Longitudinal Coordination of Care Interoperable Care Plan Exchange using Direct. May 12, 2014

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1 Longitudinal Coordination of Care Interoperable Care Plan Exchange using Direct May 12, 2014

2 Today s Discussion Program Overview Technology Overview: GSIHealthCoordinator Demonstration Pilot Architecture Questions and Answers 2

3 PROGRAM OVERVIEW 3

4 Social Service Provider OASAS/Addiction Services Case Management Public Health Authorites SHIN-NY/BHIX Care Coordination Platform Home Care SPOA Social Services Primary Care Physician Speciality Physcians Care Coordination Platform GSI Health Therapist Specialists Care Manager Patient Care Coordination Platform Intensive Care Management Providers Psychiatrist Specialists Care Navigator Care Coordination Platform Social Services Family Payer Homeless Shelters SHIN-NY/BHIX Peer Advocacy Correctional Services Supporting Housing Organizations Background 2005: BHIX Consortium of hospitals, nursing homes, home health providers & insurers establish BHIX with HEAL NY funds. Jan. 2010: HEAL 10 MMC received $7 million to develop MHH model and HIT infrastructure; seven stakeholders and South Beach Psychiatric enter into HEAL contracts to improve care for schizophrenics Jan. 2011: HEAL 17 MMC received $10 million; five stakeholders added and diagnoses expanded to include schizoaffective disorder, bi-polar disease and serious depression July 2012: HCIA MMC received $14.8 million CMS Health Care Innovation Award to enhance HIT functionality, develop care management training program and migrate from fee for service to total cost of care payment model April 2104: DSRIP $6.9 billion funding opportunity announced. MMC and partners developing Community Care of Brooklyn proposal : Co-location of primary care & behavioral health services at South Beach 1,500 1, Oct. 2010: Development of Mental Health Home Standards completed SHIN-NY/BHIX SHIN-NY/BHIX Dec 2011: Health Home MMC designated as Medicaid Health Home (Brooklyn Health Home), receiving PMPM fee for IT-enabled, comprehensive care management Jan. 2014: HARP Pilot MMC, Brooklyn Health Home, FEGS and Healthfirst initiate HARP Pilot, integrating a payer into the care model in a meaningful way SHIN-NY/BHIX SHIN-NY/BHIX

5 Partners Care Management Providers Baltic Street Interborough Developmental and Brooklyn Community Services (BCS) Consultation Services CAMBA Kingsboro Psychiatric Center Catholic Charities Lutheran Medical Center Family Services Network of New York Maimonides Medical Center FEGS NADAP Jewish Board of Family and Children Ohel Children s Home and Family Services (JBFCS) Services Health Care Choices Promoting Specialized Care and Health ihealth: (PSCH) - AIDS Service Center NYC The Puerto Rican Family Institute, Inc. - APICHA Services for the Underserved - Argus South Beach Psychiatric Center - Bailey House Village Care - Diaspora Community Services Visiting Nurse Service of New York - Gay Men s Health Crisis, Inc. (VNSNY) - Harlem United - Heartshare Human Services of NY - HELP/PSI Services Corp - Housing Works - Narco Freedom Inc. - Richmond Home Need Services Network Providers Beth Israel Medical Center Black Veterans for Social Justice Realization Center Bridge Back to Life Brookdale Hospital Brooklyn AIDS Task Force Brooklyn Hospital Brooklyn Plaza Medical Center Center for Behavioral Health Services Center for Urban Community Services (CUCS) Institute for Community Living Liberty Behavioral Management Medisys Health Network Providers National Alliance on Mental Illness (NAMI) Phoenix House Public Health Solutions (PHS) St. John s Riverside Hospital SUNY Downstate Medical Center White Glove Community Care 5

6 Care Team Responsibilities Population Management Operational & Outcomes Reporting Total Cost of Care Model Develops a single integrated care plan (medical, behavioral and social issues) available to all members of care team Coordinated Care Plan Reviews care plan with patient and families Provides paper and/or electronic access to care plan Messages patient with reminders and educational materials Analyzing & Improving Patient Engagement Enrollment Patient Consent Appointments Referrals Care Transitions Events Monitoring & Managing Case Conferences Communication & Collaboration Holds interdisciplinary case conferences to diagnose, evaluate and reevaluate ongoing treatment plan Document case conference notes captured via Coordinated Care Plan for automated updates Communication & Collaboration among core team, specialists, social service organizations Updates and notifies members of the care team of actions 6

7 Brooklyn Health Home Model Key Feature of the BHH model: Virtual colocation of providers and services enabled by health IT and coordination of services

8 TECHNOLOGY OVERVIEW: GSIHEALTHCOORDINATOR 8

9 GSI Health Company Overview Veteran health IT team, including policy leadership with Federal and State governmental appointments Product solutions focused exclusively on care coordination and population health management Extensible cloud-based platform Care coordination apps provide workflow functionality for virtual care teams Embedded HIE and Direct Infrastructure to interoperate with existing 3 rd party systems Embedded analytics and reporting solution utilizing 4 data types: Clinical (HIE, EHR), Claims (public and private sources), Administrative and Care Coordination Deep domain experience in Care Coordination, Interoperability, Medicaid ACOs and Health Homes, complex patient populations

10 Unifies applications into a seamless workflow for care coordination EHR Care Coordination Apps Care Delivery Information Systems HIE Analytics & Reporting Health Information Exchange & Data Import (Optional) Admin Claims Data Systems Public Payers Private Payers Unifies data into a virtual repository, data warehouse and marts for operational and outcomes measurement and reporting 10

11 DEMONSTRATION 11

12 PILOT ARCHITECTURE 12

13 Pilot Architecture Overview 13

14 Summary Want to identify 3 rd party candidates to receive and digest LCC CDA EHRs HIEs Other Care Management Systems Focusing on mapping of Care Plan document fields to applications. Leveraging clinical and technical insight Rich set of high-value use cases in New York for piloting 14

15 QUESTIONS? 15

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