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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
3
What is Spotlight and What Does it Provide for MiPCT POs and Practices?
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
.
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
.
6
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.
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
Functionality 1: MiPCT Member Lists CTC Spotlight
Functionality 1: MiPCT Member Lists CTC Spotlight, cont.
10
Functionality 1, cont. : New Member Alerts via CTC Spotlight
11
Functionality 2: Admission/Discharge Alerting
12
A Detailed Look at ADT Alerting in Spotlight
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
13
14
•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
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
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)
16
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
17
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
Phase 2: Admission/Discharge AlertingPatient Admitted Email Alert
Phase 2: Admission/Discharge AlertingPatient Discharged Email Alert
Phase 2: Admission/Discharge AlertingPatient ER Visit Email Alert
Alerting – Acknowledge via emailLogin to Spotlight
Alerting – Acknowledge via emailClose Alert
Admission/ER Visit Information
Discharge Dispositions:
26
Care Management Workflows
St. John Providence, Partners in CareMiPCT-P.O.- Soft launch Partner
CTC/ADT alert only process flow
developed by:
Workflow for Inpatient Alert
CM Workflow for Discharge Alert
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
CM Workflow for ED Alert
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.
Transitions of Care Integrated Workflow
(displays inpatient, discharge and ED flows in one screen)
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
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.
39
Contact Information
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