Clinical Transformation

Transcription

1 Beacon Communities Program Clinical s Worksheet Wave 1: January - June 2012 Type Clinical Transformation NOTE: HIBC will begin clinical transformation work in January Hawaii County population estimates include 185,000 total residents of which 120,800 are adults over the age of 18. 9% of adults are estimated to have diabetes, 26% high blood pressure, 18% smoke, 28% have high cholesterol and 26% are obese as reported in the Hawaii County BRFSS results for 2010 and the 2009 Hawaii Primary Care Needs Assessment Data Book. Approximately 25% of our adult population is ed for intervention as some level with various clinical transformation activities. s Approx. % of physicians in Practice Re-Design Care Transitions PCMH Coaching HIBC will partner with TransforMED to bring a structured approach to achieving PCMH transformation across the participating provider network. This Rapid Adoption Transformation Model combines adult learning principles, interactive training methods and skillfocused learning through collaborative meetings, ed assessments and site visits. will learn how to lead practice-based teams. Practices will utilize care coordinators as part of the patient-centered team base approach to care and use clinical data from their EHRs and the HIE for decision support and facilitation of care transitions. 50, ,000 20% 10 20% EMR Adoption/Stage I MU HIBC will provide technical support, education, and training to physicians, in conjunction with Hawai i Pacific Regional Extension Center (HPREC) efforts, to increase EHR adoption and achieve Stage 1 Meaningful Use. 30, ,000 20% % Care Coordination HIBC will conduct a 12-month pilot project designed to improve care coordination for complex, chronically ill patients, with a single or combination diagnosis of diabetes, cardiovascular disease and mental health conditions, through a care delivery initiative focused on utilizing care coordinators and patient navigators within the Patient Centered Medical Home (PCMH). Care Coordinators within the PCMH will be proficient in the use of patient registries for identifying high risk patients, developing care plans, monitoring medications, conducting patient and family education, engaging self-management, making referrals to community-based resources and monitoring individual and population clinical outcomes. 1, % 40 67% Hospital Discharge Planning HIBC will conduct a pilot project designed to facilitate care transition initiatives with the three acute care hospitals in Hawai i County. Activities are focused on standardization of a patient discharge summary tool to be utilized across all three facilities. Hospitals will also participate in a training and mentoring program involving Project BOOST methodology designed to improve hospital discharge processes and communications with primary care providers (PCPs) through their care coordinators, long term care facilities, hospice, home health, support/enabling services for populations at risk, patients and their families. 2, % 10 33% East Hawaii Private Practice PCPs FQHCs in East, North, and West Regions 1 of 12 HIBC Clinical s Spreadsheet

2 Beacon Communities Program Clinical s Worksheet Wave 1: January - June 2012 Type Patient and Community Engagement PCP/Specialist Communication HIBC will pilot an on-line tool called Doc2Doc to facilitate the referral process and transition of patients from PCP to specialists. Care transitions include any movement of a patient from one care provider or level of care to another, including from emergency departments to PCPs, from doctors to home health, and from inpatient settings to long-term care. The Doc2Doc platform will be evaluated for a more broadly based application as it can be used to initiate, coordinate and manage patient care transitions to completion, and can do this securely from any point A to point B. Enabling Services HIBC will facilitate this care delivery initiative that is focused on strategies for providing patients with resources (e.g., education, self-management skills, transportation, financial assistance, translation) that are culturally appropriate and that care coordinators and hospital discharge planners may partner with to assist patients with services and programs that patients may need to effectively manage their chronic illnesses. Educational programming is focused on diabetes and hypertension management, behavioral health, physical activity and nutrition. s Approx. % of physicians in % 4 33% 250 n/a % n/a n/a HEAL Grants HIBC will fund individual community projects focused on reducing behavioral risk factors, improving nutrition and physical activity, and preventing tobacco use to promote better health and increase wellness in communities throughout Hawai i County. These unique, community-based programs will feature community driven strategies to address prevention and health behaviors. They will also provide care coordinators with options for increasing patient engagement in prevention and management of chronic illnesses. 31,600 n/a 7,900 25% n/a n/a Smart Cards HIBC will facilitate the implementation and distribution of patient identification cards for healthcare consumers. Cards will serve as portable Personal Health Records (PHRs) allowing individuals to track/monitor their own health status indicators. The cards will hold up-todate demographic information for each patient, resulting in improved operating efficiencies of health facilities' registration processes. These cards will also allow important clinical information to be shared with other providers as patients move around the health care system. 5, , % % Small pilot in the East North and West Regions Health Information Exchange Amalga Advanced Analytics A clinical and claims data repository that will provide longitudinal understanding of population health, patient care and improved analytical fidelity in supporting assessment of impacts by care interventions 100,000 TBD 2 of 12 HIBC Clinical s Spreadsheet

3 Beacon Communities Program Clinical s Worksheet Wave 1: January - June 2012 Type s Approx. % of physicians in Wellogic Decision Support NHCH A SaaS (software as a service) cloud based model capable of exchanging clinical lab and prescription orders, results of the orders (lab results or dispensed drugs), secure messaging between participants, workflow presentation via a web based portal interface and other health information exchange capabilities 30,000 TBD 3 of 12 HIBC Clinical s Spreadsheet

4 Beacon Communities Program Clinical s Worksheet Wave 2: July - December 2012 Type Clinical Transformation NOTE: HIBC will begin clinical transformation work in January Hawaii County population estimates include 185,000 total residents of which 120,800 are adults over the age of 18. 9% of adults are estimated to have diabetes, 26% high blood pressure, 18% smoke, 28% have high cholesterol and 26% are obese as reported in the Hawaii County BRFSS results for 2010 and the 2009 Hawaii Primary Care Needs Assessment Data Book. Approximately 25% of our adult population is ed for intervention as some level with various clinical transformation activities. s Practice Re-Design PCMH Coaching HIBC will partner with TransforMED to bring a structured approach to achieving PCMH transformation across the participating provider network. This Rapid Adoption Transformation Model combines adult learning principles, interactive training methods and skillfocused learning through collaborative meetings, ed assessments and site visits. will learn how to lead practice-based teams. Practices will utilize care coordinators as part of the patient-centered team base approach to care and use clinical data from their EHRs and the HIE for decision support and facilitation of care transitions. 50, EMR Adoption/Stage I MU HIBC will provide technical support, education, and training to physicians, in conjunction with Hawai i Pacific Regional Extension Center (HPREC) efforts, to increase EHR adoption and achieve Stage 1 Meaningful Use. 30, Care Coordination HIBC will conduct a 12-month pilot project designed to improve care coordination for complex, chronically ill patients, with a single or combination diagnosis of diabetes, cardiovascular disease and mental health conditions, through a care delivery initiative focused on utilizing care coordinators and patient navigators within the Patient Centered Medical Home (PCMH). Care Coordinators within the PCMH will be proficient in the use of patient registries for identifying high risk patients, developing care plans, monitoring medications, conducting patient and family education, engaging self-management, making referrals to community-based resources and monitoring individual and population clinical outcomes. 1, Hospital Discharge Planning HIBC will conduct a pilot project designed to facilitate care transition initiatives with the three acute care hospitals in Hawai i County. Activities are focused on standardization of a patient discharge summary tool to be utilized across all three facilities. Hospitals will also participate in a training and mentoring program involving Project BOOST methodology designed to improve hospital discharge processes and communications with primary care providers (PCPs) through their care coordinators, long term care facilities, hospice, home health, support/enabling services for populations at risk, patients and their families. 2, % 23 46% 12,080 40% 48 40% % 20 33% North Hawaii Private Practice PCPs Adding 20 PCPs in East, North and West Regions Care Transitions % 10 33% 4 of 12 HIBC Clinical s Spreadsheet

5 Beacon Communities Program Clinical s Worksheet Wave 2: July - December 2012 Type s Patient and Community Engagement PCP/Specialist Communication HIBC will pilot an on-line tool called Doc2Doc to facilitate the referral process and transition of patients from PCP to specialists. Care transitions include any movement of a patient from one care provider or level of care to another, including from emergency departments to PCPs, from doctors to home health, and from inpatient settings to long-term care. The Doc2Doc platform will be evaluated for a more broadly based application as it can be used to initiate, coordinate and manage patient care transitions to completion, and can do this securely from any point A to point B. Enabling Services HIBC will facilitate this care delivery initiative that is focused on strategies for providing patients with resources (e.g., education, self-management skills, transportation, financial assistance, translation) that are culturally appropriate and that care coordinators and hospital discharge planners may partner with to assist patients with services and programs that patients may need to effectively manage their chronic illnesses. Educational programming is focused on diabetes and hypertension management, behavioral health, physical activity and nutrition n/a HEAL Grants HIBC will fund individual community projects focused on reducing behavioral risk factors, improving nutrition and physical activity, and preventing tobacco use to promote better health and increase wellness in communities throughout Hawai i County. These unique, community-based programs will feature community driven strategies to address prevention and health behaviors. They will also provide care coordinators with options for increasing patient engagement in prevention and management of chronic illnesses. 31,600 n/a Smart Cards HIBC will facilitate the implementation and distribution of patient identification cards for healthcare consumers. Cards will serve as portable Personal Health Records (PHRs) allowing individuals to track/monitor their own health status indicators. The cards will hold up-todate demographic information for each patient, resulting in improved operating efficiencies of health facilities' registration processes. These cards will also allow important clinical information to be shared with other providers as patients move around the health care system. 5, % 5 42% n/a n/a n/a n/a 15,800 50% n/a n/a n/a n/a n/a n/a Health Information Exchange Amalga Advanced Analytics A clinical and claims data repository that will provide longitudinal understanding of population health, patient care and improved analytical fidelity in supporting assessment of impacts by care interventions 100,000 5 of 12 HIBC Clinical s Spreadsheet

6 Beacon Communities Program Clinical s Worksheet Wave 2: July - December 2012 Type s Wellogic Decision Support NHCH A SaaS (software as a service) cloud based model capable of exchanging clinical lab and prescription orders, results of the orders (lab results or dispensed drugs), secure messaging between participants, workflow presentation via a web based portal interface and other health information exchange capabilities 30,000 6 of 12 HIBC Clinical s Spreadsheet

7 Beacon Communities Program Clinical s Worksheet Wave 3: January - March 2013 Type Clinical Transformation NOTE: HIBC will begin clinical transformation work in January Hawaii County population estimates include 185,000 total residents of which 120,800 are adults over the age of 18. 9% of adults are estimated to have diabetes, 26% high blood pressure, 18% smoke, 28% have high cholesterol and 26% are obese as reported in the Hawaii County BRFSS results for 2010 and the 2009 Hawaii Primary Care Needs Assessment Data Book. Approximately 25% of our adult population is ed for intervention as some level with various clinical transformation activities. s Practice Re-Design PCMH Coaching HIBC will partner with TransforMED to bring a structured approach to achieving PCMH transformation across the participating provider network. This Rapid Adoption Transformation Model combines adult learning principles, interactive training methods and skillfocused learning through collaborative meetings, ed assessments and site visits. will learn how to lead practice-based teams. Practices will utilize care coordinators as part of the patient-centered team base approach to care and use clinical data from their EHRs and the HIE for decision support and facilitation of care transitions. 50, EMR Adoption/Stage I MU HIBC will provide technical support, education, and training to physicians, in conjunction with Hawai i Pacific Regional Extension Center (HPREC) efforts, to increase EHR adoption and achieve Stage 1 Meaningful Use. 30, Care Coordination HIBC will conduct a 12-month pilot project designed to improve care coordination for complex, chronically ill patients, with a single or combination diagnosis of diabetes, cardiovascular disease and mental health conditions, through a care delivery initiative focused on utilizing care coordinators and patient navigators within the Patient Centered Medical Home (PCMH). Care Coordinators within the PCMH will be proficient in the use of patient registries for identifying high risk patients, developing care plans, monitoring medications, conducting patient and family education, engaging self-management, making referrals to community-based resources and monitoring individual and population clinical outcomes. 1, Hospital Discharge Planning HIBC will conduct a pilot project designed to facilitate care transition initiatives with the three acute care hospitals in Hawai i County. Activities are focused on standardization of a patient discharge summary tool to be utilized across all three facilities. Hospitals will also participate in a training and mentoring program involving Project BOOST methodology designed to improve hospital discharge processes and communications with primary care providers (PCPs) through their care coordinators, long term care facilities, hospice, home health, support/enabling services for populations at risk, patients and their families. 2, % 17 34% 12,080 40% 48 40% n/a n/a n/a n/a West Hawaii Private Practice PCPs plus additional PCPs from East Hawaii No new population of focus. Care Transitions % 10 33% 7 of 12 HIBC Clinical s Spreadsheet

8 Beacon Communities Program Clinical s Worksheet Wave 3: January - March 2013 Type s Patient and Community Engagement PCP/Specialist Communication HIBC will pilot an on-line tool called Doc2Doc to facilitate the referral process and transition of patients from PCP to specialists. Care transitions include any movement of a patient from one care provider or level of care to another, including from emergency departments to PCPs, from doctors to home health, and from inpatient settings to long-term care. The Doc2Doc platform will be evaluated for a more broadly based application as it can be used to initiate, coordinate and manage patient care transitions to completion, and can do this securely from any point A to point B. Enabling Services HIBC will facilitate this care delivery initiative that is focused on strategies for providing patients with resources (e.g., education, self-management skills, transportation, financial assistance, translation) that are culturally appropriate and that care coordinators and hospital discharge planners may partner with to assist patients with services and programs that patients may need to effectively manage their chronic illnesses. Educational programming is focused on diabetes and hypertension management, behavioral health, physical activity and nutrition n/a HEAL Grants HIBC will fund individual community projects focused on reducing behavioral risk factors, improving nutrition and physical activity, and preventing tobacco use to promote better health and increase wellness in communities throughout Hawai i County. These unique, community-based programs will feature community driven strategies to address prevention and health behaviors. They will also provide care coordinators with options for increasing patient engagement in prevention and management of chronic illnesses. 31,600 n/a Smart Cards HIBC will facilitate the implementation and distribution of patient identification cards for healthcare consumers. Cards will serve as portable Personal Health Records (PHRs) allowing individuals to track/monitor their own health status indicators. The cards will hold up-todate demographic information for each patient, resulting in improved operating efficiencies of health facilities' registration processes. These cards will also allow important clinical information to be shared with other providers as patients move around the health care system. 5, % 3 25% n/a n/a n/a n/a 7,900 25% n/a n/a n/a n/a n/a n/a Health Information Exchange Amalga Advanced Analytics A clinical and claims data repository that will provide longitudinal understanding of population health, patient care and improved analytical fidelity in supporting assessment of impacts by care interventions 100,000 8 of 12 HIBC Clinical s Spreadsheet

9 Beacon Communities Program Clinical s Worksheet Wave 3: January - March 2013 Type s Wellogic Decision Support NHCH A SaaS (software as a service) cloud based model capable of exchanging clinical lab and prescription orders, results of the orders (lab results or dispensed drugs), secure messaging between participants, workflow presentation via a web based portal interface and other health information exchange capabilities 30,000 9 of 12 HIBC Clinical s Spreadsheet

10 Beacon Communities Program Clinical s Worksheet Wave 4: 2013 (Ending May) Type Clinical Transformation NOTE: HIBC will begin clinical transformation work in January Hawaii County population estimates include 185,000 total residents of which 120,800 are adults over the age of 18. 9% of adults are estimated to have diabetes, 26% high blood pressure, 18% smoke, 28% have high cholesterol and 26% are obese as reported in the Hawaii County BRFSS results for 2010 and the 2009 Hawaii Primary Care Needs Assessment Data Book. Approximately 25% of our adult population is ed for intervention as some level with various clinical transformation activities. s Practice Re-Design Care Transitions PCMH Coaching HIBC will partner with TransforMED to bring a structured approach to achieving PCMH transformation across the participating provider network. This Rapid Adoption Transformation Model combines adult learning principles, interactive training methods and skillfocused learning through collaborative meetings, ed assessments and site visits. will learn how to lead practice-based teams. Practices will utilize care coordinators as part of the patient-centered team base approach to care and use clinical data from their EHRs and the HIE for decision support and facilitation of care transitions. 50, EMR Adoption/Stage I MU HIBC will provide technical support, education, and training to physicians, in conjunction with Hawai i Pacific Regional Extension Center (HPREC) efforts, to increase EHR adoption and achieve Stage 1 Meaningful Use. 30, Care Coordination HIBC will conduct a 12-month pilot project designed to improve care coordination for complex, chronically ill patients, with a single or combination diagnosis of diabetes, cardiovascular disease and mental health conditions, through a care delivery initiative focused on utilizing care coordinators and patient navigators within the Patient Centered Medical Home (PCMH). Care Coordinators within the PCMH will be proficient in the use of patient registries for identifying high risk patients, developing care plans, monitoring medications, conducting patient and family education, engaging self-management, making referrals to community-based resources and monitoring individual and population clinical outcomes. 1, Hospital Discharge Planning HIBC will conduct a pilot project designed to facilitate care transition initiatives with the three acute care hospitals in Hawai i County. Activities are focused on standardization of a patient discharge summary tool to be utilized across all three facilities. Hospitals will also participate in a training and mentoring program involving Project BOOST methodology designed to improve hospital discharge processes and communications with primary care providers (PCPs) through their care coordinators, long term care facilities, hospice, home health, support/enabling services for populations at risk, patients and their families. 2, , % % 30, % % 1, % % 2, % % Island wide Private Practice PCPs Total 196 By end of project 25% of PCPs achieve PCMH status At least 60% of Island wide PCPs (120 of 196) have achieved Stage I Meaningful Use Minimum 60 PCPs (FQHC and Private Practice) participating in Care Coordination efforts for population of focus. 30 Hospitalists trained in BOOST methodology using standard discharge summary templates focused on Diabetic and CHF patients. 10 of 12 HIBC Clinical s Spreadsheet

11 Beacon Communities Program Clinical s Worksheet Wave 4: 2013 (Ending May) Type Patient and Community Engagement PCP/Specialist Communication HIBC will pilot an on-line tool called Doc2Doc to facilitate the referral process and transition of patients from PCP to specialists. Care transitions include any movement of a patient from one care provider or level of care to another, including from emergency departments to PCPs, from doctors to home health, and from inpatient settings to long-term care. The Doc2Doc platform will be evaluated for a more broadly based application as it can be used to initiate, coordinate and manage patient care transitions to completion, and can do this securely from any point A to point B. Enabling Services HIBC will facilitate this care delivery initiative that is focused on strategies for providing patients with resources (e.g., education, self-management skills, transportation, financial assistance, translation) that are culturally appropriate and that care coordinators and hospital discharge planners may partner with to assist patients with services and programs that patients may need to effectively manage their chronic illnesses. Educational programming is focused on diabetes and hypertension management, behavioral health, physical activity and nutrition. s n/a HEAL Grants HIBC will fund individual community projects focused on reducing behavioral risk factors, improving nutrition and physical activity, and preventing tobacco use to promote better health and increase wellness in communities throughout Hawai i County. These unique, community-based programs will feature community driven strategies to address prevention and health behaviors. They will also provide care coordinators with options for increasing patient engagement in prevention and management of chronic illnesses. 31,600 n/a Smart Cards HIBC will facilitate the implementation and distribution of patient identification cards for healthcare consumers. Cards will serve as portable Personal Health Records (PHRs) allowing individuals to track/monitor their own health status indicators. The cards will hold up-todate demographic information for each patient, resulting in improved operating efficiencies of health facilities' registration processes. These cards will also allow important clinical information to be shared with other providers as patients move around the health care system. 5, % % % 31, % n/a n/a 5, % % Small pilot to test the feasiblity of the Doc2Doc product with a limited number of PCPs and Specialists Enabling services available through special programs designed to assist care coordinators with patient engagement. Includes outreach and number of people/patients touched through HEAL programs and mass media. Small pilot to test the usefullness and practicality of a card style personal health record. Health Information Exchange Amalga Advanced Analytics A clinical and claims data repository that will provide longitudinal understanding of population health, patient care and improved analytical fidelity in supporting assessment of impacts by care interventions 100, of 12 HIBC Clinical s Spreadsheet

12 Beacon Communities Program Clinical s Worksheet Wave 4: 2013 (Ending May) Type s Wellogic Decision Support NHCH A SaaS (software as a service) cloud based model capable of exchanging clinical lab and prescription orders, results of the orders (lab results or dispensed drugs), secure messaging between participants, workflow presentation via a web based portal interface and other health information exchange capabilities 30, of 12 HIBC Clinical s Spreadsheet