Building an Intelligent

Care Coordination Platform

June, 2015

North Shore LIJ Health System, New York

Presentation to the

Board of Trustees

November 25, 2014

- 8 million people in service area - Over 4 million patient contacts - 141,345 ambulatory surgeries - 282,044 hospital discharges - 27,368 births - 664,915 emergency visits - 688,660 home care visits - 102,277 ambulance transports - $7.8 billion annual operating budget - 14th largest healthcare system in the US - More than 51,000 employees

• More than 10,000 physicians • More than 10,000 nurses • More than 1,500 medical residents and fellows

-More than $686.4 million in community benefit (10.9 percent of operating expenses) by participating in 1,966 unique programs, serving more than 1.9 million community members and training 24,862 health professionals.

Key Facts

Goal: Reducing Costs of High Risk Patients

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≥2 chronic conditions in an advanced state with functional

impairment

Provide both curative and comfort care to patients at home and in

the community to patients with 18-36 months to live.

> 1 chronic (incurable, but controllable) conditions

Provide proactive disease management to maximize

quality of life and postpone complications.

Services typically provided for a minimum of 12

months, and can continue for decades.

Initial care management programs should be targeted to people with multiple disease conditions, who are at high-risk for unnecessary care, and who have the greatest opportunity for reducing health care costs.

Top of the Pyramid

•10% (Tier 3) of patients

account for 64% of total costs

•5% (Tier 3 A) account for 50%

of total costs

Source: Conwell LJ, Cohen JW. Characteristics of people with high medical expenses in the U.S. civilian non-institutionalized population,

2002. Statistical Brief #73. March 2005. Agency for Healthcare Research and Quality, Rockville, MD.

Tier 3

Rationale: Managing the top of the Pyramid

Patient flows and Data Flows are Complex

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Hospital SNF/LTC Home

Care Community

600 applications in NSLIJ Health System

Myriad of transition paths for patients

How to Manage Millions of Data Points?

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Components of a Care Management Platform

High performance application integration engine

– More than just regular HL7

– Enterprise Service Bus – need to orchestrate next generation web

services based capabilities in modern applications

Comprehensive Health Record

– Patient record that spans all venues of care

– Normalized to remove redundancy of data . E.g. same allergy

captured in 2 different systems

Process Orchestration and rules engine

– Detect significant events in real time – simple events like

admission/discharge , complex events like change in clinical data

– Rules processing to act on events by automation e.g. auto-generate

post discharge appointment or escalate for human intervention

Modify EMRs to support PCMH Certification

Integration with Data Warehouse (Registries, Optum) to enhance

outcomes planning, monitoring and management

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NSLIJ Reference Architecture

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EHRs

Ancillaries

RHIO

Billing

Reg

Community

ESB

HL7, MFT, CCD

Webservices,

APIs

Normalize

terminology and

structure

EMPI, Provider Master, Location Master, HLI - Vocabulary

CHR BPM

EHR

Portal

Mobile

Composite Apps

Active Analytics

Source Systems Enterprise

Service Bus

EDW

Comprehensive Health

Record and Business

Process Management

Engine

Destination

Systems

Master Data Management Real-time

Analytics

Optum

Registries

‘Care Tool’ for Care Coordination

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Comprehensive Health Record Data

HSPI Patient

Matching Provider

Registry

Program

Registry Workflow

Engine

Rules

Engine

Clinical

Viewer Auditing Roles HSPD

Shared

Services

List

Mgmt

Dash-

boards Care

Plans Assessm

ent Calendar

Custom

Services

Identification

Clinical Assessment

Care Plan Management

Quality Outcomes

Composite

Application

PC/Laptop Mobile Tablet User

Interface

Requirement: Core Capabilities

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CHR

• Heath Risk Asessment (HRA)

• SF 12

• Fact-GP (HH)

• PHQ-2

• Follow Up Notes

• Physical exam

• Quality Reports

• Operational

Reports

• Outcomes

• State reporting

• Share Care Plans

• Rules Driven

• Tight integration with Tasks

• Risk Stratification

• Gaps in Care

• Clinical Indicators

• Import Lists

• Cohort Identification

• Notification

• Reminders

• Alerts (Contraindications, Risks etc. )

• Task Management

• Appointment f/u

• Data sharing / Collaboration

• Enrollment Activities

Case Study Stroke 60 Days in the Life of a Patient

1 2 3 4 5 6 7 8

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Stern

Skilled Nursing

Home with Home

Care Services

February March April

Care Navigator

ED Admission

Case Presentation:

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• 71 year old woman

• “history of diabetes”

• “atrial fibrillation on Coumadin”

• “presenting with:

• dizziness

• headache

• Nausea”

• “CT head showed bleeding in the head”

Diagnosis:STROKE

Care Coordination Begins

Admit to Plainview ED

– Stroke Work up

Transfer to NSUH

Discharge Planning by Inpatient Case

Manager

Care Navigator initiates Care

Coordination Process with Patient,

Family and IP Case Manager

Monitor Discharge Readiness (MCG)

Notification of Navigator at Discharge

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Week 1

Strategies for Patient Identification

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Case Level: Identified at the time of high risk event

• Specific DRGs (e.g. Bundled Payments for Care

Improvement)

• Health risk assessment

• Referral by physician or staff, or patient self-referral

Population Level: Identified by clinical or claims data

• Quantitative risk-prediction

• Acute-care utilization focused

• High-risk condition or medication-focused (e.g. HCC

score)

Care Tool – BPCI Identification

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Integration with Case Management

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MCG

Medication List

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Clinical Interaction Note

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Care Plan

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Provider from Care Tool to Clinical Viewer

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Coordination at Skilled Nursing Facility

Patient transfer to Skilled Nursing Facility

Care Navigator contacts SNF Nurse

Medication Management

Monitor Progress

Notification of Readmit Risk (AKI)

IV Fluids prevent readmission

Discharge to Home with Home Care

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Week 2-4

Coordination at Skilled Nursing Facility

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March

“notified by SW of pending Discharge week or 3/16”

“Pt plan to be d/c'd today, however AM labs indicated

AKI s/p UTI with elevated Creat., NS at 85 ml/hr

initiated for 24 hours. Labs to be repeated in AM and

pt to be d/c'd home Thursday 3/12/15 if stable”

Patient Discharge to HOME

Monitoring Progress – AKI Risk

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Labs across multiple settings

Coordination while at Home

Notification of Discharge to Navigator

Care Navigator contacts Home Care Nurse

Home Care MD Evaluates Patient (HCFA Cert & Plan)

Medication Management

Monitor Progress

Monitor Labs (Core Lab)

Provide Emergency Call Info

Call Center Notifies Care Navigator of Fall

Care Navigator Contacts Patient

Fall Prevention Education and Monitoring

Discharge from BPCI Program

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March 13 – April 9

Clinical Viewer :Home Care Plan

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Assessment Feature

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Coordination while at Home

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Week 5-8

“Spoke with HC RN, CN information provided”

“Called and s/w pt. who stated she feels fair. Pt.

stated she fell on 4/8/15, when she was walking with

walker, and let go of walker.”

“Called pt s/p email from CCC that the pt fell yesterday. Pt states she fell she

was trying to walk without walker and she fell "on her side" and denies hitting

her head. States "i have a small bruise on my side, but I'm completely fine""

As per pt, MD does not want pt participating in PT until the afib is under control.

Pt states she is using walker at all times, stating she learned a tough lesson

Discussed impt of using walker for balance and fall prevention, to which pt

verbalized an understanding.