The Road to Innovation: An Update on NJ s and care Initiatives June 23, 2015
care Landscape and
Delivery Care Trends Documented Charity Care 6 Year Trend Documented Charity Care Data submitted by NJ Hospitals to DOH Office Care Financing for 2007-2014 and
Delivery Care Trends Visits to Federally Qualified care Centers 2008-2014 All visits data submitted by FQHCs to DOH Office Primary Care 2008-2014 and
Delivery Care Trends General Acute Care Hospitals Inpatient Admissions Year: 2010-2014 Admissions Data Submitted by Hospitals to DOH Office Care Financing 2010-2014 and
Delivery System Incentive Payment Program (DSRIP) NJ 1 6 states 1 st incentive-based hospital funding program in NJ 5-year pilot $833M total Currently in 3 rd year 49 hospitals participating Asthma Behavioral Cardiac Care Chemical Addiction/Substance Abuse Diabetes Obesity Pneumonia HIV/AIDS Implement Quality Initiatives Achieve Measurable Clinical Outcomes Receive Funding Incentives and
Regional Planning and
Regional Planning NJ has 3 Efforts: Trenton Team, Greater Newark Care Coalition, & Camden Coalition care Providers All 3 Initiatives share Common Goals: Organizational non-prits status Active HIE to ensure patient info is in the hands provider while patient is in front provider Communicating with each other & communities through use Community Advisory Boards & health advocates Develop policies & a plan informed by data to: Target specific conditions for improvement health outcomes (e.g., diabetes, asthma) Collaborate on care (ambulatory, acute, behavioral, social services) to manage/improve residents health outcomes with specific conditions Collaborate on care to manage ED utilization and ED super-utilizers Collaborate on wellness initiatives for residents and
Clinical Decision Supports Care Coordination Clinical Decision Support Trenton HIO and
HIT & Clinical Data and
DOH HIE Partners HCFFA NJIT NJHIN Advisory Council State HIE Partners Office Information Technology (OIT) Banking & Insurance Human Children & Families Labor care Stakeholders HIT Office Federal Influencers HIOs Patients Providers care facilities Payers Biotech Pharma Pharmacies Labs Pressional Associations DHS Medicaid State Medicaid HIT Plan Mental & Addiction Medicaid Provider EHR Incentive Program DOH NJ Information Network (NJHIN) NJHIN Advisory Council Medicare & Medicaid Provider EHR Incentive Program (PH registries) Hospitals, FQHCs & other Licensed care Facilities DOBI Insurance Payers ehit Office OIT CTO for Affinity Group Strategy ARRA HIPAA OBRA ONC HHS NJ-HITEC Physician Training Awareness Education HCFFA Oversight ONC funds Financing to grantees and
St Mary s Hospital Bergen Regional Medical Center St Luke s Warren Hospital Mountainside Hospital Camden HIO Highlander Jersey Connect Bayonne Hospital Center Hoboken University Medical Center Christ Hospital University Medical Center at Princeton Trenton Team Virtua HIO NJSHINE Unaffiliated Hospitals Memorial Hospital Salem County AtlantiCare Regional City Campus & Mainland Campus and
Phase 1: NJHIN Architecture NJHIN Core State Registries Node Camden HIO Jersey Connect Virtua Highlander NJSHINE Trenton HIO Legend Information Organization (HIO) Physician s Office Hospital FQHC Behavioral Provider Long-Term Care Provider Patient (Access to PHR) Radiology Laboratory Social Local Public Rehabilitation (Physical) and
List Available Patient Info Web Directory NJHIN Core Certificate/Registration Authority Patient Info Patient Info Camden HIO Here is the Patient Info we need Jersey Connect 1. Facesheet 2. Discharge Summary 3. History & Physical 4. Continuity Care Summary 5. Progress Notes NJSHINE Here is the list Patient Info we have 1. Facesheet 2. Discharge Summary 3. History & Physical 4. Continuity Care Summary 5. Progress Notes 6. Nurses Notes Jersey Connect & NJSHINE respond to Camden HIO: Here is the patient info we have for John Does. and
HIE Accomplishments $11.6M ARRA Grant for health information exchange (HIE) spent down 99.23% grant by 3/14/14 $9.8M awarded to HIOs $1.6M for NJ Information Network (NJHIN) $200K for ONC required evaluation Expanded Regional HIOs to statewide coverage - 2013 Facilitated achievement meaningful use & award $723 + M in federal EHR incentive funds to NJ providers through 2015 Invested in Immunization Information System modernization to expedite achievement meaningful use by providers Provided 3 ways to achieve meaningful use for providers DOH Immunization registry DOH Electronic lab reporting DOH Syndromic surveillance and
Care Coordination/Patient Matching Failures care coordination cost $35 billion¹ in annual healthcare waste and cause: Complications Hospital readmissions Declines in functional status Increased dependency Links from patients to electronic medical information increasingly complicated to establish & maintain Data is stored in various formats across disparate systems Demographics may be outdated and are subject to human error Medical mistakes cause 46 deaths per hour in US² Benefits Coordination/Patient Matching: Minimizes mismatches / finds right records Links individuals and their health information across multiple organizations, applications and services Improves patient safety through higher data integrity Reduces workflow significantly in care coordination Improves outcomes and reduces cost Enables mapping any HIT/HIE endpoint to Master Person Index (MPI) ¹ Eliminating Waste in US Care JAMA, April 11, 2012 Vol 307, No. 14 ² The Witching Hour Philadelphia Inquirer. Dec 28, 2014 and
Discharge Summary Example Patient Matching Challenges Data Sharing Organization (DSO) Tricia Franklin MRN: 19860122 NJHIN Data Sharing Organization (DSO) Specialist Trisha Franklin MRN: 19980119 Franklin Trisha MRN: 19360204 Primary Care Tricia Franklin Trish Franklin MRN: 20100116 Care Coordinator 1) Tricia is admitted to hospital with MRN 19860122 and discharge summary (ADT) initiated 2) Tricia has slightly different demographics in each provider EHR 3) Care Team challenged to coordinate care across organizations and systems Source: Michigan Information MiHIN and
Discharge Summary Example With Patient Matching Data Sharing Organization (DSO) Tricia Franklin MRN: 1234567 CK: 2FZ4UR79H NJHIN Data Sharing Organization (DSO) Specialist Trisha Franklin MRN: 19980119 MPI: 2FZ4UR79H Franklin Trisha MRN: 19360204 MPI: 2FZ4UR79H Primary Care Tricia Franklin Care Coordinator Trish Franklin MRN: 20100116 MPI: 2FZ4UR79H 1) Tricia admitted to hospital with MRN 19860122 and ADT initiated 2) MPI accurately and reliably links Tricia to her Care Team 3) ADT is enriched with MPI for efficient and safe coordination Tricia s care Source: Michigan Information MiHIN and
Prevention & Wellness Promoting y People & Communities and
Partnering for a y New Jersey Goal is to reduce chronic disease burden Launched a statewide approach for collaboration Highlights evidenced-based strategies for intervention Promotes a culture prevention and wellness Winnable Battles: Increase physical activity Improve nutrition Eliminate tobacco use Improve environmental health Enable self management Increase early detection Improve access to quality health care nj.gov/health/fhs/chronic/index.shtml and
Working Well in NJ Working Well in NJ Toolkit provides: Key elements healthy lifestyles in NJ worksites Successful strategies used by NJ employers to support and maintain a culture wellness Resources to support, establish, and maintain worksite wellness initiatives Tools to support the Return on Investment (ROI) for employers Working Well in NJ Toolkit can help: Identify the strengths and limitations current health and wellness promotion policies Convene a Wellness Committee for worksite Develop a Work Plan to improve the worksite wellness program www.state.nj.us/health/fhs/workingwell/toolkit.shtml and
Improving Birth Outcomes
Prenatal Care Providers Improving Pregnancy Outcomes Initiative Primary Care Providers Community- Based Agencies Consumers and Families Community Worker (CHW) Community Outreach Identifies women & families needing services Completes intake Refers to Central Intake (CI) Agenda for Local Collaboration Develop interagency agreements for referral/data sharing Establish a referral flow chart Provide cross-training & shared in-service Tracking & analysis Identify gaps in resources & referral network Coordinate Consumer-Driven Community Advisory Board Central Intake (CI) Reviews, refers & links parent/family to partner agency for follow-up for initial assessment, prevention education, and/or other needed services. Children are linked to a medical home/developmental screening Prenatal & Early Childhood Community-Based Home Visiting - Evidence-based models Early Head Start and Head Start Programs Pregnant/Parenting Teen Parent Linking Program / Project TEACH CCR&R - Infant & Child Care Providers State-Funded Preschool - Family Outreach Early Intervention - Part C - Birth to 3 Special Education - Part B - 3 and up Special Child Birth to 21 yrs and Community-Based, Family Support & Social Ex. Medical Home/Primary Care Mental & Addiction Child Behavioral Developmental Disabilities Domestic Violence WIC Program Food Assistance / SNAP Family Success Centers Child Lead Poisoning Local s And more 23
Central Intake Referrals 2500 Referrals to Central Intake FY 2014 vs FY 2015 Year To Date 2000 1500 1000 500 0 July August September October November December January February March FY14 FY15 YTD and
Improving Birth Outcomes Working Groups Data Chair: George Rhodes, MD, MPH School Public, Rutgers Wellness Chair: Ruth Perry, MD Payment Strategies Chair: Wardell Sanders, Esq. New Jersey Association Plans Optimize/use data sources to: Enhance data collection across the state Deepen understanding issues affecting outcomes Maximize success efforts with surveillance Standardize data definitions Create a mechanism to: Enhance collaboration, communication & coordination interventions to promote wellness across life span Engage payors to: Discuss best practice financing Explore opportunities for evidence-based initiatives to improve outcomes and
For more information visit: www.nj.gov/health Follow us on Twitter: https://twitter.com/njdepthealth and