Enhancing Care Coordination through Community Information Exchange 12/11/14

Transcription

1 Enhancing Care Coordination through Community Information Exchange 12/11/14 Scott Bechtler-Levin (Exec. Director) m Nancy Sasaki (Exec. Director) nsasaki@alliancehealthcarefoundation.org m Enhancing Care Coordination through CIE San Diego 12/11/14 p. 1

2 Agenda Introductions / Framing Nancy 15 min Overview of CIE San Diego Scott Bechtler-Levin 30 min Discussion All 30 min Next steps and wrap-up All 15 min Enhancing Care Coordination through CIE San Diego 12/11/14 p. 2

3 What is the Community Information Exchange Key Takeaways Cohort #1 (downtown homeless) live Cohort #2 (downtown elderly) committed Strategic plan with path to sustainability Next steps Enhancing Care Coordination through CIE San Diego 12/11/14 p. 3

4 Seamless care coordination that improves people s health outcomes Enhancing Care Coordination through CIE San Diego 12/11/14 p. 4

5 Step 1: CIE is embedded in Father Joe s CSTAR system! User experience User selects a client WITHIN their native CSTAR or StreetSense system Presses CIE icon Views client record in CIE Technology works! Real-time API integration Single sign-on Auto-quick search Validate view rights by user role Enhancing Care Coordination through CIE San Diego 12/11/14 p. 5

6 Step 2: Review Dashboard (provider support) Enhancing Care Coordination through CIE San Diego 12/11/14 p. 6

7 CIE notification auto-populates From: To: Sent: Subject: Hi Kris, Sally Smith Kris Kuntz 4/9/14 8:50 AM CIE client notification - DF This message is for you and 3 other case managers regarding a consented client Sam Fake (xxx-xx-3490, xx-xx-1960, 54 years old) will be discharged by taxi from UCSD Medical Center in 1-3 hours. Please contact me about client care plan urgently. Sally Smith Discharge planner, UCSD SSmith@UCSD.edu Enhancing Care Coordination through CIE San Diego 12/11/14 p. 7

9 Key Takeaways Enhanced care coordination is a bold and significant opportunity The timing is right for CIE San Diego CIE San Diego is making strong progress Strategic plan with path to sustainability Cohort #1 (homeless) go-live Cohort #2 (elderly) on track for Jul2015 go-live Next step confidence in inevitability CIE needs 18 months of runway Enhancing Care Coordination through CIE San Diego 12/11/14 p. 9

11 10. Analysis 1 st Cohort: Downtown San Diego homeless (many of whom are frequent EMS users) 1. Client is drunk in public 2. Ambulance arrives (or even 3. Client transported at erap or dispatch) to E.D. 4. Look-up and view client s history in CIE 5. Hospital discharge manager decides to notify In Out Program Contact 9. Client s case manager takes action 8. Client s case manager receives notification Phone Text 7. Notification sent or call made 6. Client s case manager identified Secure CIE Enhancing Care Coordination through CIE San Diego 12/11/14 p. 11

12 What we aim to learn from cohort #1 (downtown SD homeless) 1. How partners benefit from using CIE 2. What parts of the technology should change 3. How to reduce barriers to sharing data 4. What will be CIE s role in helping partners become ready to share 5. How might we adjust our approach for greater scalability UC San Diego Health System Hillcrest Medical Center Enhancing Care Coordination through CIE San Diego 12/11/14 p. 12

13 Cohort #1 - Success Stories 1. Frequent EMS user prevention program (Father Joe s) Used CIE to look-up current clients EMS usage (well beyond P25) Allowed Father Joe s staff to research root-cause of client issues Currently working to design intervention protocol to reduce preventable EMS transports Projected outcome: Avoid EMS transport cost and ED treatment cost. Address clients underlying need. 2. Deliver clients with orphaned identification (Scripps) Scripps Mercy Hospital has file drawers full of homeless patients original identification (birth certificates, driver s licenses, social security cards) gathered at great expense by hospitals staff to facilitate reimbursement Used CIE to look-up clients case managers so that client can claim their original paperwork Projected outcome: Avoid duplication of effort by 25 Cities and other homeless service providers who also work with clients to obtain original identification so that the client can qualify for County and other benefits Enhancing Care Coordination through CIE San Diego 12/11/14 p. 13

14 Cohort #1 Summary 800+ client dashboards available Roughly 80% of clients asked opt-in 400+ Dashboard views in Nov Initial technology adjustments have stabilized Unanticipated benefits emerging Few notifications are being sent CIE staff are nudging Participant organizations to own their process change Evaluation Phase 1 (July-Dec2014) likely to be qualitative Adding new Participants with synergy between cohort #1 and #2 By end-april, evaluate timing for the end of pilot (plan is Jun2014) Enhancing Care Coordination through CIE San Diego 12/11/14 p. 14

16 10. Analysis Cohort #2: Aging in Community (Homebound seniors receiving meals in downtown San Diego) 1. Homebound senior falls 2. Ambulance arrives 3. Client transported to E.D. 4. Hospital Intake looking for emergency contact 5. Look-up and view client s history in CIE In Out Program Contact 9. Meal delivery Resumes. Client needs assessed to avoid readmisison 8. Upon discharge, manager receives notification Phone Text 7. Notification sent or call made 6. Client s Meals-on-Wheels case manager identified Secure 3a. No panic cycle CIE Enhancing Care Coordination through CIE San Diego 12/11/14 p. 16

17 Cohort #2 - Downtown SD Aging in Community (Participants and others likely) New Current UC San Diego Health System Hillcrest Medical Center Enhancing Care Coordination through CIE San Diego 12/11/14 p. 17

18 Cohort #2 Finalists (all interested in exploring later participation) Aging in community Selected to begin implementation January 2015 North County Community Clinics and CBOs Prioritization, timing and cross-incentive issues Military Transitions (MTSP) Ramp-up timing and diverse participant issues Enhancing Care Coordination through CIE San Diego 12/11/14 p. 18

19 Selected Cohort #2 Summary Seniors Aging in Community selected 3 MOUs expected to be signed in December (Serving Seniors, Meals-on-Wheels, ElderHelp) Other organizations are interested in phase 2 (expansion) Strong synergy between Cohort #1 (homeless) and Cohort #2 (seniors) Participant organizations Implementation begins January, 2015 First Client Alert sent by end-july, 2015 Enhancing Care Coordination through CIE San Diego 12/11/14 p. 19

21 Strategic plan with path to sustainability Key points Scale is key to sustainability Market size supports our plan Target segments sized Future cohorts are interested Community Information Exchange (CIE) San Diego Strategic Plan A community-wide opportunity - Enhanced care coordination Throughout San Diego County, many of the more than 9,700 nonprofit organizations (1,900 with paid employees) are serving the same people. Yet each organization approaches an underserved client with their own lens and limited knowledge of others services. Care silos mean clients with complex and interrelated needs, including difficulty self-navigating multiple programs and organizations, often receive redundant services or go without the care they need until problems escalate and become crises. Without efficient systems to allow care managers to talk to each other across program silos, it is nearly impossible for care givers to coordinate care on behalf of their clients. To manage homelessness, to change the course of chronic disease, to prevent readmissions to hospitals and emergency departments, and to focus on health not just healthcare requires social service and other healthcare providers to effectively share information and coordinate their efforts. See Appendix A for a glossary of key terms. 2. CIE s solution Client history dashboards with alerts and analytics Community Information Exchange (CIE) San Diego is building county-wide trust networks that enable a care provider to view a more complete picture of a client s program history and current needs. Using sophisticated software, people and processes, CIE allows information to be exchanged, often in realtime, between network participants thereby enabling holistic care coordination for the most complex, expensive, and underserved clients. As a result of transforming care delivery coordination, program selection decisions will be more appropriate, less expensive, and more effective. Our Vision: Our Mission: Seamless care coordination improves people s health outcomes Enable information sharing and actionable insights across social service and healthcare providers so that San Diegans can live well The CIE network of networks will enhance care by supplementing siloed case management and allowing real-time sharing of client data and by providing analytical tools to facilitate cross-sector care coordination for clients with multiple needs. Flexible reporting and client-specific alerts will enable policy decisions and case manager action to be taken across organizations. Client consent and rolebased sharing rules will control who can access data and how it may be used. Enhancing Care Coordination through CIE San Diego 12/11/14 p. 21

22 # of clients $/client/month (PCPM) CIE s Scale-Up Strategy 25,000 Scale leverages fixed cost ($/client/mth drops as cohorts are added) $47.38 $50 1. More clients Grow cohort-by-cohort Focus on large client-bases Partner overlap (geographical, needs) Each cohort has positive margin 20,000 15,000 10,000 5,000 $10.60 $8.50 $5.70 $45 $40 $35 $30 $25 $20 $15 $10 $ $0 2. More lenses on existing clients More data sources shared Portion of view per client 3. Leverage client opt-ins Others client consent activity Future Use Case 11/19/13 pre p. 22 Enhancing Care Coordination through AHF Program CIE San 5/12/14 Diego 12/11/14 (final) p. 22 p. 22

23 Enhancing Care Coordination through CIE San Diego 12/11/14 p. 23

24 % of total risk $ Sustainability Impact / ROI Technical Process / Compliance Adoption Key risk reduction milestones Cohort #1 Go-Live Cohort #2 Go-Live Cohort #4 + #5 Go-Live Cohort #6 + #7 Go-Live Cohort #8 + #9 Go-Live Adoption Compliance Governance / Process Technical Outcomes $ Sustainability AHF i2 Grant + Leadership 2 nd AHF Grant Cohort #1 Outcome Study + #3 Go-Live Cash flow breakeven Enhancing Care Coordination through CIE San Diego 12/11/14 p. 24

25 Revenue Sources Earned Income Network participation fees cover nearly 70% of expenses within 5 years Agreements include early adopter discounts Interface costs subsidized for cohorts Participation fees waived for year of cohorts 1 Participation fees waived for first 6 months of cohorts 2 Effective July 1, 2015 (for cohort 1), monthly fees begin Standard: $350 --$950 / agency / month Early Adopter and data sharer (33% off) : $235 $637 / agency / month Sustainably cover 100% of expenses ( $1.5M/yr) during year 7 Roughly 300 participating organizations paying monthly fees of $500/mth Enhancing Care Coordination through CIE San Diego 12/11/14 p. 25

26 Building the exchange infrastructure for San Diego KIP County Services SD Health Connect Medical CIE Social/Econ Enhancing Care Coordination through CIE San Diego 12/11/14 p. 26

27 Status of Funding Conversations Summary $15k grant from City of San Diego / SDHC / RTFH CIE Board members have made personal contributions $370,000 in grant applications pending (4 foundations) $70,00 grant applications denied (2 foundations) Important meetings scheduled / follow-up with Blue Shield of CA Foundation, CA Healthcare Foundation, The California Endowment SD Grantmaker s forum Enhancing Care Coordination through CIE San Diego 12/11/14 p. 27

29 Next Steps (through Dec, 2015) Expand and evaluate cohort #1 (downtown homeless) More clients, more participants, more usage Validate earned income model (July, 2015) Pilot evaluation to prove value is created (Sept, 2015) Launch cohort #2 (downtown aging in community) Commit by end-dec, 2014 Implementation: Jan Jul 2015 Validate earned income model (Jan, 2016) Pilot evaluation to prove value is created (Sept, 2016) Secure funding beyond Alliance Healthcare Foundation By May 2015 Launch cohort #3 (tbd) Commit by end-june, 2015 Implementation: Jul 2015 Jan 2016 Enhancing Care Coordination through CIE San Diego 12/11/14 p. 29

30 What: CIE Celebration Tonight 4-6p Networking with brief comments by: Rob McCray, Board Chair, and Nancy Sasaki, Executive Director, of Alliance Healthcare Foundation Supervisor Ron Roberts Nick Macchione, Director of San Diego County HHSA Scott Bechtler-Levin, Executive Director, CIE San Diego When: Thursday, 12/11, 4-6p Where: Father Joe's Villages Guild Room (1st Floor) 1501 Imperial Avenue San Diego, CA Free, safe, underground parking. The entrance is on the right-hand side of 16 th Street just south of Imperial. Why: CIE San Diego is celebrating several milestones, and thanking those who have enabled us to reach them! First cohort network launched for homeless clients in downtown San Diego. $1M in additional funding from Alliance Healthcare Foundation. Designation as a Live Well San Diego partner. More information: 12/9/14 Press Release: press release : Learn about CIE San Diego: Free registration: Enhancing Care Coordination through CIE San Diego 12/11/14 p. 30

31 Key Takeaways Enhanced care coordination is a bold and significant opportunity The timing is right for CIE San Diego CIE San Diego is making strong progress Strategic plan with path to sustainability Cohort #1 (homeless) go-live Cohort #2 (elderly) on track for Jul2015 go-live Next step confidence in inevitability CIE needs 18 months of runway Enhancing Care Coordination through CIE San Diego 12/11/14 p. 31

32 Agenda Introductions / Framing Nancy 15 min Overview of CIE San Diego Scott Bechtler-Levin 30 min Discussion All 30 min Next steps and wrap-up All 15 min Enhancing Care Coordination through CIE San Diego 12/11/14 p. 32

33 Enhancing Care Coordination through Community Information Exchange 12/11/14 Scott Bechtler-Levin (Exec. Director) m Nancy Sasaki (Exec. Director) nsasaki@alliancehealthcarefoundation.org m Enhancing Care Coordination through CIE San Diego 12/11/14 p. 33