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Use of a Registry for Chronic Disease Management in a Small County Behavioral Health Setting. Karen Stockton, Ph.D., M.S.W., B.S.N. Health Services / Behavioral Health Director, Modoc County. Platform Selection: The Small County Challenge. - PowerPoint PPT Presentation
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Use of a Registry for Chronic Disease Management
in a Small County Behavioral Health Setting
Karen Stockton, Ph.D., M.S.W., B.S.N.Health Services / Behavioral Health Director,
Modoc County
Platform Selection: The Small County Challenge
• Be able to accomplish with minimal technological support
• Be able to embed as a normal part of service delivery
• Be simple enough that MH Specialists and Peer providers can use
• Be able to produce and interpret basic reports without statistical expertise– Note: as a very small county, we were exempt
from PEI evaluation
Background
• We were looking for an inexpensive system that was appropriate for small county data management to measure outcomes across all programs and funding requirements.
• Desired an application that had promise for real-time quality improvement at all system levels, was appropriate for integrated health care, and that would also have capacity to submit data to oversight entities.
• We decided early on to set the security level to comply with HIPPA & 42CFR – and manage access by release of information.
Our journey in search of an alternative to pencil and paper tracking
• Pencil & Paper• Spreadsheets
– Stand alone with limited use for general population or interface with other programs
• EHR– The primary use of an electronic health record is
mostly to process billing and supporting documentation.
– Much of the data is not in searchable fields.• Chronic Disease Management Registry
Adaptability
• A registry is designed to be more adaptable to collect needed information.
• Data available at all levels of program (client, groups of the population)
• Makes job easier – no paper chart• Makes it possible to do things that we couldn’t do
before– Plan with our beneficiaries their treatment based on their
progress reports– Staff use individual data for planning and intervention while
in session
Testing chronic disease management registries (PECSYS & eCiMH CC Tracker)
• Registry is a tool to help you keep track of people and manage their health.
InterfacesData Input
– Direct data entry via web access• Data entry notices/reminders• Mobile system entry with web access
– Data import • From providers’ systems under testing through EHR interface
Data Output users– Data exports
• Canned reports• Custom reports
Role based interfaces (front desk, clinician, QA, billing, IT, management)– System administration– Users support
Content & Outcomes
• Structure and Process Information – Can collect any measurable information that is
predetermined and assigned a field
• Outcomes Information– Client Outcomes
• Core measures (across programs)• Custom measures (specific to a program)
– Program Outcomes• Milestones • G&O – If assigned a numeric value
Annotated Time Series
0
100
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Targ
et P
opul
atio
n
Per
cen
t
Lassen
4/11 MET our goal of 85%, we were 86% due to calls to clients.
8/31/11 increased to 91.6%
100
105
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140Clients in the Target Population
0
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12 New Clients in Target Population
0
0.5
1
1.5
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2.5
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3.5
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4.5
Client Who Leave Prior to 6 Months
100
105
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0
10
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30
40
50
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70Average Length of Service
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80
100Percentage of Clients with Current Recovery Measurement
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10
0
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40
60
80
100Percentage of Successful Transitions to Comm
0
5
10
15
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0
5
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45Percentage of Transitions to Higher Level (a)
36
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50
0
5
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25
30Percentage of Transitions to Higher Level (b)
0
1
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0
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90Percentage of Readmissions
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0
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100Percentage of Clients Served
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120
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90Percentage Positive On Satisfaction Survey
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120
0
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80Percentage Positive on Client Wellness Survey
0
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120
0
2
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12Average Number of Days of Meaningful Activities
0
1
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90Percentage of Readmissions
Santa Maria County Mental Health
Data Utilization of the Registry• Use data proactively manage health and wellness
for a chronic condition• Collect and use data for integration of whole
health and shared care plans• Collect and analyze data that is useful for quality
improvement• Demonstrate individual progress and program
outcomes• Guide delivery of, and monitor adherence to, best
practices and protocols
• Provide a mechanism to share key information across the integrated team through VPN or HIE – ACA data exchange requirements
• With appropriate releases of information, through VPN access, integrated team members can bi-directionally exchange information “real time”.
• Client level data in aggregate is very useful for demonstration of program/department and collaborative outcomes
• Fixed data elements in “searchable fields” have significant potential for TIMELY outcome measurement, evaluation and/or research at all system levels while remaining HIPPA/and 42CFR compliant.
