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MiPCT Spotlight ADT Alert Overview and Workflow Training for Care Managers and PO Leads February, 2014

MiPCT Spotlight ADT Alert Overview and Workflow Training for Care Managers and PO Leads February, 2014

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Page 1: MiPCT Spotlight ADT Alert Overview and Workflow Training for Care Managers and PO Leads February, 2014

MiPCT Spotlight ADT Alert Overview and Workflow Training for Care Managers and PO Leads

February, 2014

Page 2: MiPCT Spotlight ADT Alert Overview and Workflow Training for Care Managers and PO Leads February, 2014

AGENDA

1. What Is Spotlight and What Does it Provide?

2. A Detailed Look at ADT Alerting in Spotlight

3. Care Management Workflows ▫ Prompt action on Transitions of Care▫ How ADT alerts can be used to prioritize

and manage your caseload

Page 3: MiPCT Spotlight ADT Alert Overview and Workflow Training for Care Managers and PO Leads February, 2014

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What is Spotlight and What Does it Provide for MiPCT POs and Practices?

Page 4: MiPCT Spotlight ADT Alert Overview and Workflow Training for Care Managers and PO Leads February, 2014

What Functionality Does the MiPCT Spotlight Offering Provide? 1) Web-based access to MiPCT member

lists

2) Near real-time alerts when patients

are hospitalized or discharged

.

Page 5: MiPCT Spotlight ADT Alert Overview and Workflow Training for Care Managers and PO Leads February, 2014

More Details on the MiPCT Spotlight Offering• At no cost to POs (cost is absorbed by the MiPCT

administrative budget)

• To receive ADT alerting, PO signature on Carebridge

MOU is required

• ADTs added as available (schedule provided in later

slide)

• Up to two PO CTC Leads from each organization

▫ Changes to Leads must be communicated to MiPCT

and CTC

▫ PO CTC Leads responsible for CM/practice

mapping and updating

.

Page 6: MiPCT Spotlight ADT Alert Overview and Workflow Training for Care Managers and PO Leads February, 2014

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Spotlight Data Security• External security audit review performed in 2012 with

CynergisTek and subsequent review planned for 2013 upon CCM Version 2 rollout completion

• Annually CTC undertakes:▫ Risk analysis of the company, our processes, assets,

applications, data (under a NIST 800-30 based risk management program)

▫ Review of all our policies and BAAs internally and with lawyers▫ Disaster recovery test▫ External network/application security tests

• Worked with Healthcare Law Consultancy (CCM) to address new HIPAA omnibus regulations (September 2013)▫ Policies in place and updated as HIPAA regulations change to

address things such as security breaches including notification to affected parties.

Page 7: MiPCT Spotlight ADT Alert Overview and Workflow Training for Care Managers and PO Leads February, 2014

Changes in Care Manager /Physician/Practice Mapping

• Apprising CTC ASAP about changes in mapping is a critical link for information security for your PO

• How to make changes:▫ Highlight rows with changes in spreadsheet▫ When adding care managers, MUST add to physicians,

practices AND users tabs▫ When removing care manager assignments, explicitly

indicate in “changes description” column for each row• Process for change acknowledgement and processing at

CTC▫ Upon receipt of mapping change, CTC sends email

confirmation to PO CTC Lead▫ CTC makes mapping change within five business days

and sends email confirmation to PO CTC Lead

Page 8: MiPCT Spotlight ADT Alert Overview and Workflow Training for Care Managers and PO Leads February, 2014

Functionality 1: MiPCT Member Lists CTC Spotlight

Page 9: MiPCT Spotlight ADT Alert Overview and Workflow Training for Care Managers and PO Leads February, 2014

Functionality 1: MiPCT Member Lists CTC Spotlight, cont.

Page 10: MiPCT Spotlight ADT Alert Overview and Workflow Training for Care Managers and PO Leads February, 2014

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Functionality 1, cont. : New Member Alerts via CTC Spotlight

Page 11: MiPCT Spotlight ADT Alert Overview and Workflow Training for Care Managers and PO Leads February, 2014

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Functionality 2: Admission/Discharge Alerting

Page 12: MiPCT Spotlight ADT Alert Overview and Workflow Training for Care Managers and PO Leads February, 2014

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A Detailed Look at ADT Alerting in Spotlight

Page 13: MiPCT Spotlight ADT Alert Overview and Workflow Training for Care Managers and PO Leads February, 2014

ADTs: From Alert to Care Delivery

• Alert appears in web-based member listing

• Care Manager acknowledges

• Repeat reminders to prompt activity

Care Mgr Receives Electronic

Alert

• Care Manager accesses health system EMR, discharge summary, or available clinical information

• Care Manager communicates with facility discharge planning contacts or via call to patient

Care Manager accesses available patient

info.

• Medication reconciliation and TOC activites

• Identification of patient needs and initiation of follow-up care

• Bill (G/CPT) if applicable

Initiate Near Real

Time Transition of Care Activity

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Page 14: MiPCT Spotlight ADT Alert Overview and Workflow Training for Care Managers and PO Leads February, 2014

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•Through partnership with MiHIN

•Leverages MiHIN/CareBridge ADT work

•Expands ADT availability with additional feeds with prioritization of ADT feeds of greatest value to MiPCT practices

Spotlight Leverages ADT Access

Page 15: MiPCT Spotlight ADT Alert Overview and Workflow Training for Care Managers and PO Leads February, 2014

Admission, Discharge, Transfer MiPCT Data Flow and Progress

Over half of our POs participate in the Crimson Care Management (CCM)/MiPCT partnership• Care managers now receive member lists electronically via a web interface• ADT notifications being added

Page 16: MiPCT Spotlight ADT Alert Overview and Workflow Training for Care Managers and PO Leads February, 2014

ADT Progress to Date

• “Soft Launch” PO (Partners in Care) for Beaumont ADTs went live 12/9/13

▫ Partners in Care has developed customized care management workflows

▫ Useful learnings will improve expansion to full launch

• Management tracking and reporting tool

• Working on clinical record access for MiPCT CMs with Trinity and HFHS (pilot development in progress)

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Page 17: MiPCT Spotlight ADT Alert Overview and Workflow Training for Care Managers and PO Leads February, 2014

ADT Next Steps and Timing•Expansion to full launch early to mid-February•Addition of other health system ADT feeds

▫HFHS Macomb (target: March 9th)▫Trinity (target: April; confirming resources)

Mercy General Health Partner Mercy Health Partners-Hackley Campus Mercy Health Partners- Lakeshore Campus St. Joseph Mercy- Oakland St. Joseph Mercy- Ann Arbor St. Mary’s Mercy-Livonia St. Mary’s Healthcare- Grand Rapids

▫Remaining HFHS facilities (W Bloomfield, Main Hospital, Wyandotte: (target: May; confirming resources)

•Continued monitoring of alert tracking and impact on care

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Page 18: MiPCT Spotlight ADT Alert Overview and Workflow Training for Care Managers and PO Leads February, 2014

ADT Progress –Alert Contents18

Beaumont HS Henry Ford HS

Message Types All AllPatient ID / Medical Record (MR) X XPatient Name X XDate of Birth X XAdministrative Sex X XAddress If Available If AvailablePhone number – home If Available If AvailablePatient Account Number X XPatient Death Indicator If Applicable If ApplicablePrimary Care Physician (ID, Name) X XPatient Class IP, ER OBS, IP, ER

Assigned Patient Location (Room / Bed) X XPrior Patient Location N/A N/AAttending Physician (ID, Name) IP Only IP OnlyReferring Physician (ID, Name) X XConsulting Physician (ID, Name) X XAdmit Source X XAdmitting Physician (ID, Name) IP Only IP OnlyPatient Type X XDischarge Disposition IP Only IP OnlyAdmit Date X XDischarge Date X XPlan ID / Name X XGroup Number X XPolicy Number X X

Page 19: MiPCT Spotlight ADT Alert Overview and Workflow Training for Care Managers and PO Leads February, 2014

Phase 2: Admission/Discharge AlertingPatient Admitted Email Alert

Page 20: MiPCT Spotlight ADT Alert Overview and Workflow Training for Care Managers and PO Leads February, 2014

Phase 2: Admission/Discharge AlertingPatient Discharged Email Alert

Page 21: MiPCT Spotlight ADT Alert Overview and Workflow Training for Care Managers and PO Leads February, 2014

Phase 2: Admission/Discharge AlertingPatient ER Visit Email Alert

Page 22: MiPCT Spotlight ADT Alert Overview and Workflow Training for Care Managers and PO Leads February, 2014

Alerting – Acknowledge via emailLogin to Spotlight

Page 23: MiPCT Spotlight ADT Alert Overview and Workflow Training for Care Managers and PO Leads February, 2014

Alerting – Acknowledge via emailClose Alert

Page 24: MiPCT Spotlight ADT Alert Overview and Workflow Training for Care Managers and PO Leads February, 2014

Admission/ER Visit Information

Page 25: MiPCT Spotlight ADT Alert Overview and Workflow Training for Care Managers and PO Leads February, 2014

Discharge Dispositions:

Page 26: MiPCT Spotlight ADT Alert Overview and Workflow Training for Care Managers and PO Leads February, 2014

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Care Management Workflows

Page 27: MiPCT Spotlight ADT Alert Overview and Workflow Training for Care Managers and PO Leads February, 2014

St. John Providence, Partners in CareMiPCT-P.O.- Soft launch Partner

CTC/ADT alert only process flow

developed by:

Page 28: MiPCT Spotlight ADT Alert Overview and Workflow Training for Care Managers and PO Leads February, 2014
Page 29: MiPCT Spotlight ADT Alert Overview and Workflow Training for Care Managers and PO Leads February, 2014

Workflow for Inpatient Alert

Page 30: MiPCT Spotlight ADT Alert Overview and Workflow Training for Care Managers and PO Leads February, 2014
Page 31: MiPCT Spotlight ADT Alert Overview and Workflow Training for Care Managers and PO Leads February, 2014

CM Workflow for Discharge Alert

Page 32: MiPCT Spotlight ADT Alert Overview and Workflow Training for Care Managers and PO Leads February, 2014

Best Practice Transitions of Care Process: Practices with Care Team Connect(CTC) and Admission, Discharge and Transfer(ADT) Feeds

Care Manager receives Alert in CTC: Responds within 24-48 hours of receiving the alert

Patient Transfer to Long Term Acute Care, Rehabilitation, or Skilled Nursing Facility

Patient Discharge

CM enters assigned patient list. Locates patients name. Receives hospital name and

pertinent information.

CM enters assigned patient list. Locates patients name. Receives hospital name and

pertinent information.

CM reviews patient EMR/discharge summary to determine the name of the facility patient was

transferred to. CM reviews patient EMR/discharge

summary.

CM contacts facility Case Manager or Social Worker for TOC call.

CM records receipt of CTC Discharge alert and communication with facility Case Manager or

Social Worker. Record plan for anticipated discharge as well as anticipated timeline for CM

follow up in CTC and patient medical record (EMR or paper chart).

CM records receipt of CTC Discharge alert and communication with patient or

caregiver. Record initial care management plan and anticipated timeline for CM follow up in CTC and patient medical record (EMR

or paper chart).

CM contacts patient for TOC call.

CM places patient name on CM schedule

for follow up.

When the CM does not have access to the hospital record: · Arrange to receive daily faxes of pertinent patient information (admission history and physicals for

admissions and discharge summaries for discharges).· Contact the inpatient case manager to arrange receipt of the needed patient medical information

(admission history and physical, discharge summary, medication list and any other information needed to arrange and provide appropriate follow up care).

· Contact the patient or care giver if unable to determine the patient’s disposition.

Patient discharged to home

Fax from hospital

Access the hospital EMR

Fax from hospital

Access the hospital EMR

Page 33: MiPCT Spotlight ADT Alert Overview and Workflow Training for Care Managers and PO Leads February, 2014

CM Workflow for ED Alert

Page 34: MiPCT Spotlight ADT Alert Overview and Workflow Training for Care Managers and PO Leads February, 2014
Page 35: MiPCT Spotlight ADT Alert Overview and Workflow Training for Care Managers and PO Leads February, 2014

ADT Alerts Best Practice Process

• The following steps are completed by the CM 24-48 hrs. after alert notice.

• Acknowledge receipt of admission, discharge or ER alert from CCM.

• Investigate patient change in status and determine care management intervention.

• Document receipt of alert, intervention(review of EMR and follow up with facility contact, patient and physician) and planned follow up with patient in EMR.

Page 36: MiPCT Spotlight ADT Alert Overview and Workflow Training for Care Managers and PO Leads February, 2014

Transitions of Care Integrated Workflow

(displays inpatient, discharge and ED flows in one screen)

Page 37: MiPCT Spotlight ADT Alert Overview and Workflow Training for Care Managers and PO Leads February, 2014

Best Practice Transitions of Care Process: Practices with Care Team Connect(CTC) and Admission, Discharge and Transfer(ADT) Feeds

Care Manager receives Alert in CTC: Responds within 24-48 hours of

receiving the alert

Patient Inpatient

Admission

Patient Transfer to Long Term Acute Care,

Rehabilitation, or Skilled Nursing Facility

Patient Discharge

CM enters assigned patient list. Locates

patients name. Receives hospital name and

pertinent information.

CM reviews patient inpatient information

CM contacts hospital

Inpatient Case Manager

CM records receipt of CTC Admission alert and communication with IP Case Manager. Record

plan for anticipated discharge and timeline for CM follow up in CTC

and patient medical record (EMR or paper

chart).

CM places patient name on CM schedule for

follow up.

CM enters assigned patient list. Locates patients name. Receives hospital name and

pertinent information.

CM enters assigned patient list. Locates patients name. Receives hospital name and

pertinent information.

CM reviews patient EMR/discharge summary to determine the name of the

facility patient was transferred to.

CM reviews patient EMR/discharge summary.

CM contacts facility Case Manager or Social

Worker for TOC call.

CM records receipt of CTC Discharge alert and

communication with facility Case Manager or Social Worker. Record

plan for anticipated discharge as well as

anticipated timeline for CM follow up in CTC and patient medical record (EMR or paper chart).

CM records receipt of CTC Discharge alert and

communication with patient or caregiver.

Record initial care management plan and anticipated timeline for CM follow up in CTC and patient medical record (EMR or paper chart).

CM contacts patient for TOC

call.

CM places patient name on CM schedule for

follow up.

CM places patient name on CM schedule for

follow up.

When the CM does not have access to the hospital record: · Arrange to receive daily faxes of pertinent patient information (admission history and physicals for

admissions and discharge summaries for discharges).· Contact the inpatient case manager to arrange receipt of the needed patient medical information

(admission history and physical, discharge summary, medication list and any other information needed to arrange and provide appropriate follow up care).

· Contact the patient or care giver if unable to determine the patient’s disposition.

Patient discharged to home

Fax from hospital

Access the hospital EMR

Fax from hospital

Access the hospital EMR

Fax from hospital

Access the hospital EMR

Page 38: MiPCT Spotlight ADT Alert Overview and Workflow Training for Care Managers and PO Leads February, 2014

ADT/CTC Summary of Key Points• Alerts need to be acknowledged on a timely basis

throughout the day to minimize multiple alerts on the same patient. (i.e. admission alert that is not acknowledged by the time of discharge will generate another alert -> discharge alert)

• When acknowledging an alert by email, click on “view care plan” button once logged in CTC. Clicking “close” will remove alert from your home page and require you to look up patient by name. ( Patient hospitalization report is being developed via CTC website to see patient TOC activity.)

• It is recommended that review of the discharge disposition code be incorporated into your process.

Page 39: MiPCT Spotlight ADT Alert Overview and Workflow Training for Care Managers and PO Leads February, 2014

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Contact Information

Page 40: MiPCT Spotlight ADT Alert Overview and Workflow Training for Care Managers and PO Leads February, 2014

Contact Information• For Care Management Workflow and Transition

of Care Activity Upon ADT Receipt▫Paula Amormino ([email protected])

• For PO Participation Agreement in MiPCT/CTC Spotlight Partnership and MOU▫Diane Marriott ([email protected])

• For Care Management/Practice/Physician Mapping Changes; CTC System Issues▫CTC Help Desk (877-736-4631 or

[email protected] )▫ if no response, contact Jeff Scehovic

([email protected])