SWAN Alerts and Best Practices for Improved Care Coordination

SWAN Alerts and Best Practices for Improved Care Coordination

IHIN and SWAN Course Overview Our Goal: To educate healthcare providers in how to manage SWAN alerts for meaningful impact at the point of care, to improve health outcomes in the State of Iowa Intended Audience: o Iowa Healthcare Providers; special focus on C3 communities, all levels and all specialties o Public Health Agencies in C3 communities o Social Service Agencies in C3 communities o Health Care Administrators in C3 communities 2

IHIN and SWAN Training: Outline of Content SWAN Overview What is IHIN? Best Practices and Care Coordination Igniting Positive Change 3

Definition of SWAN 1. Swan [swon] Any of several large, stately aquatic birds of the subfamily Anserinae, having a long, slender neck and usually pure-white plumage in the adult 2. SWAN State Wide Alert Notification System 4

A bit of SWAN history. SIM (State Innovation Model) grant was awarded to Iowa Medicaid Enterprise in 2014 by CMS (Center for Medicare and Medicaid Services) Included funding for IDPH (Iowa Dept. of Public Health) to implement an event notification system as part of the IHIN (Iowa Health Information Network) Began with the IME (Iowa Medicaid Enterprise) member eligibility files in December 2015 Medicaid transitioned to managed care in 2016; member eligibility files were then to be sent instead from the MCOs (Managed Care Organizations), and ACOs (Accountable Care Organizations). 5

State Wide Alert Notifications (SWAN) Initial function is to provide real-time notifications for Medicaid population, to their care providers and care managers Goals: To support providers statewide in developing care coordination processes needed to improve outcomes and lower costs for the Iowa Medicaid population To support interoperability of electronic health information and advance meaningful use of the data To support providers transforming from a volume-based system into a value-based system 6

Current Use Cases The SWAN IT platform performs member matching on the member eligibility lists, for alerts and notifications to the members healthcare providers and/or care managers Alert notifications are triggered by unplanned patient encounters: Emergency Department visit Inpatient Admit Inpatient discharge 7

Current Process for SWAN 1. Member eligibility files are sent from the MCOs (Managed Care Organizations) and Medicaid-based ACOs (Accountable Care Organizations) on a monthly basis. These files identify within the SWAN system the members for which these care managers want to receiver alerts. 2. Most hospitals send to the SWAN system a real-time ADT feed (ADT = Admission, Discharge, and Transfer). A few systems send files twice daily. 3. SWAN sends a daily Digest of ADT files back to the ACOs and MCOs, to be leveraged through internal care coordination processes. 8

State Wide Alert Notifications 1 Participating ACO/Payer Patient List Updated Nightly Alert Rules Engine Received Real Time Hospital Source Systems Care Team Responds within Workflow ADT Events Eligible Subscribing Participant s System ADT Events delivered using eligibility to participants Multiple Secure Delivery Options 9

Eligibility Files / Patient Attribution MCOs - In Iowa, Medicaid MCOs are the PAYERS who offer managed care health plans to Iowa Medicaid members MCOs send SWAN monthly Eligibility Files listing patients that are currently covered by that Medicaid MCO MCOs will receive ADT alerts for these covered members 10

Eligibility Files / Patient Attribution ACOs ACOs are PROVIDER organizations that are accountable / responsible for managing the care of a defined group of patients in an effective, efficient manner Payers identify which provider is accountable for which patient. For Iowa Medicaid, this is largely the three MCOs ACOs send eligibility lists comprised of their attributed patients; these are the patients for which they will receive ADT alerts

SWAN File Layout for Eligibility File 12

ADTs (Admission, Discharge, and Transfer) -- What goes into SWAN 13

ALERT DIGEST: ADTs (Admission, Discharge, and Transfer) -- Comes out of SWAN 14

Utilization of SWAN Alerts Currently, the receiving MCO or ACO distributes alerts to providers / care managers of the identified members Focus is on COORDINATION of CARE for IMPROVED OUTCOMES The SWAN needs your people and processes to thrive! 15

The IHIN is Hospital Long- Term Care Primary Care Provider The IOWA HEALTH INFORMATION NETWORK A hub that facilitates sharing of patient health information between authorized participants. Health System Pharmacy IHIN Public Health Specialty Provider Lab

IHIN History - 2015 The Iowa Legislature authorized the movement of the Iowa Health Information Network (IHIN) into a nonprofit status, outside of state government. 2017 Following a bidding process by the Iowa Department of Public Health (IDPH), the Hielix/Koble Group (HKG) application was selected to take over stewardship of the non-profit IHIN. HKG officially began stewardship of the IHIN on March 31. Current IHIN is currently in process of replacing the entire IHIN platform, to expand scope and services.

Current IHIN Services (soon to expand!) IHIN Patient Query: Ability to seamlessly access information available through the IHIN within a provider EHR. IHIN Portal: Secure internet-based portal that allows access to information available through the IHIN. Direct Secure Messaging: Ability to send and receive secure messages between providers using the IHIN portal.

Current IHIN Services (soon to expand!) Health Information Service Provider (HISP) Services: Ability to use the IHIN for Direct through EHR for HISP agnostic systems. Cancer Registry Reporting: Ability to electronically report cancer data to the State Health Registry of Iowa (SHRI)..g. EPIC & Meditech) Electronic Reporting of Reportable Diseases: Ability to report required laboratory results for reportable diseases or conditions to public health. Statewide Alert Notification System (SWAN): Ability to create alerts for care teams using ADT feeds from hospitals. Supported by IME SIM grant.

Iowa Healthcare Eco System

Timeline of Future IHIN Services

Leveraging SWAN to Improve Clinical Outcomes IMPROVING COORDINATION OF CARE

Coordination of Care: Current Frustrations for Patients & Providers Referral specialist does not have notes on referral from PCP PCP does not receive a report back from the specialist PCP is not aware of hospitalization, or discharge instructions (e.g. med changes) Test results are not communicated to the patient; to the PCP; or to the ordering physician

Coordination of Care: Current Barriers Busy schedule: productivity requirements and documentation requirements EMR is a challenge as stand-alone; may not communicate well or at all with other systems Continued struggles identifying efficient method to communicate with other providers Social determinants impacting patient seem disconnected from current system

Unintended Consequences from Lack of Care Coordination Gaps in medical history and recent course of treatment, due to multiple sources and fragmented documentation Delays and miscommunications in care planning that may be dangerous Wasted resources related to unnecessary referrals and duplicate testing Missed benefits of a multidisciplinary team that consider the entire person s health and wellbeing Needs and preferences of the individual patient may be lost in the endeavors of providers to piece together essential pieces of documentation

Specific Activities of Care Coordination CHOOSE Choose to be accountable Decide to improve your area s practices of care coordination Clarify internal tracking and follow up processes for referrals and transitions PROVIDE Provide proactive patient support: Assess and advocate for patient s needs and goals, including selfmanagement Collaborate with coproviders on holistic care plan Monitor for changes in needs, and follow-up accordingly BUILD Build relationships and develop agreements with other providers and agencies Talk through typical cases Agree on roles and responsibilities in care transitions and hand-offs

How does a high quality care transition look? SAFE: Planned and managed to prevent patient harm, from either medical or administrative errors or omissions EFFECTIVE: Decisions are based on scientific knowledge, and executed well for maximum benefit TIMELY: Patients are transitioned to new level of care or referral when it is needed and planned; no unnecessary delays PATIENT-CENTERED: The patient and her/his support group have been asked and listened to in terms of patient needs and preferences E F F I C I E N T: Avoids duplication of diagnostic tests and treatment options EQUITABLE: All patients receive the same quality of care and attention, regardless of status or characteristics. Institute of Medicine s (IOM) report Crossing the Quality Chasm: A New Health System, for the 21 st Century

Support and engage in health information exchange, for improved care coordination: Improved quantity of applicable data in patient alerts and notifications Broader networks of engaged providers and community agencies, including social services and other ancillary providers Increasingly robust population health strategies Better informed utilization of resources More efficient and accurate quality reporting Bi-directional exchange across state lines

Where to begin? ADT Alerts Get them, and use them Transition support for patient and family Medication reconciliation Post discharge case management to decrease readmissions Specialist Referrals Create a process, and stick to it Community Agencies Network and connect Guidelines for referrals: information to be shared, and tracking for follow-up Expectations for continued care post-referral Case management coordination to avoid duplication of services Tracking on lab and imaging results Tracking of referrals for social determinants of health

Performance Measures: From Unique Patients to Population Health Historically, data utilized to measure healthcare quality has been primarily gathered from administrative and billing areas within hospitals, physician offices, and health plans. With gradual movement toward clinical measures and value based purchasing, data aggregation for analysis has continued to be a problem, due to the lack of interoperability between systems. Health Information Exchange will allow for fulsome real-time data for best decisions and optimal outcomes, and robust quality analysis.

Care Coordination leads to better outcomes and health for individuals and communities Access to real-time data with real-time sharing Up-to-date medical history Accurate medication lists Real-time diagnostics Integration of additional key perspectives and solutions Home Health Long-Term Care Public Health Agencies Behavioral Health Audiologist Optometrists Pharmacies

Social Determinants of Healthcare Family Planning DME Dieticians Screening Centers Genetic Counseling Ambulance Physical Therapy Department of Aging School Nurses Education Centers Meals on Wheels Substance Abuse Smoking Cessation Department of Corrections

IMPROVING OUTCOMES Through People and Processes Individuals at the center of their care Providers able to access healthcare history safely and securely, from a variety of sources Predictive analytics to portray long-term health assessment Public health agencies and researchers developing and delivering new treatments for the benefit of all.

Rapid Cycle Change: Plan Do Study Act PDSA PLAN Design a new process with input from key stakeholders Communicate plan with all those who need to know DO Implement the new process May utilize a pilot model with a small subset of the population (e.g. one C3) May implement with entire population after careful planning

Rapid Cycle Change: Plan Do Study Act PDSA STUDY Collect and analyze data Collect anecdotal feedback ACT Tweak the process as indicated (after providing thorough communication to Stakeholders)

SWAN and IHIN: Moving Forward IHIN is changing to a new platform in late calendar year 2017. Current functionality will continue: Electronic Lab Reporting Records Query Statewide Alert Network (SWAN) Direct Secure messaging

Planned Capability with New Platform See previous slide, plus: Bi-directional C-CDA Exchange Quality Measure Reporting Eligibility and Claims for Payors Data Analytics, Informatics, and Population Health Capability Patient Portal Provider Directory Interstate Connectivity Telehealth See next slide

Planned Capability with New Platform (continued from previous slides) Numerous Bi-directional Registries, including: Substance Abuse Electronic Case Reporting Cancer Trauma PCMP API Functionality and Support for Numerous Applications

Care Coordination: Living the Dream Iowa s new Health Information Network will help improve your care coordination, by: Enabling accurate medication reconciliation Decreasing duplicate testing Improving diagnostic capabilities Access an accurate medical history at point of care Order and send results more quickly Ensuring patient s goals and preferences are shared among providers

Networking, Coordination, and Collaboration Begin to bring more ancillary aspects of care into the active team: Food, nutrition, and supplements (food insecurity) Housing needs and concerns Social Needs: child care, transportation, employment, education, relationships Smoking cessation; abusive relationships; alcohol misuse or substance dependencies

Make connections NOW!! Begin drawing ancillary providers and agencies into your care management planning now Integrate care planning into daily work flow, and include two-way communication with other providers IHIN information exchange ensures greater efficiency for people and processes in the healthcare community.

Sustaining Positive Change SWAN Alerts IHIN Improved Patient Outcomes People and Processes Improved Care Coordinat ion

For questions or comments, please contact: Becky Simer Technical Assistance and Support Lead for C3 Clinicians Becky.Simer@ihin.org Renee Gilley-Gates Interface with Swan Participants Renee.Gilley-Gates@ihin.org Allen Wentland Onboarding and Allen.Wentland@ihin.org Andi Bryan SWAN SME Andrea.Bryan@ihin.org Dale Emerson IHIN CEO Dale.Emerson@ihin.org www.ihin.org 45