Technology and the Uninsured: Increasing Access and Coordinating Care Doing the Impossible Leveraging Technology to Reduce Costs and Improve the Quality of Care for the Uninsured COUNTY OF ORANGE HEALTH CARE AGENCY Hank Fanberg Manager of Research & Development Dan Castillo, MHA, FACMPE, CHE Program Administrator 2007 National Congress on the Un and Under-Insured
Today s Objectives To share with you how two different types of healthcare organizations are utilizing technology in their efforts to serve the underserved. What a Provider System is currently doing What a Public Health (Payor) System is currently doing
Today s Objectives (cont.) We will demonstrate the different technology applications that have been implemented and how they support our respective initiatives. We will share with you the outcomes of our efforts and how leveraging technology has not only made our respective systems more efficient but how it has enhanced the patient s quality of life.
Today s Objectives (cont.) The Provider Perspective Hank Fanberg CHRISTUS Health The Public Health (Payor) Perspective Dan Castillo Orange County Health Care Agency
Our Healing Ministry
PRESENTATION GUIDE CHRISTUS Health background Market Statistics re: un and under insureds Programmatic Approach to Care Technology Tools to Accomplish
Our Vision What We Are Striving To do. Strengthen current ministries and expand into new locations and services Implement innovative approaches to caring for the whole person Increase access to health care for the poor and underserved through advocacy and other initiatives Make significant contributions to creating healthy communities Create a work environment filled with hope, dignity and mutual respect
Our Legacy In 1866, Texas was faced with illness, disease and poverty of staggering proportions. Galveston Bishop Claude M. Dubuis turned to his native France and issued a plea to Religious Sisters for assistance Three Sisters answered the Bishop s call, Mother Blandine, Sister Ange, and Sister Joseph
Our Legacy The Sisters arrived in Galveston in October 1866 and founded the Congregation of the Sisters of Charity of the Incarnate Word. In 1887 the Sisters opened the state s first Catholic hospital in Galveston, Charity Hospital. Mother Madeline, Sister Agnes and Sister Pierre traveled from Galveston to San Antonio in 1869 Within months, the Sisters established Santa Rosa Infirmary in San Antonio.
Facts and Figures - Today 40 hospitals and other health care ministries in more than 70 communities Dozens of other health services in Texas, Louisiana, Arkansas, Utah, Oklahoma and Mexico Approximately 27,000 employees More than 8,000 staffed beds Cont d
Uninsured in Texas and Louisiana Demographics Texas leads nation in uninsured; Louisiana is third (2005) Majority are: - Working families with low and moderate incomes - Young adults age 19-34 - Disproportionately Hispanic and African-American - Legal, US residents Health care coverage is not available from employer or is unaffordable Sources: Health Policy Institute; The Access Project
Uninsured and Underinsured in Texas and Louisiana, 2005 Percent of Population 50.00% 45.00% 40.00% 35.00% 30.00% 25.00% 20.00% 15.00% 10.00% 5.00% 0.00% LA TX Medicaid/CHIP Uninsured
CHRISTUS Direction From Focus on high cost, ER-based charity care to treat illnesses that Could have been prevented. To Comprehensive strategies to address the symptoms and underlying causes of health problems. Proprietary approaches to planning and implementation. Community collaboratives that mobilize and build upon existing community assets.
Three Pronged Approach Provide Access to Care Identify/establish medical homes Identify/develop other building blocks Uninsured Population Manage Care Identify high risk patients Manage Lifestyle Navigate the System Manage Acute Care Develop clinical pathways/ supply chain management Implement strategic pricing Implement communication plan
Current Building Blocks Enrollment Wellness & Prevention Medical Home Disease Management Care Management Pharmaceuticals Access Diagnostic Service Referrals System Durable Medical Goods
Comprehensive Integrated Care Enrollment Medical Home Admission Wellness & Prevention Disease Management Prepare for treatment & discharge Mental Health Dental Health Care Management Community Collaboration Diagnostic Service Medical or surgical treatment Pharmaceuticals Access Referrals System Durable Medical Goods Expanded Insurance Coverage Discharge to home and/or aftercare
Success Requires Tech and Touch Technology: variety of tools that fit the need Touch: Community Health Workers
Community Health Workers People who are residents of underserved communities who are uniquely knowledgeable about their neighbors needs Care Managers by many different names Health Promoter Family Health Care Advisor Natural Caregiver Promotora Resource Mother
CHRISTUS Spohn Kleberg Preliminary Results (12-06) A study of 77 chronically ill clients during the first 6 months of intervention by CHWs Utilization Impact 52 of 77 had no ED visits or admissions 49 ED visits by 25 patients 28 admissions by 20 patients Financial Impact (6 months) $123,329 in net savings for ED & Acute Care Costs of $35,152 Return on investment (ROI) $3.80 per $1 invested in the Kleberg CHW program
Patient Specific Results 22 year old Caucasian female Diabetic ED as primary care site Admitted to ICU ~ 6 weeks for acidkerotosis Community Health Worker + Home Monitoring No admissions 11 months 3 ED visits $215,000 cost avoidance
Home Monitoring Device
What Technology building Blocks Are Needed? Clinical Systems Communications Systems Financial Systems
Map the technology to the Need NEED SOLUTION Enrollment Financial Eligibility & Enrollment Medical Home Clinical/ Comm EMR/PHR Wellness Clinical PHR, on line Diagnostics & Clinical Home Monitoring Disease Mgmt Referrals Communications Portals Medications Clinical eprescribing Data Analytics Data base Oracle SQL
What Technology building Blocks Are Needed? Clinical Systems Shared electronic medial record Community Wide Master Patient Index Vital sign monitoring device in the home Communications Systems Secure network for accessing and sharing Web based access and applications Financial Systems Eligibility verification Strong Authentication Positive patient identification and verification
CDA document-based network PMpaper EMR HL7 ^v2 data All transform to CDA View the complete record No loss in computable semantics HL7 ^v2 text text chart RIS/dictation LIS text DICOM HL7 ^v2 paper NCPDP erx/paper EHR V-EHR PHR Patient Portal Physician Portal Health Record Bank
HIE Infrastructure
OUTCOMES TO DATE AND FUTURE NEEDS Divert inappropriate care from ED By using home monitoring devices and Community Health Workers for support Provide a medical home with electronic linkages to entire care team Virtual PHR using grid technology Establish a community wide referral network Web site, in early development Collect de-identified data for analytics Not yet robust enough Identified the major components to implement and integrate much more work to be done
Still Building Infrastructure Evaluating social networking model (i.e. Face Book) for sharing and notifications Standardizing terminology across multiple systems Integrating eligibility and financial systems with clinic systems Continue to develop the virtual EMR Continue to improve communication and collaboration tools Continue to automate as much as possible
Summary The Need drives the technology Not the other way around Technology by itself is insufficient But it is necessary Underlying Foundation is the Medical Home Requires sharing of information
Doing the Impossible Leveraging Technology to Reduce Costs and Improve the Quality of Care for the Uninsured 2007 National Congress on the Un and Under-Insured Dan Castillo, Medical Services Initiative Administrator
About Orange County MSI Orange County s state mandated indigent program Serves as the County s safety net program for the underserved Operates without the benefit of a County controlled healthcare delivery system Public-private partnership No County-Employed Physicians No County-Run Hospital system Annual enrollment of 25,000 patients $87 million annual budget
By the Numbers 22 hospitals reporting admit and discharge data Over 10,000 ER admits electronically reported Over 3,000 hospital stay notifications 14 Community Clinics connected Over 200 ER Physicians connected Over 200 Primary Care Physicians connected Over 500 Pharmacies connected
By the Numbers (cont.) Over 5,000 eligibility checks per month by provider network Over 10,000 ER Queries in 12 Months Over 2,000 ER Physician notes submitted Over 700 e-referrals to Community Clinics
e-fficiencies Result in Cost Savings Reduction of inappropriate ER utilization by 11% over the last quarter Hospital cost savings per re-admitted patient is $2,000 Duplicate prescription cost savings per patient per year is $600 (avoidable) Diagnostic and ancillary cost savings is $130 per patient per year Improved quality of care: PRICELE$$
The Bottom Line Improving Care Medical Home linkage (over 12,000 patients assigned) Reduction in prescription errors Increased continuity of care Increased access to timely care Improved outcomes Increased patient satisfaction
The Dark Ages Manual enrollment process with paper record keeping More likely to wait over 45 days for eligibility determination Limited medical home linkage Less likely to have a regular source of care Lack of clinical information at the point of care More likely to report they have not received needed care
Health IT Renaissance Standardized paperless enrollment 30% reduction in eligibility staff Patient eligibility wait times decreased to less than 30 days Balancing Stakeholder ROI with quality patient care Enhanced Physician and Clinic reimbursement through P4P Increased ability to monitor and manage program costs Addressed through Case Management enrollment, patient outreach, and consultation with Medical Homes.
Need Drove Technology The four pillars to our technology initiative: 1. Electronic Eligibility Determination & Enrollment 2. Hospital Census Notification and Tracking 3. ER Connect 4. Clinic Connect With these technologies, MSI is the most technologically progressive Safety Net Program in the State.
Electronic Eligibility & Determination A streamlined and automated web-based enrollment and eligibility determination System. An immediate and automated way to screen and enroll applicants online Workflow approach promoting efficiencies in management oversight and processor accountability
Hospital Census Notification & Tracking Collects daily census data electronically from hospital scheduled batch runs Uploads data automatically and provides the user with a current daily census report in a web-based environment Tracks and displays Level of Care and Length of Stay information Case Management linkage
ER Connect Provides usable patient data at the point of care Facilitates communication between ER physicians Tracks patient s utilization activity Reduces consumption of the community s scarce healthcare resources
ER Connect Patient History Tab
ER Connect Prescriptions Tab
Clinic Connect It s an innovative, technology-based, data communication platform, facilitating the use of available patient information. It allows Clinic Providers to access patient information with the goal of enhancing the health services both at the point of care and for ongoing care management purposes. It s a patient flow management tool for those patients referred into the clinic.
Clinic Connect Patient Referral Worklist
Clinic Connect Patient Summary
Clinic Connect Patient Encounter Documented
MSI Technology Schema e-referral Referrals Emergency Room Medical Home Medical Home Prescriptions Lab Results Eligibility Data Accessed by ERs Claims History Case Management Hospital Activity Fiscal Intermediary
Critical Success Factors End-user was included from the beginning Community clinics and ED physicians created it! Early adoption by the hospital association Proven return on investment Reduction in redundant procedures and prescriptions Reduction in delays and costs associated with enrollment Efficiency savings to us and our partnering hospitals from avoided tests Increased patient safety Better continuity of care Improved provider reimbursement
Current and Future Opportunities Additional funding from Federal Govt. (CI) OCPRHIO this is viewed as a potential backbone for the RHIO in Orange County Platform to expand Chronic Care Management Easily modified to support e-referral system providing access to over 5,000 specialists in OC Expansion to other public health sectors such as County Medicaid that manages ~350,000 lives.
Closing Remarks The MSI Program is now a proven leader in utilizing innovative technologies within the County health sector
The Common End Goal To Address the issues of serving the Underserved. How? Technology supports Payor and Provider initiated programs. Why? Increased accountability, enhanced efficiencies, and most of all improved the quality of patient care. Where? Technology knows no boundaries. It allows our services to extend our reach across many underserved populations. When? Now. Both organizations have presented today what is currently on the ground and operating in their respective regions.
CHRISTUS Objectives - Revisited What has CHRISTUS Health, a Provider system, done with technology? The medical home as the foundation Share clinical information among providers electronically virtual EMR (grid) Include touch with the tech Continue to install and integrate the necessary clinical, financial and communication systems
OC MSI Objectives Revisited What has Orange County MSI, a Public Health Payor system, done with technology? Implemented an electronic enrollment system Deployed an ER-based, patient history, query system Integrated an electronic referral system Enhanced the linkage of unattached patients with a Medical Home Improved quality of care
Whether through a Provider System such as CHRISTUS Health or a Payor system such as Orange County MSI, technology has clearly improved the delivery of health care services, supported targeted patient programs, increased the ability to track and manage our transient population, and has more efficiently utilized our scarce health care resources.
Hank Fanberg Questions & Answers Manager of Research & Development CHRISTUS Health Office (504) 838-1550 E-Mail hank.fanberg@christushealth.org Dan Castillo, MHA, FACMPE, CHE Administrator County of Orange Medical Services Initiative Office (714) 834-6249 E-Mail dcastillo@ochca.com