Creating a Shared Data Ecosystem to Assist in Managing Transitions in Care May 16, 2018 2:45 PM 3:30 PM
Overview of Presentation Overview of C3 Providing the context: Overview of our Model of Care Overview of Transitions of Care program and goals o Historic impediments to these efforts Pilot ACO work Genesis of work with MAeHC Overview of MAeHC and capabilities o Current members of the MAeHC ecosystem Learning by Doing: Positive impact on TOC program and remaining challenges
Overview of Community Care Cooperative In 2016, 15 Community Health Centers (all FQHCs) formed a new MassHealth Accountable Care Organization (ACO) called Community Care Cooperative (C3) (www.c3aco.org) o Today we have 17 FQHCs C3 is a Primary Care ACO which means patients can access the full MassHealth PCC Network. Patients may see any specialist or hospital that accepts MassHealth at any time with no new paperwork rules We are the largest FQHC-ACO in the country taking twosided financial risk, and the only one taking TCOC risk
C3 s Statewide Footprint
Detail on Leveraged Data Assets HOSPITALS SURVEYS PAYERS LABS Berkshire Anna Jaques Baystate BIDMC Health Boston Children's Healthify MassHealth Quest LabCorp Boston Healthnet Boston Med Center Cambridge Health Emerson Holyoke Lawrence General Milton / Needham / Plymouth Partners Signature Brockton South Coast HYH Assessment MassHealth POSC MassHealth SFTP Quest SFTP LabCorp SFTP Steward UMass HRA 834s, Member List, QPRs, Settlement Reports Member Roster, Claims Extracts Lab Data BEHAVIORAL HEALTH Beacon Health MAeHC SFTP MAeHC ADT Integration MAeHC VPN ADT HYH SFTP Provider Extract Healthify SFTP Brockton (NextGen) Charles River (NextGen) FQHCs (EMRs) Cape Cod (OCHIN Epic) Dimock (ecw) East Boston (Epic) Provider Data Formstack EDW Eligibility Extract Attribution File EMK (NextGen) Family (NextGen) Fenway (Centricity) Franklin (Greenway) Hilltown (ecw) Holyoke (NextGen) Lynn (OCHIN Epic) North End (Epic) North Shore (Centricity) Uphams (OCHIN Epic) Analytics Engine ARCADIA EMR Integration Arcadia SFTP EMR Identifi Care Identifi Practice EVOLENT Identifi Analytics RAF
How We Use Data to Help Us Provide the Right Care at the Right Time Patient screens EHR SDoH data Claims ADT & Auth alerts Risk of Big Events Complex Care Risk of Readmissions Transitions of Care The Main Brain Data Warehouse with a Rules-based engine Care & Social Needs Care Coordination Performance Analytics Cost & Quality performance information Gaps in Quality & Care Population Health & Risk Adjustment
The Model of Care Practice Transformation Complex Care Transitions Care Population Health Our Model of Care: Builds on existing capabilities and strengths at our health Centers Integrates new MoC programs at the provider level (Health Center or Hospital) Improves quality of care for patients Brings targeted and tailored care to the entire population
Complex Care Management Objective: Focus on 3-5% of members with rising risk, where interventions and management can make a measurable difference, with the aim that patients graduate within 120 days PTx Complex Care ToC Pop Health Run By: ACO and Health Centers Key Program Elements: Highly structured program where care management team provides intense case management to patients with medical conditions, BH, or both. Team includes RNs, LCSWs and CHWs Patients enter into this program based on stratification (predictive analytics) Identifi Care application used by care managers Must meet contractual requirements for Comprehensive Assessments and Care Plan development: Comprehensive Assessments completed within 30 days Face-to-face Care Plans completed within 15 days
Population Health Management PTx Complex Care ToC Pop Health Objective: Manage quality and coding gaps, identify performance improvement opportunities, including EHR use optimization Key Program Elements: Annual strategy to achieve quality and coding goals Involvement of multiple members to the Health Center care teams to maximize top-of-license Use of Identifi Practice to provide insights Population Health Manager (PHM) works with operations, clinical and billing staff to find opportunities for workflow optimization Constantly analyze workflows to identify opportunities for improvement
Practice Transformation PTx Complex Care ToC Pop Health Objective: Strengthen health center processes to create more efficient systems that eventually lead to the achievement of the quadruple aim: Increase quality Decrease cost Improve patient experience Increase staff satisfaction Key Program Elements (for PY1 2018): Pre-Visit Planning Care Coordination Includes behavioral health integration and Social Determinants of Health
Transitions of Care Objective: Reduce Readmissions Run By: ACO PTx Complex Care ToC Pop Health Key Program Elements: A hospital-based program (mental health and med/surg) that manages members with high risk for a readmission Efforts start with inpatient bedside engagement The team of RNs, LICSWs and CHWs will help manage patients from discharge up to 30 days post discharge, to ensure safe return home and that all services and medications are available This team will coordinate with health centerbased teams after the 30 days to ensure smooth transition
Transition of Care Program (TOC) As noted on the Main Brain slide, our enterprise data warehouse ingests ADT feeds When these alerts are co-mingling with other data in the Main Brain, we are able to automatically stratify high risk members into the TOC program High risk is defined as top 30% of physical health and all mental health admissions TOC staff of RNs, social workers and CHWs endeavors to meet patients at the bedside as well as do home/community visits during the 30-day post-discharge period Goal of the program is to prevent readmissions and emergency department re-use after inpatient stays and improve quality (7 day post discharge visits, timely med recs, community tenure, etc.) 12
Historic impediments to these efforts Health centers taking on total cost of care (TCOC) risk face significant challenges in managing transitions because access to real time information is hard to obtain o Major issue in our ACO since we are only heath centers o But even ACOs that include anchor hospitals probably only see 50-60% of admits happen at that hospital and even if they do occur at anchor hospital, automated notification are not always in place 13
Beta Efforts during the ACO Pilot Program Assessment Action Beta Strategy Discussions with health centers made it clear that lack of timely knowledge of inpatient stays was one of the largest barriers to effective population health management efforts Physical health admission information was limited and inconsistent; behavioral health admissions were a black hole without timely post-discharge visits or discharge summaries During the Pilot, we talked to hospitals, vendors (Patient Ping), EOHHS/MA Highway, and IT leaders We contacted MBHP and learned that they received timely notification of BH admissions through their prior authorization process We decided for the pilot to focus on ingesting mental health inpatient notices from MBHP 14
Design of Inpatient Mental Health Beta Work Goal Provide clinical information to the facility, make contact with the patient, schedule follow up visit, and ensure services were in place in the community/home Design Based on paid claims data, health centers were provided data on mental health admissions by facility and initiated contact and visits to top 3-5 hospitals Health centers received daily admission notification emails from MBHP Staff at each health center followed up on admissions by placing phone calls to the mental health inpatient units/facilities 15
Success of the Beta Project Inpatient encounters Beta results Participation: 7 of 9 health centers 168 admissions to 35 inpatient facilities - 46% to 6 hospitals 55 113 (67%) contacted by health center prior to discharge (including getting a release) Follow-up primary care visits kept for 56% of contacted patients (44% for BH visits) 113 Post-discharge medical reconciliation for 68% of contacted patients Pre-discharge contact 16
Beta Project Key Learnings It is extremely difficult to get timely call-backs from inpatient facilities, although this did improved over time Individuals with unstable housing tenancy experience significantly more readmissions The value of the information was limited by the lack of dedicated staff in the field to engage with patients in hospital and home Building relationships at the health center level was arduous as admissions were widely distributed geographically and multiple health centers were calling the same hospital 17
Background on Non-profit founded in 2004 with funding from BCBSMA Officers: Larry Garber, MD (Chair), Rick Lord (Vice-Chair), Ellen Hafer (Treasurer) Now provide clinical practice consulting, technical project management, strategic advice, and data warehousing/clinical quality analytics Data warehouse/clinical quality analytics o Receive medical records (CCDs) from provider organizations in 34 states (7M+ unique patients, 60M+ records, +130K records per day) o Quality analytics and reporting: BIDCO, BCH, Aledade, IHANY, VillageMD, ChartLogic, etc ADT/ENS Service o Launched in fall 2017 o Have received over 5M ADTs through March 2018 (72K per day) Partners and Steward going live in May 2018 18
Genesis of Work with MAeHC Pilot assessment led us to MAeHC: o Found out BIDMC was already in production o Transparency on plumbing, pricing o No click fees; all-you-can-eat subscription fee o Affordable o No stand alone software Worked with the other Pilot ACOs to craft a community-wide strategy o Philosophy of reciprocity: that ACOs who ingest also need to be submitters o Leadership of many early adopters Early collaborative efforts have led to a local, not-for-profit community-based ADT ecosystem that has been rapidly growing 19
MAeHC ADT/ENS Service Status (as of 4/26/18) Commitment/Contract Implementation Go-live status ADT Source Beacon Health Options (MBHP) Complete Complete LIVE BIDMC Complete Complete LIVE Boston Medical Center (BMC) Complete Complete LIVE Holyoke Complete Complete LIVE Signature Brockton Complete Complete LIVE Anna Jaques Hospital Complete In Progress Early May Steward Healthcare System Complete In Progress Rolling beginning in May 2018 w/ Meditech upgrade Partners Complete In Progress Testing complete, go-live May 28 Cambridge Health Alliance (CHA) Complete In Progress Early August Baystate Complete In Progress Early August BIDMC Milton/Needham/Plymouth Complete In Progress Fall 2018 w/ Meditech upgrade Lawrence General Complete In Progress July OCHIN health centers Complete In Progress June South Coast Hospital Finalizing contract In Progress July Emerson Finalizing contract Complete Testing complete, awaiting contract signing Boston Children's Hospital (BCH) Finalizing contract U Mass Memorial Finalizing contract Berkshire Health Reviewing contract ADT Subscriber BMC HealthNet Plan Community Alliance Complete Complete LIVE BMC HealthNet Plan Mercy Alliance Complete Complete LIVE BMC HealthNet Plan Signature Alliance Complete Complete LIVE BMC HealthNet Plan Southcoast Alliance Complete Complete LIVE C3 (Community Care Cooperative) Complete Complete LIVE CHICO Complete In Progress June BIDCO Finalizing contract Complete June Partners Complete In Progress TBD South Coast Hospital Finalizing contract In Progress July 8 Community Partners (ehana) Reviewing contract
Initial TOC Results: March 1 - April 27, 2018 426 total admissions Transition-of-Care Results 121 236 Physical health (36%) Behavioral health (64%) 30% engaged 33 readmissions (7.7%): o 3 physical health o 30 mental health Pre-discharge contact 21
Case Studies: Successes 38 year old male Pt admitted to local hospital with new dx of paranoia. TOC team met at the bedside and followed with home visit but patient was never at home; finally connected with him and engaged him and his mother in the care. The team helped coordinate PCP and BH intake appointment which he completed successfully. A week later, pt self-referred to ED with paranoid delusion of testicular cancer and TOC team was able to coordinate with ED so patient could follow with outpatient team rather than get admitted. As of today, two readmission have been avoided and patient has completed several outpatient visits consistently. 22
Case Studies: Successes 42 year old female History of depression, diabetes, morbid obesity, recurrent skin infections and multiple hospitalizations. Well known by ED s, hospitals and ambulance teams. Sent to ED by new PCP who alerted the TOC team and they met her at the bedside; during hospitalization they met mother and sister and engaged them in the care. Following discharge, they have done regular home visits and have re-connected patient with PCP and home BH team; have addressed some of her SDOH s and maximized home services. Patient is grateful and says she s never felt as supported by a consistent team. 23
Case Study: Barriers 50 year od male: 3/8: Assigned to TOC team and team attempted but was unsuccessful in the outreach. History of SUD, with multiple ED and hospitalizations in 2016 & 2017, housing instability and know to local shelters. 3/12: admitted to Arbor JP for depression, Hep C and SUD. Hospital social worker and TOC team made a plan for an in person visit on 3/16. 3/14: Call from social worker reporting patient was transferred to Salem hospital and case transferred to the North shore TOC team. 3/16: Patient discharged from Salem hospital per his request after incident of snorting Wellbutrin and upset with Psychiatrist making a change to the medications. 3/20: Admitted to Arbour-Fuller; TOC team scheduled visit for 3/23 3/23: Patient refused visit and TOC program; TOC staff continue to follow and look for opportunity to engage after discharges. 24
ADT Feeds Beyond TOC Program ADT feeds are also an asset within other aspects of our Model of Care: o Health centers are notified of admissions that do not stratify and they follow-up to ensure safe transitions, including scheduling and tracking follow-up visits with PCP o Predictive analytics uses ADT feeds to stratify for complex care management (more timely than claims data) Future Plans using built infrastructure o Intervene in ED to triage to health center Need to revisit how EMTALA is interpreted in this state Need willing hospital partners o For other ACOs, offering ADTs for more than MassHealth population o Ingesting other encounters Outpatient specialty care BH CP transactions 25
Conclusion ADT feeds are transformative in population health o TOC has potential to reduce readmissions, ED visits after hospitalization, increase community tenure Momentum created by a community effort resulted in benefits to all ACOs and better care for members/patients o Potential future uses for community-wide sharing of data As the case studies show, even with ADT feels, we face underlying social problems: HOUSING! 26