Using Healthix to Support DSRIP: Opportunities and Challenges. February 25, 2016
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1 Using Healthix to Support DSRIP: Opportunities and Challenges February 25, 2016
2 Contents 1. Community Care of Brooklyn Overview (2 5) 2. Healthix Enablement of CCB IT Strategy (6-13) 3. Challenges (slide 14) 4. Discussion 1
3 Community Care of Brooklyn Maimonides Medical Center = PPS Lead and fiduciary Maimonides Performing Provider System (Maimonides PPS) = a broad network of health and social services providers, Brooklyn-based community groups and others Community Care of Brooklyn (CCB) = the name of the Maimonides PPS CCB is not a separate entity; it is established via Master Services Agreements (MSAs) between CCB Participants and MMC Includes 3,000 providers (including 1,100 primary care physicians) and more than 300 partner organizations including 6 hospitals, 8 FQHCs, a number of community-based organizations, other entities Governance through committee structure, with consensus-based approach to decision-making Maimonides Central Services Organization (CSO) = team providing management services to support CCB 2
4 CCB Governance Structure CMS NYSDOH Maimonides (Fiduciary) Maimonides CSO Nominating Committee CCB Executive Committee Community Engagement Committee Compliance Committee Workforce Committee Finance Committee Information Technology Committee Care Delivery & Quality Committee October
5 CCB Initiatives / DSRIP Projects Initiatives Descriptions / Participant Types Status Create IDS (2.a.i) Reduce 30-day readmissions (2.b.iv) ED Triage (2.b.iii) Overarching, cross-cutting work that will support multiple DSRIP projects, achievement of overall DSRIP goals Hospital-based program focusing on identifying patients at risk for readmission, effecting linkages to primary, specialty care and social services as appropriate Reducing the number of low-intensity ED visits; requires availability of accessible PCP services, urgent care, care management and social services support Ongoing Launched with key Participants, ongoing rollout Launch underway, ongoing rollout 4
6 CCB Initiatives (continued) Initiatives Descriptions / Participant Types Target Launch PCMH + (2.a.iii HH at risk, 3.a.i integration of behavioral health and primary care, 3.d.ii home-based asthma care, 3.b.i management of cardiovascular disease, 3.g.i palliative care) Population Health: HIV Access to Care (4.a.iii) Population Health: MHSA (4.c.ii) Ensure that PCPs achieve required level of Patient Centered Medical Home (PCMH) designation; early focus on Federally Qualified Health Centers (FQHCs), free-standing Diagnostic & Treatment Centers (DTCs) and larger physician practices Citywide effort; NYCDOHMH serving as lead; work focused on ten (10) interventions to improve screening and early access to care Citywide effort; target population is youth and young adults (ages 12-25); focusing on school-based health services to improve MHSA identification and linkages to care Launched with key Participants, rollout ongoing Planning underway Planning underway 5
7 CCB IT Strategy Leverage and build upon previous local, NYS, and Federal investments in Health IT: Scale and adapt to the MMC PPS the proven and compliant Care Coordination platform, available via the internet and interoperable with Healthix/SHIN-NY, that was established and enhanced by MMC as part of the HEAL, Health Home, and CMMI HCIA Programs. Expand and enhance the use of MU certified EHRs for core clinical data capture and exchange, and promote connectivity to the Healthix/SHIN-NY infrastructure and participation in state-wide Health Information Exchange (as a verb) for all Participants in the PPS. Promote and leverage current and future NYS Health Information Exchange infrastructure, data, and services including Healthix, the SHIN-NY, MAPP, Salient analytics, etc. 6
8 Social Service Provider OASAS/Addiction Services Case Management Public Health Authorites Home Care SPOA Care Coordination Platform GSI Health Therapist Speciality Physcians Specialists Care Manager Patient Care Coordination Platform Intensive Care Management Providers Psychiatrist Specialists Family Payer Homeless Shelters Peer Advocacy Correctional Services Supporting Housing Organizations MMC Technology for Population Health 2005: BHIX Consortium of hospitals, nursing homes, home health providers & insurers establish BHIX with HEAL NY funds. Jan. 2010: HEAL 10 MMC received funding to develop MHH model and HIT infrastructure; seven stakeholders and South Beach Psychiatric enter into HEAL contracts to improve care for schizophrenics Jan. 2011: HEAL 17 MMC received additional funding; five stakeholders added and diagnoses expanded to include schizoaffective disorder, bipolar disease and serious depression July 2012: HCIA MMC received CMS Health Care Innovation Award to enhance HIT functionality, develop care management training program and migrate from fee for service to total cost of care payment model April 2014: DSRIP planning begins. MMC and Steering Committee of partners organize Community Care of Brooklyn : Co-location of primary care & behavioral health services at South Beach 1,500 1, Oct. 2010: Development of Mental Health Home Standards completed SHIN-NY/BHIX SHIN-NY/BHIX Care Coordination Platform Social Services Primary Care Physician Care Navigator SHIN-NY/BHIX Care Coordination Platform Social Services SHIN-NY/BHIX Dec 2011: Health Home MMC designated as Medicaid Health Home (Brooklyn Health Home), receiving PMPM fee for IT-enabled, comprehensive care management Jan. 2014: HARP Pilot MMC, Brooklyn Health Home, FEGS and Healthfirst initiate HARP Pilot, integrating a payer into the care model in a meaningful way April 2015: DSRIP Q1 begins. Community Care of Brooklyn initiates first DSRIP projects SHIN-NY/BHIX SHIN-NY/BHIX 7
9 Adapt PPS Model from BHH Model Key Feature of the BHH model: Virtual colocation of providers and services enabled by health IT and coordination of services 8
10 Care Coordination, Communication, and Reporting Platform User Interface/ Dashboard Apps Enrollment Care Teams Coordinated Care Plan Alerts Messages EHR SHIN-NY EHR Patient Engagement Population Manager EHR EHR Patient Summary/ CareBook 2015 GSI Health LLC. All rights reserved. GSI Health LLC and the GSI Health logo are registered trademarks of GSI Health, LLC. All other trademarks are the property of their respective owners. 9
11 GSIHealthCoordinator Clinician Engagement Healthix CCD data combined with Care Coordination data One page summary view depicting patients history and current medical/behavioral/social issues Access to platform from MMC ED EHR system (July) Continuous care documentation GSI Health LLC. All rights reserved. GSI Health LLC and the GSI Health logo are registered trademarks of GSI Health, LLC. All other trademarks are the property of their respective owners.
12 GSIHealthCoordinator Operational Reports Assessment Report Encounters Report Care Teams Report Care Plan Issues Report Healthix Alerts Report Gaps in Care Report GSI Health LLC. All rights reserved. GSI Health LLC and the GSI Health logo are registered trademarks of GSI Health, LLC. All other trademarks are the property of their respective owners.
13 GSIHealthCoordinator Mobile App Ability to View and Send Messages Notification for new alerts and messages Same view and functionality as GSIHealthCoordinator App available in App Store and Google Play Healthix HISP-HISP Direct Messaging Healthix CENs (Alerts) GSI Health LLC. All rights reserved. GSI Health LLC and the GSI Health logo are registered trademarks of GSI Health, LLC. All other trademarks are the property of their respective owners.
14 Healthix CENs Brooklyn Health Home received Alerts from 25 Healthix connected facilities. Please see the list below for count of Alerts of all types since 9/27/2015, a weekly average of 364. Facility Total Alerts Beth Israel Kings Highway 74 Beth Israel Petrie Division 38 Brookdale University Hospital and Medical Center 1179 Forest Hills Hospital 13 Franklin Regional Hospital 16 Good Samaritan Hospital Medical Center 3 HHC Correctional Health Services (Rikers Island) 34 Jamaica Hospital Medical Center 5 Jewish Home Lifecare 1 Kingsbrook Jewish Medical Center 142 Lutheran Medical Center 1028 Maimonides Medical Center 919 Mount Sinai 63 Mount Sinai Sant Luke's Hospital 18 Nassau University Medical Center 1 New York Hospital Medical Center 5 New York University Medical Center 68 NYP/Columbia 30 NYP/Cornell 43 Richmond University Medical Center 30 Roosevelt Hospital 23 Staten Island University Hospital 17 SUNY Downstate 162 The Brooklyn Hospital Center 523 Wyckoff Heights Medical Center
15 Challenges Funding CRFP Funds for EHRs and Healthix Connectivity Confusion - swirl of vendors, solutions, and mandates Care Coordination, Predictive and other Analytics, Patient Engagement/Activation, SMS Text Based Messaging, etc. Example - Options and/or Mandates re Care Coordination / Care Plan My local EHR or Care Plan PPS(s) Care Plan(s) Planned Healthix Care Plan NYS DOH Care Plan (MAPP - Curam) Where do I invest my time and money? What is the data of record? What will really be required and/or provided and when? NYS (and national) Consent Policy Opt-Out vs Point of Access vs Community Wide vs Program Consent SAMHSA Requirements and Possible Changes Availability and Utility of NYS Claims (MCD/PHI) Data Channels Direct vs. MAPP Salient vs. Curam vs. Healthix Technical Security and Process Requirements Practicality I can have it, but how can I use it? 14
16 Discussion Questions and Comments 15
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