0% 0 0 0% Physician % 0% 0% 100% 0% 100% 0 0 0% Physician % 0% 0% 100% 0% 100% 0 0 0% Physician % 0% 100% 0% 0% 0% 0 0 0% Physician % 0% 0% 100% 0% 100% %

150 BPCI Discharge Disposition Patterns Primary Joint Replacement HJD / Tisch Primary Joint Replacement Lutheran

151 20% BPCI 90-day Readmission Rate Trends 18% TJR - NYU TJR - Lutheran 16% 14% 12% % Readmission 10% 8% 6% 4% 2% 0% Baseline CY 2013 CY 2014 CY 2015 CY 2016 CY 2017 Time

152 BPCI Average Length of Stay TJR - NYU TJR - Lutheran Length of Stay in Days Baseline CY 2013 CY 2014 CY 2015 CY 2016 CY 2017 Time

153 Lessons Learned - Concept of bundle payment is still very new - Continuous engagement requires reminders re-education around reports, and data, new goals and targets, and regular discussion of performance - Data is consumed and understood differently by different groups - Leverage IT platforms (EMR, HIE, analytics) to identify population of interest at preadmission and during inpatient stay - Early identification of BPCI patients is critical to success - Place focused information in the hands of clinicians on a timely basis in order to facilitate care redesign - Develop tools to risk stratify patients to allow targeted clinical intervention - Developed and tested Care Coordination workflow manually - Advance clinical and technical relationships with post acute partners to expand influence with care delivery

154 Questions

155 In Summary

156 VBM Pathways

157 Paperless Registration

158 BPCI Discharge Disposition Patterns Primary Joint Replacement HJD / Tisch Primary Joint Replacement Lutheran Total Joint Arthroplasty Bundled Payment Care Initiative

159 Thank you for your consideration.