Care Coordination and Transitions in Care: Improving the Information Flow

HealthBridge 2011 Meaningful Use and Health Care Transformation Conference

May 20, 2011

Julie Schilz BSN MBAColorado Beacon Consortium

Teams Are Reaching Goals Every Time

Exploring One Beacon Communities Experience

Brief Description of the Beacon Community

Overview of Colorado Beacon Consortium

Linkages to Care Coordination & Care Transitions

Today’s Discussion

3

Look through Patient & Family Eyes for Value

National Quality Strategy 2011 Two Priorities

Safer CareEliminate preventable health care-acquired conditions

Care CoordinationCreate a delivery system that is less fragmented and more

coordinated, where handoffs are clear, and patients and clinicians have the information they need to optimize the patient-clinician partnership

http://www.healthcare.gov/center/reports/nationalqualitystrategy032011.pdf

4

Sorting Through the Acronyms( and methodologies)

REC?

PCMH?

ACOs?

MU?

Transitions of Care?

PPACA? Or ACA?Project RED

Boost

Starr? ONC?

ARRA?

5

The Beacon Community Program

Goal: Share best practices that help communities achieve cost savings and health improvement

17 demonstration communities that will:–Build and strengthen their HIT infrastructure and

exchange capabilities and showcase the Meaningful Use of EHRs

–Provide valuable lessons to guide other communities to achieve measurable improvement in the quality and efficiency of health services or public health outcomes

Bangor

Rhode Island

Keystone

Greater Cincinnati

Southern Piedmont

Inland Northwest

Utah

Colorado

San Diego

Hawaii

Southeastern Central Southeast WesternMinnesota Indiana Michigan New York

Greater Tulsa Delta Blues Crescent City

The Beacons

Activities across the CoPs will align to enable high quality, cost efficiencies, patient-focused health care, and population health

through clinical transformation

ONC Beacon Community Integrated Learning Networks

8

Colorado Beacon ConsortiumThe CBC is a collaboration of health providers and community agencies in Western Colorado. The project is led by the following Community members:

9

Colorado Beacon Consortium Region

Overall AimCBC Offerings

Technology Enhancements

HIE Connectivity

EMR Interface

Provider Portal (simplified sign on)

Improved Analytics & Reporting

Community Registry

Inter-HIE Connections

Practice Transformation

Clinical Process Efficiency Consultation

Performance Improvement Skills

Practice Transformation

Collaboration with REC Partner for Meaningful Use

Financial incentives to reduce barriers to participation.

HIE

PhysicianAddress

Book

MasterPatientIndex

EMR Xchange+ Registry

EMR Xchange + Registry

QHN + Beacon ObjectivesData Layer and Access Layer

Provider

Provider

EMR

Vir

tual H

ealt

h R

eco

rd

Provider

EMR

Provider

EMR

EMR Xchange + Registry

Data Layer

Data layer aggregates data: -Major Sources (HIE ) -EMRs (HIE ) -Admin (claims) -Billing, -Pharm -Public Health -Others

BillingAdmin

Pharm

Access Layer/Middleware

Access Layer provides: -Traditional interfacing ease --VPN, SFTP, etc. -Web Services capabilities --Middleware/ SOA -Security and access control --Granular, --User, group, role, etc. -Logging and auditing --Utilization

HIPAA , Regulatory

Practice Transformation Program Guiding PrinciplesIHI Triple AimIOM Six Aims

Program MethodologyCare ModelModel for ImprovementPerformance ImprovementQIAs and Learning Collaboratives

Timeframe and GoalsOne Year with Advisors and Learning CollaborativesClose the Gap by 50% from Baseline MeasuresImprove Value–Team, Evidence Based Guidelines, Patient-Centered, HIE/HIT

13

Our Philosophy, Tools & Program

CBC Change Package Performance ImprovementSteps for Performance Improvement

•Choose a measure.•Determine a baseline.•Evaluate your performance.•If performance is not what you would like, develop a performance aim.•Make changes to improve performance.•Monitor performance over time.

Practice Transformation Based on the Expanded Care Model

Curriculum Pre-Work Curriculum Year long transformation with Learning Collaboratives Monthly Narrative & Measure Reporting

14

Adapted from IHI Breakthrough Series Collaboratives

Pediatric & Adult Measures

PediatricPhase I Asthma – Appropriate

Medications for Persistent Asthma

Immunizations – Up to date by age 2

Phase II Child Weight Assessment

& Counseling

AdultPhase I

Diabetes (BP & HbA1c) IVD (Lipid screen and

control) Depression Screening

(Diabetes & IVD)

Phase II Adult Weight Assessment

& Counseling Breast Cancer Screening Tobacco Ask & Counseling

CBC Practice Transformation Program Highlights with emphasis on HITs supporting role Team Based Care Care Compacts Care Coordination/Transitions

Multi-Disciplinary and HIT/HIE Focus

Specialty Practices Request the Following Information: Patient name Patient demographics Patient Insurance (if known) Diagnosis or symptoms Relevant notes, lab and radiology results Current medications list ICD-9 code, if possible Send in QHN

Primary Care Practices Request the Following from Specialty Practices: Date and time of the appointment Notification if the patient was a “no show” Copy of transcription from the specialist, use QHN to cc the PCP!! Outline of the plan of care Communication about who will manage the medications When there are critical issues, pick up the phone and call!

All Parties Request and Agree: A standardized process for creating and responding to referrals is best Each office should have a referral contact person Provide adequate information so both parties can treat the patient!! Use QHN when possible Use fax as second choice Use phone calls when in doubt

Community Referrals using QHN

All Parties Request and Agree: A standardized process for creating and responding to referrals is best Each office should have a referral contact person Provide adequate information so both parties can treat the patient!! Use QHN when possible Use fax as second choice Use phone calls when in doubt

Primary Care Practices Request the Following from Specialty Practices: Date and time of the appointment Notification if the patient was a “no show” Copy of transcription from the specialist, use QHN to cc the PCP!! Outline of the plan of care Communication about who will manage the medications When there are critical issues, pick up the phone and call!

Specialty Practices Request the Following Information: Patient name Patient demographics Patient Insurance (if known) Diagnosis or symptoms Relevant notes, lab and radiology results Current medications list ICD-9 code, if possible Send in QHN

How HIT Fits!

CBC Practices at Work

-Consistency around registry data capture

-Work flows around Health Information Technology

-Medication reconciliation for Diabetic patients

-Establishing focused care visits

-Transitioning to Meaningful Use Electronic Medical Record

-Creating Electronic Medical Record templates

-Redefining office protocols around the Beacon chronic disease measure set

-Implementation of team huddles and daily patient preparation

-Processes around patient check in/check-out procedures and scheduling

-Standardizing office standing orders

-Streamlining lab reconciliation processes

PDSA Examples from Cohort 1

24

What Can You Do By Next Tuesday?

Questions ?

Teams Are Reaching Goals Every Time