MHNConnect Implementation in the ACHN.

Transcription

1 MHNConnect Implementation in the ACHN 1

2 Goals for Today s Session Review MHNConnect s role in the ACHN s transitions of care strategy Understand MHNConnect functionality and basic flow of information Review best practices for implementation in the ACHN, including: Clinic workflows to support timely follow-up How to select MHNConnect champion(s) and users How to monitor timely follow-up rates Review next steps in implementation & available MHN resources 2

3 The Medical Home Network (MHN) is a 4-year-old formal provider collaborative working to improve the health of Medicaid recipients in underserved Chicagoland areas by enhancing care coordination and quality, improving access and reducing fragmentation and cost, all while reinforcing the Medical Home. 3

4 MHNConnect: IT Infrastructure for Care Coordination Across the Continuum 4

5 ER Connect: ED Referral to Medical Home Print Out Printable Referral forms will be generated at the Patient s discharge from the ED. Each referral form will include: Clinic contact information & operating hours A map detailing public transportation options An image of the clinic façade 5

6 Clinic Connect: Real-Time Hospital Activity Alert Sample MHNConnect: New Hospital Activity MHN Event Alerts Sent: Tuesday 3/13/2012 7:15 AM To: Stephanie Robinson You currently have hospital activity for the following Medical Home(s): Medical Home Current Inpatients Current ER Patients Inpatient Discharges ER Patient Discharges Englewood Health Center 1 Woodlawn Health Center 1 Near South Health Center 2 Please log on to the MHNConnect Web Portal to view your patient activity at Thank you, MHNConnect 6

7 Clinic Connect: User Log In & Welcome Page User Log In View Real-Time Hospital Activity Census Feeds 7

8 Clinic Connect: Real-Time Dashboard Access Real-Time Patient Dashboard Details by clicking on the Census tab, click individual Dashboard to view details. 8

9 Clinic Connect: Real-Time Dashboard Views Proactively manage care and track follow-up outreach status immediately post-discharge from the ED and inpatient settings 9

10 10 Clinic Connect: Tracking Patient Outreach Post-Discharge Schedule timely follow-up appointments immediately post-discharge from the ED and inpatient setting Timely Follow-Up = Post-discharge Appointed Completed within 7 days (non-maternity) or 11 days (maternity) Easily select Follow-up Status: Phone Contact Appointment Scheduled Appointment Missed Appointment Completed Unreachable Appointment Declined Contact Information Inaccurate Patient Deceased Physician Inpatient Visit Update Follow-Up Status from Appointment Scheduled to Appointment Completed

11 Clinic Connect: Tracking Patient Outreach Post-Discharge Follow-up Status Patient Deceased Physician Inpatient Visit Phone Contact Patient Unreachable Contact Information Inaccurate Appointment Declined Appointment Scheduled Appointment Missed Appointment Completed No Follow-Up Entered Use By Clinics Clinic learns patient has died, either during or following hospital event. The patient's PCP saw the patient during hospitalization. Clinic has called the patient to schedule appointment (may have left a message). Clinic communication/outreach protocol has been exhausted. Phone numbers from all available sources are inaccurate. Patient has directly declined the appointment or missed numerous scheduled appointments. Clinic has scheduled a follow-up appointment for the date entered. The patient missed the scheduled appointment. Patient completed the appointment on the date entered. The clinic did not make any attempt to follow-up post-discharge. Census Action Removes event from census immediately. Event stays on census for 30 days post discharge. Event stays on census for 30 days post discharge. Removes event from census immediately. Removes event from census immediately. Removes event from census immediately. Event stays on census until closed status entered (highlighted in blue). Event stays on census for 30 days post discharge. Removes event from census immediately. Event stays on census for 30 days post discharge. 11

12 Clinic Connect: Patient Details Select the drop down lists under Patient Details for information on: Filled Prescription History MHN Hospital Activity (real-time) Claims History (diagnoses, procedures, etc.) Follow-up Activity 12

13 MHNConnect: Clinic Workflows to Support Timely Follow-Up Patient Outreach Convey the why to patients and give them a choice of appointments. Establish communications protocol (i.e. call three times then mail a letter). Scheduling Appointment must be scheduled in Cerner System. Check to see if patient has already scheduled attempt to move appointment into timely window. Use longer slots if not established patient (as available). Prioritize empaneled doctor/team. Use walk-in slots to ensure timely appointments. Put patient reminder sheet in binder and indicate that appointment is for follow-up. Day of Appointment Use patient reminder sheets for day s appointments to guide huddle discussion. Ongoing Monitoring of Timely Follow-up Success Give administrators access/training to use Medical Home Visits w/i 7 Days and Tracking Follow-up Status. Use reports to monitor progress and make sure follow-up is being closed out, as appropriate. 13

14 Clinic Connect: Medical Home Visits w/i 7 Days Report Select the Date Range, Visit Type and Medical Home criteria and click Download as CSV to run the Medical Home Visits w/i 7 Days report. Last Name First Name DOB RIN Facility Name Visit Type Admit Date Discharge Date MH Name New Patient Follow-up Status Status By Elapsed Days Appt Time Timely Complete AXXXXX A 7/27/ Holy Cross Hospital ER 11/1/ :52 11/1/ :52 Medical Home Name N Appointment Declined Megan Moore BXXXXX B 1/6/ Holy Cross Hospital ER 9/1/ :36 9/1/ :36 Medical Home Name Y Phone Contact Megan Moore CXXXXX C 12/13/ Rush University MediER 9/8/ :34 9/9/2012 0:09 Medical Home Name N Appointment Missed Laura Merrick DXXXXX D 3/24/ Saint Anthony Inpatient 10/31/ :10 11/1/ :37 Medical Home Name N EXXXXX E 9/25/ Sinai Hospital ER 10/19/ :16 10/20/2012 1:01 Medical Home Name N Phone Contact Megan Moore FXXXXX F 6/16/ Rush University MediInpatient 10/2/ :30 10/11/ :31 Medical Home Name N Appointment Completed Megan Moore 8 10/19/ :30 N 14

15 MHNConnect: Facilitating PCMH Activities Beyond Timely Follow-up Monitor new patient census list/report to conduct outreach to new patients Investigate historical claims & Rx (particularly helpful for newly assigned patients or those who frequently leave the system) Monitor Frequent MHN ER Activity report to target high-risk patients for more intensive outreach 15

16 Clinic Connect: Assigned MHN Patient Panel Report Select the Medical Home and Patient Panel criteria, then click Download as CSV to run the Assigned MHN Patient Panel report. New Patient Assign Start Date Assign End Date Elig Start Date Elig End Date MH Name Last Name First Name DOB RIN Phone Address N 2/17/ /1/2012 1/31/2013 Medical Home Name AXXXXX A 6/26/ S ANYWHERE AVE, CHICAGO, IL N 2/17/ /1/2012 1/31/2013 Medical Home Name BXXXXX B 4/27/ S ANYWHERE AVE, CHICAGO, IL Y 12/27/ /1/2012 Medical Home Name CXXXXX C 5/13/ S ANYWHERE AVE, CHICAGO, IL N 5/18/2007 2/1/2011 Medical Home Name DXXXXX D 2/17/ S ANYWHERE AVE, CHICAGO, IL N 2/6/2010 2/1/2011 Medical Home Name EXXXXX E 11/21/ S ANYWHERE AVE, CHICAGO, 16 IL N 12/4/2007 2/1/2011 Medical Home Name FXXXXX F 11/9/ S ANYWHERE AVE, CHICAGO, IL 60000

17 17 Clinic Connect: Frequent MHN ER Activity Report Select the Date Range, ER Visit Threshold and Medical Home criteria and click Download as CSV to run the Frequent MHN ER Activity report.

18 MHNConnect: Implementation Steps Identify the clinic implementation team Sr. Leadership accountable for implementation (Medical Director, Nurse Coordinator, Administrative Leader, Charge Nurse, etc.) Clinic Team Lead (possibly Administrative Leader or Charge Nurse) MHN Project Lead (Megan Moore or Amanda Hahn) Hold a formal kick-off meeting to accomplish the following: Engage MHNConnect Implementation Team Lead & Members Review Portal Functionality Identify Primary Users (Medical Assistants, Social Workers, Health Advocates) Develop & Document Clinic Workflow to Support Use of Portal Establish Launch Timetable Authorize and set-up users (MHN Project Lead) Conduct MHNConnect Portal trainings (MHN Project Lead, if desired) Launch MHNConnect Provide ongoing MHNConnect user support (MHN Project Lead) 18