Patient Centered Health Home and Data Analytics. Amanda Stangis, Director of Programs, CPCA Andrew Principe, VP Strategy, Arcadia Solutions

Transcription

1 Patient Centered Health Home and Data Analytics Amanda Stangis, Director of Programs, CPCA Andrew Principe, VP Strategy, Arcadia Solutions

2 Agenda What is a Health Home? What is the connection between Health IT and successful Health Homes? What technology do I need? Best practices for using Health IT to manage quality and outcomes in a Health Home Supporting California Clinics the PCHH Initiative Conclusion

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4 Cheers! (Where Everybody Knows Your Name) What is a Health Home? The CPCA definition: A health home is an approach to delivering primary care that uses a whole person orientation to provide comprehensive health care by facilitating an active partnership between patients, their family, and their primary care provider team to provide high quality, timely care in a coordinated and consistent way. This approach provides patients with what they need and when they need it, in a manner that patients and providers work as partners in managing their care that is coordinated with the right people talking to each other.

5 The Connection Between Health IT and PCHH (Perfect Strangers) 1. Timely and continuous management and tracking of health data and services over a patient s lifetime for all providers, patients, families, and guardians, 2. Comprehensive organization and secure transfer of health data during patient care transitions between providers, institutions, and practices, 3. Establishment and maintenance of central coordination of a patient s health information among multiple repositories (including personal health records and information exchanges), 4. Translation of evidence into actionable clinical decision support 5. Reuse of archived clinical data for continuous quality improvement. *** From: Pediatrics; Policy Statement Health Information Technology and the Medical Home; April 25, 2011.

6 EHR, HIE, and Analytics (Three s Company) The connection between Health IT and PCHH EHR HIE Collects and organizes longitudinal patient information Provides decision support based on best-available data Capable of providing point of care reminders Platform for the care team to coordinate care Supports med. rec. post hospitalization and eprescribing Supports tracking of tests, referrals, care at other facilities Electronic access via Patient Portals*** Coordination of care through Provider Portals*** Analytics Identify patients with specific needs: high risk, conditions Track utilization measures Support continuous improvement activities Used to demonstrate improved performance *** Different EHR vendors include portals as included or excluded from HIE offerings, but they are largely considered to be exchange capabilities and components

7 Case Study: An FQHC at the Forefront (Growing Pains) Preface This is an advanced Health Center who has invested years in developing EHR, HIE, and Analytics capabilities They have redesigned their care team models around their Health IT environment Reporting and analytic capabilities are key to prioritizing care team work and decision making Their reimbursement environment is (slowly) shifting to reward them for cost and quality outcomes

8 Case Study: HIT Infrastructure (Small Wonder) Clinical Data Labs ADT Imaging ER Provider Portal Patient Portal H I E EMR System External Interfaces Centralized Database Member Roster High Risk Info Claims Utilization Payer Claims Data Reporting Platform

9 Case Study: Care Team (Who s the Boss?) Shifted from individual physicians working with a single MA to a multi-physician care team model. Introduced 2 new roles: RN to support execution of care plans Analytically focused case management to assist in prioritizing care team activities Analytics / Case Management MD MD MD RN MA MA MA MA

10 Case Study: Using Health IT (Diff rent Strokes) In The Patient Encounter (Physician) EHR based decision support Quality Evidence Based Cost Based Daily Care Team Huddles (MA) Reports to show most pressing issues to be addressed with today s patients Monthly Care Team Performance Reviews (Analytics / Case Management) Reports to show performance against goal Total Medical Expense Quality Weekly Care Team Planning Meetings (Nurse) Reports to show prioritized gaps in care for entire panel

11 Case Study: Results (Head of the Class) $2M saved in 2010 Significant focus on high utilizers and chronic diseases Key technology capabilities to manage performance Leadership commitment What s in it for? Providers: improved satisfaction with role and feeling of being able to make informed decisions Patients: happier (and healthier) and able to access care more readily The CHC: better financial performance The CEO: better data to lead negotiations with payers and partners

12 Case Study: The Verdict (Night Court) While there is no one size fits all approach, themes are emerging: Health IT allows us to work smarter, divide up work, and track performance in real time Its not just about building the right technology, but about redesigning roles and responsibilities to maximize technology s value Leading organizations go well beyond recognition and focus on quality and cost outcomes

13 PCHH, Data, and CPCA

14 CPCA s Goal: Partnership and Team Work Create an integrated strategy to support CHCs in achieving patientcentered health home recognition, improve health outcomes, and position CHCs for ongoing participation in primary care delivery under health reform. I love it when a plan comes together!

15 Supporting California CHCs Leverage work of leading California CHCs Quickly assess CHC readiness Partner with national experts to recognize CHCs as Health Homes Convene training, technical assistance, and other resources Align, with other relevant initiatives Support variation in CHC needs Collect data to support local, regional and statewide advocacy Inform emerging payment models

16 Initiative Overview Three Phases of Training and TA CHCs Select the Level of Support Integration with Technology Tools Strategic Alignment with NCQA

17 CHCs Select Level of Engagement All participating CHCs will receive an assessment and plan The portal will be the primary mechanism for interactions between the practices and their coaching team Learning modules are pre recorded and live training and TA CHCs that choose DRVS will have access to pre validated analytics to support the Health Home Coaches help guide CHCs through the process of recognition

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19 Computers, Information and Speed

20 DRVS Integration DRVS is a web based, quality measurement and improvement platform that has been designed specifically to meet the needs of Community Health. Using data captured directly from EMR & EPM, DRVS measures and monitors performance on key clinical, operation and financial metrics at all levels PCA and CHC focused EHR agnostic; proven, mature and scalable Simple, user friendly designed Long term commitment to platform CMS Patient Centered Health Home programs, PCMH UDS changes Evolving Federal & State reporting requirements Meaningful Use Integration of Cost Data Used by clinic managers, CMO s, QI teams, individual providers and system wide advocacy groups 20

21 Data Reporting for NCQA Documentation The portal will integrate with recognition tools, so submission and review are simplified. Analytics tools will be prevalidated, meaning many recognition criteria will be completed automatically Where appropriate coaches have access to analytics to support ongoing transformation.

22 Data Beyond Recognition: A Dynasty for the Future Data will focus on helping CHCs thrive under emerging Health Reform models: Analytics Aren t Enough Participating in Reform style contracts New partnerships Strategic Planning for Growth Continuous Improvement and Innovation Redesigning Incentives Governance and Synergy with Data Use and Aggregation

23 Technical Overview Data Usages Data Usages EBG & Management Integrated Member Management Quality, Outcomes, & Performance Mgmt Clinic based Care Mgmt External Data Inserted in EHR Data Warehouse Direct Mailbox S-FTP Server Master Patient Index Data Loading Service Data Access Layer Core Data Warehouse Staging Database Reporting Database Reporting OLAP Cube Backend Systems Medical Record System(s) Practice Mgmt. System(s) Non DRVS Authorization Analytics Systems System(s) Claims System(s) Membership System(s) Pharmacy System(s) Rating System(s) Lab System(s)

24 Next Steps Evaluate Your CHC s Approach to Implementing Health Home Determine Your Priorities and Resourcing for Data Infrastructure Development and Use Explore Partnerships for Data Sharing and Public Reporting Get Involved with Your Regional Associations and CPCA hoping each time, that his next leap will be the leap home.

25 Saved By The Bell