Improving Financial & Clinical Performance Through Health Information Exchange & Enhanced Transitions

Transcription

1 8/28/2017 Improving Financial & Clinical Performance Through Health Information Exchange & Enhanced Transitions LeadingAge NY 2017 Financial Professionals Conference Al Kinel: President Strategic Interests Travis Masonis: CIO Jewish Senior Life Cesar Perez: Sr. Account Manager Healthix (NYC RHIO) Jeff Norton: VP of Sales, SNF & ALF PointClickCare August 30,

2 8/28/2017 Agenda Measures Positively Impacted by HIE & ToCs Industry Actions to Utilize HIE to Enhance ToCs Perspectives of Jewish Senior Life Capabilities, Perspectives & Example from a RHIO Capabilities, Perspectives & Example from PCC Discussion: Barriers & Actions to Make a Difference 2

3 8/28/2017 CMS 5-Star Short-Stay Quality Measures Claims Based Measures Measures: % Short-Stay Residents with 30 day Readmissions Hospital readmissions from SNF rehab Includes hospitalizations following SNF stay % Short-Stay Residents ED visit within 30 days Pop Health, Care Management, provider access Collaboration and use of telehealth % Short-Stay Residents Successfully Discharged to Community MDS to identify patients discharged & claims Success: 30 days no hospital, SNF readmit death Mechanics: Claims, in conjunction with MDS used to build stays Medicare FFS, soon to include Medicare Advantage Short stay residents following hospital stay Risk adjusted, based on claims, MDS & enrollment Source: Nursing Home Compare 3

4 8/28/2017 Transitions of Care Where Information Gaps Appear & Compromise Care Inpatient Rehab Hospital(s) SNF LTPAC Assisted Living PT/OT Disabilities Behavioral Health Community - PCMH Home Care / PGHD PCP / FQHC Health Home Labs, Rads, Geneticists Non-PCP Specialist Urgent Care CBOs / Social Services Key Transitions Use Case 1: HOSPITAL to HOME Use Case 2: HOSPITAL to LTPAC Use Case 3: LTPAC to HOME Use Case 4: PCMH PCP to Other Use Case 5: HOME to HOSPITAL Use Case 6: LTPAC to HOSPITAL Use Case 7: HOSPITAL to HOSPITAL Use Case 8: HOME to LTPAC Use Case 9: PROVIDER to BH/CBOs Use Case 10: Specialist to Specialist 4

5 8/28/2017 Impact of Problems Associated with ToC 2001 Institute of Medicine (IOM) report, Crossing the Quality Chasm, described US healthcare as decentralized, complicated, and poorly organized, noting layers of processes and handoffs that patients and families find bewildering and clinicians view as wasteful. Health Affairs 2012: Inadequate care coordination, including inadequate management of care transitions, estimated to cause $25 to $45 billion in wasteful spending in 2011 through avoidable complications and unnecessary hospital readmissions. Commonwealth Fund 2013: Substantial proportion of readmissions caused in part by poor discharge and transition planning and execution: ~ 20% hospitalized Medicare beneficiaries are readmitted within 30 days > 33% readmitted within 90 days 5

6 8/28/2017 Causes of Problems Associated with ToC Communication: Providers do not effectively or completely communicate important information to each other, the patient, or caregivers Lack Standard Gap in Expectations No Time for ToC Procedure Different Style / Culture Successful Handoff Patient Education: Patients or caregivers receive conflicting direction, confusing medications, and unclear instructions about follow-up care. Patients may lack a understanding of medical condition or the plan Accountability breakdowns: In many cases, there is no physician or clinical entity that takes responsibility to assure that the patient s health care is coordinated across various settings and among different Source: Joint Commission Hot Topic in Health Transition Planning

7 8/28/2017 Keys for Successful ToCs More than HIE Right information, right time, right format without extra noise Comprehensive Care Coordination, Health Coaching and PCMH Model Medication Management Effective Hand-offs to Providers and Social Workers Timely Post Discharge Follow-up Self-Management Care Plans with Patient Education and Clear Follow-up Identify and Provide Resources for Social Determinants of Care High Patient Satisfaction (correlated with lower 30 day readmit rates) Sources: Project BOOST (Better Outcomes by Optimizing Safe Transitions) Care Transitions Interventions (CTI) CMS Community-Based Care Transitions Program (CCTP) Guided Care Comprehensive Primary Care for Complex Patients Project RED (Re-Engineered Discharge) State Action on Avoidable Rehospitalizations (STAAR) 7

8 8/28/2017 Partnering to Improve Transitions of Care (ToC) Hospitals & LTC/Home Health partners can jointly improve ToC effectiveness by reviewing areas on both sides to change discharge planning, admit process & HIE: Improve Hospital-LTC ToC: discharge/admit Screening and discharge efficiently getting patients to right facility Process & tools to provide LTC data needed to receive patient Collaborate After ToC: address patients & risks together Process, tools, and alignment to identify patients at risk, gaps in care, actions to address them, & means for team to communicate Improve LTC-Home ToC: discharge/admit Discharge efficiently to home health agency, PCP, or both Process & tools to provide data and alert hospital 8 8

9 8/28/2017 Using IT & HIE to Improve Transitions of Care Process Hospital Discharge Planning Referral Admin Process Healthcare Information Exchange (HIE) Manage Patients at Risk LTC Discharge Process & HIE Technologies Care Management Tool - Creation of Care Plan Risk Profile Scoring Tool Discharge-Referral Process LTC Admit Process Metrics Reporting Key Data from Hospital EMR in C-CDA Transport Data (RHIO, DIRECT, Other) Ability to Load Key Data in LTC EMR Population Health by payer, risk & other criteria Dashboards & Rounding Tool with Alerts & Gaps Telehealth: Surgeon, Care Team, Behavioral Health Key Data from LTC EMR in C-CDA Transport Data (RHIO, DIRECT, Other) Ability to Load Key Data in Home Health/PCP EMR 9 Transition Of Care Transition Of Care 9

10 8/28/2017 LTPAC Attempting to Improve ToCs S&I Framework

11 8/28/2017 Care Coordination Tool for ToC to LTC Data Data Proposed to be Provided by Hospital Discharge 11

12 8/28/2017 DSRIP: Hospital Data that Facilitates LTPAC Care FLPPS compared data requested by LTPAC to enable successful transitions vs. ability to enable ToC to include additional data Data Desired by LTPAC Recipient Priority Source Availability Ease of Extraction CDA Compatibility Referrer Contact for Questions High High High Mod 02Sat High High High Mod Detailed Pain Information High Mod Low Low Detailed Functional and Cognitive Status High Mod Low Low Pre-hospital admission meds High High High Mod PT/OT care, abilities and willingness Mod High High Mod Pressure ulcers / skin / wounds High High High Mod Detailed Nursing Care: nutrition, hydration, devices, therapies High High Mod Low Advance Directives/MOLST High High Mod Low Relative Notified of Transiton of Care? Mod Mod Mod Low Vendor Supply / Info Mod Mod Mod Low Notification regarding ToCs High High High N/A 12

13 8/28/2017 What do we have to do in our communities to utilize HIE and other tools to improve ToCs and enhance performance of SNFs and Home Health agencies? 13

14 Technology and Challenges to Enable Better Partnerships for LTPAC Travis Masonis, CIO Jewish Senior Life Overview of Jewish Senior Life Comprehensive Portfolio CCRC/Lifecare Community SNF (362 Beds) short term rehab (68 beds, expanding to 88) Independent Living (90 Units) Assisted Living (78 Units) Adult Day Healthcare (85 slots) Outpatient Therapy Practice Companion Services Physician House Calls Alzheimer's Daytime Respite (Marian s House) 1100 Employees including Therapy Department & Medical Staff 1

15 Gather the data Gather what? Referral Tracking Understanding, managing, and improving LTPAC performance as a partner receiving referrals Internal database measures Response time Acceptance rates Referral patterns Diagnosis Classes Reason for bed denial Reason for bed refusal (by patient), where possible Curaspan Similar metrics noted above 2

16 Referral Tracking Allows JSL to understand mathematically the shifts and trends in referral types: Dx classes hard to place patients etc. More information = Better partnerships Readmission Reduction Tools/Analytics PointClickCare EMR einteract Telemedicine (URMC Cardiac) Practitioner Engagement Mobile App for providers Providers have more information at their fingertips from the mobile device after hours 3

17 Cost Accounting Measures activity based costs for the patient profiles. Includes cost information pertaining to: Diagnoses (primary and comorbidities) Demographics (age, gender, etc.) Payor type Ancillary Charges Therapy Minutes Physician Visits LOS Shows value to referring hospital partners not only means improving quality, but also reducing and controlling costs You can t improve what you aren t measuring Inbound from RHIO RHIO to PCC Lab Radiology CCD/CDA Perhaps ToC specific documents Value: Faster information at the provider s disposal One system to log into Trend data over time Current status In the midst of build for Lab/Rad Still evaluating/planning CCD/CDA 4

18 Outbound torhio PCC to RHIO ADT Consents CCD/CDA Value Improved Care Coordination MyAlerts for both JSL and the community providers Current status Discrete Data Discrete data is the enabler of interoperability Considerations when capturing data within the EMR: Usability Defined workflows/standard Process for data entry Training Structured Progress Notes and Assessments Coded Dx s on orders Up to Date Problem lists 5

19 Opportunities/Challenges Telemedicine Advanced Data Sharing Targeted ToC documents, CCD/CDA consumption, global readmission risk alerting Interoperability Costs and Complexity Hospital to RHIO to LTPAC partners. Predictive Analytics Biomedical/Telemetry Alerts for Readmission Risks Post-Discharge Monitoring (Wearables, Medication Compliance, etc.) Clinical and Operational Integration Across Organizations 6

20 Improving Financial and Clinical Performance Through Health Information Exchange (HIE) August 30, 2017 Table of Contents Slide 3: Slides 4 10: Slide 11: Slide 12: Slide 13: Slide 14: What is HIE? About Healthix HIE Value HIE Adoption Across NYS Healthix Adoption in LTC Barriers & Solutions 2 1

21 What is HIE? LTPAC Behavioral & Community Based Organizations Lab & Radiology Groups Government / Public Health Organizations HIE Primary & Specialty Care Commercial Payers / Plans & Medicaid Claims Hospitals 3 About Healthix Healthix is the largest public Health Information Exchange (HIE) in the United States Hundreds of healthcare organizations at more than 1,500 facilities across New York City and Long Island participate in Healthix. Supplies secure data to improve healthcare quality, efficiency and effectiveness Provides a range of clinical information in real-time Facilitates care coordination 4 2

22 Healthix and the SHIN-NY 5 The SHIN-NY is composed of 8 HIEs or Qualified Entities (QEs). The NYS DOH establishes common services, privacy and security policies, and technical standards for interoperability. When a user queries for patient data, Healthix automatically returns data from both Healthix and the SHIN-NY. Role of Healthix in Exchanging Information SHIN-NY PRIVATE HIEs PRIVATE HIEs INCLUDE: Health Plans Large Provider Systems PPS Pharmacies More ehealth exchange and SHIEC HEALTHIX ~ 500 Participants ~ 1,500 Facilities 6 3

23 Sources of Data The breadth of data in Healthix is expanding in the number and type of contributors In development Hospitals Independent Physician Practices of All sizes Long-term Care, Nursing Facilities Behavioral Health Facilities Federally Qualified Health Centers (FQHCs) Community Based Organizations Home Care 21 EMS Health Plans PPS Leads Medicaid Health Homes Independent Pharmacies Independent Labs & Radiology Centers NYC Correctional Health Services 1 7 All Other Public HIEs in New York State Medicaid Claims Veterans Administration 7 Demographics (Name, Gender, DOB, Race, Ethnicity, Language) Allergies Medications Medication Allergies Smoking Status Immunizations Encounters Observations Vital Signs (Hgt, Wgt, BP, BMI) Pharmacy Fill Data 8 Types of Data Lab Tests, Values / Results Radiology Reports / Images Other Diagnostic Results Diagnoses Problem Lists Procedures Functional / Cognitive Status Care Plans / Team Members Discharge Instructions /Clinical Summaries Advanced Directives In development Care Plans emolst EMS Run Sheets Image Exchange Medicaid Claims Data Social Determinants of Health 4

24 Healthix Core Services Patient Record Search: Access to a more comprehensive patient profile statewide Delivery of Clinical Summaries: Ability to electronically deliver clinical summaries (CCD, C- CDA) and lab results Clinical Event Notifications (CENs): 24/7 Custom alerts provide real-time updates for patients in care Direct Messaging: Secure HIPAA-compliant messaging Predictive Analytics: Assessing risk and managing patients to optimize care MAY 2017 USAGE PATIENT RECORDS SEARCHED VIA PORTAL 2,183 CLINICAL SUMMARIES DELIVERED 104,314 CENs SENT TO: ALL CLINICAL PROGRAMS 124,001 CENS SENT TO: PUBLIC HEALTH (NYSDOH) 361,593 DIRECT MESSAGES SENT 9,568 9 Uses of Healthix Data to facilitate care management Accessing Patient Data in an Emergency Situation Managing Patients with Serious Medical Conditions using Clinical Event Notifications Providing Transition of Care Documents for Physicians Supporting Secure Direct Messaging Between Providers Providing Alerts for Frequent Users of ED (3+ visits in 30 days) Facilitating Research using De-identified Data Connecting PPS Leads and Partners IN DEVELOPMENT Delivering Alerts from Health Plans to Providers re: Gaps in Care 10 5

25 NYS HIE Value Studies In a study published in the Journal of the American Medical Informatics Association, accessing the HIE within 30 days post discharge from a hospital admission was found to be associated with a 57% lower odds of same-cause readmission or approximately 605k in annual savings from averted readmissions. 1 In another study, published in the aforementioned research journal, researchers found that compared to an ED setting without access to an HIE, the setting with access to an HIE was associated with a 52% and 36% reduction in the estimated number of laboratory tests and radiology examinations, respectively Journal of the American Medical Informatics Association, Volume 22, Issue 2, 1 March 2015, Pages , 2 Journal of the American Medical Informatics Association, Volume 22, Issue 6, 1 November 2015, Pages , HIE Adoption Across NYS* *As of 06/30/17. Source:

26 Healthix Adoption in LTC Healthix has recruited approx. 60% of LTC facilities in target market Majority using SigmaCare or PointClickCare Developed streamlined models of integration with EMR vendors to allow for standard implementations with minimal downtime Optimal implementation of Healthix at LTC Organization 100 bed Facility in NYC using SigmaCare Bidirectional data exchange with Healthix Single Sign-On access within EMR Receiving Clinical Event Notifications (CEN s) on patients postdischarge Barriers and Solutions Barriers Cost of interoperability EHR / Care Management Systems often charge customers an integration fee along with ongoing maintenance fees HIE s typically charge one-time integration fees Organizational commitment to change Workflow Solutions Data Exchange Incentive Program (DEIP) Delivery System Reform Incentive Payment (DSRIP) Program Other value-based reform programs / initiatives Healthix provided training / education 7

27 Contact Us If you have questions, would like to see a demonstration or are interested in connecting with Healthix Cesar J. Perez cperez@healthix.org 15 8

28 Enhancing Transitions of Care Communication and collaboration What Is Interoperability at PointClickCare? Interoperability is exchange of patient s data between providers, institutions, 3 rd party vendors and with people within the patient s circle of care. 3 rd Party Vendors Patients Circle Of Care Providers & Institutions Payers & Risk Bearers Therapy Families Home Care Providers Insurance Organizations Pharmacy Patients Hospital Systems ACO/Managed Care Smart Devices.. Etc. Care Providers Post Acute Care Providers Health Data Broker Systems Data either moves point to point direct integration from A to B, or through an intermediary HIE, RHIO, Repository (i.e. DIS), Exchange Provider 1

29 Transitions Of Care Seamless Transitions and Data Interoperability is key to provide the Highest Quality of Coordinated Care Today Integrated Direct Messaging Direct Messaging Facilitated CCD and einteract transfer form Exchange Patient death or discharge automatically sends the CCD to the local integrated HIE CCD as a PDF is not Actionable Need to share the Right information at the Right time Challenges Identifying Patients and Users across systems Timing is very important HIE and Health System requirements vary greatly from one another Future Actionable CCD exchange and Service Data Insight Exchange Task and Alert Based notifications API Availability & 3 rd Party Developer Program EHR Transitions of Care Stratis Health MN completed study of how electronic exchange of information benefited nursing homes and hospitals within a system through an HIE The nursing homes used the CCD and the einteract transfer form to communicate during transitions of care. Included meeting with the ER receiving staff admitted that they SELDOM IF EVER looked at paperwork from the home o Time consuming o Lack of consistency in aggregation and presentation of papers o Found it easier to call and ask for the information rather than hunt through a package ALWAYS read the Transfer Form (current problem) and CCD (history) 2

30 Managing High-Risk Patients Identifying High Risk Residents Client Specific Various risk assessment tools o Elopement o Braden o Geriatric Depression Scale System Tools einteract POC Advanced Reporting tools AHRQ best practice toolset for identifying risk of skin breakdown COMS** 3

31 What is einteract? PointClickCare s einteract solution is a group of submodules designed to improve the identification, evaluation, and communication on changes in resident status so that hospital readmissions can be avoided. The solution includes the following components: einteract Stop & Watch Alerts Real time alerting of changes from the norm through POC einteract Change In Condition Alerts, Change In Condition Assessment & SBAR Summary Assists in the identification of residents that SHOULD be transferred to hospital and improves communication between practitioners and the facility einteract Transfer Form Assessment Ensures communication of condition to hospital is complete and when combined with CCD provides current and historical data for evaluation and treatment (continuity) einteract QI Tools Identify gaps in process at both the resident level and the facility einteract: Tools and Integrated Care Team Process Transition of Care CCD and einteract form sent via IDM 4

32 Advanced Reporting (AHRQ OnTime Reports) AHRQ Safety Program for Nursing Homes: On-Time Prevention Program integrates clinical reports (Advanced Reporting) into PointClickCare workflow using daily care capture through POC to identify residents at risk for developing pressure ulcers and support clinical decisions to decrease those risks. Reports use POC data which identify changes which put residents at risk for skin breakdown: incontinence, decrease in nutrition, changes in skin condition and weight loss or gain and combinations thereof. When integrated into daily care, homes are seeing reduction in skin breakdown of up to 25%. Benefits were initially identified using paper processes not unlike einteract and replicated in study from that replicated benefits in HIT. The entire program and resources can be found at: How to track, report and make advancements in QMs that can increase bottom line 5

33 How to demonstrate quality & reporting Embedded Analytics tools that allow you to have oversight of organization performance concerning: Readmissions Clinical Key Performance Indicator (CKPI) Quality Measure (QM) Quality Indicator (QI) outcomes. System allows drill down to specific time frames, residents, units. Readmissions (non risk adjusted) provides real time data by hospital, resident, location and time frame. Reporting and insights PointClickCare Analytics Instant access to: Interactive dashboards at the corporate, facility, and resident levels for Readmission, QM/QI and CKPI data. 6

34 How does your organization benefit? Increase Corporate Oversight Gain increased visibility with multiple tiers of reporting, with interactive dashboards available at the corporate, facility, and resident levels to quickly identify discrepancies and outlier facilities, saving you time and reducing unnecessary hospital readmissions. Improve Quality of Care Identify your highest acuity population as well as which residents are triggering negative outcomes and are at risk for readmission, enabling you to take immediate action and minimize risk. Enhance Problem Solving Capabilities Conduct detailed root-cause analysis and prepare responsive improvement plans, boosting overall corporate performance and your reputation. 7