Coordination of Care in the Hudson Valley: Shared Problems and Shared Solutions. CHCANYS Annual Conference October 27, 2013

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1 Coordination of Care in the Hudson Valley: Shared Problems and Shared Solutions CHCANYS Annual Conference October 27,

2 Agenda What is a Health Home? Technology Charge Care Plan Development: A Collaborative Process Adding Business Functions Current Status Challenges and Successes 2

3 WHAT IS A HEALTH HOME? 3

4 NYS Health Home Model Purpose: Health Homes (HH s) are intensive care management and patient navigation services for high need/cost Medicaid members. Target populations: chronically ill (including mental health, behavioral health and substance abuse) and at risk for functional decline due to limited social supports and community 4

5 Health Home Population in NYS More than five million Medicaid members in New York State 805,000 individuals meet the federal criteria for HH s Target enrollment for NYS is 446,000 (prioritizing for highest risk) There are 32 HH s serving 5

6 Health Home Networks Health Home Networks include 2 categories of providers: Care Coordination Agencies CCA s directly provide care coordination services; may have special areas of expertise: HIV/AIDS, primary care, substance abuse, other areas. Network Providers - all other entities that provide Medicaid covered services. They do not directly receive funding for HH care coordination, but serve as a 6

7 Stakeholder Priorities re: IT Promote sustainability of HH's Develop Infrastructure to link to statewide network State Lead HH Agencies Leverage existing technology Reduce administrative spend Ensure regional coverage for membership Partner w/ HH's that can support sound business practices Minimize MCO administrative burden MCO CMA Ease of use Single sign on Reduce administrative spend 7

8 TECHNOLOGY CHARGE 8

9 IT Expectations HIE interoperability across provider network Health home providers will make use of available HIT and access data through the regional health information organization/qualified entities... as feasible Health home provider commits to joining RHIOs or qualified health IT entities for data exchange and... to share information with all providers 9

10 IT Expectations Development Challenges No start-up funding to Health Home for technology No clear definition of provider network, no funds flow to partners to encourage interoperability with HH Lead Agency Chaotic vendor environment re: Care Plan functionality Adoption by primary care providers using EMRs, duplicative functionality Evolving NYS requirements 10

11 Existing HIE IT Expectations Multiple RHIOs statewide, in various stages of development SHIN-NY on the horizon 11

12 IT Expectations 12

13 Health Home Infrastructure Options Sponsored Non- Aligned Hybrid HH Network wholly owned / capitalized partnership developing administrative platform Multiple HH's w/in a region, developing separate infrastructure Regional HH's building shared administrative platforms CMAs required to be dedicated providers to one entity CMAs participate in multiple HH's requiring data input into multiple platforms CMAs utilize standard single-sign on portal 13

14 CARE PLAN DEVELOPMENT: A COLLABORATIVE PROCESS 14

15 Care Plan Development: Collaboration THINC recognized the need to act as neutral convener of the 3 Lead HH agencies in the region given significant provider overlap Strong interest in leveraging what had already been created within region Understanding of the value of Care Plan as an integral component to comprehensive care Raised possibility that THINC, with NYeC, could incorporate some basic elements 15

16 Care Plan Development: Collaboration Spring 2012 Clinical Committee, HVCC representatives: TCM, COBRA, MATS, Housing, CIDP, FQHCs, local government units (depts. of health) Social workers, counselors, RN, MD, admin Charge: Identify essential elements of a Care Plan Reach patients/families, social service agencies, BH and medical providers, 16

17 Care Plan Development: Collaboration Late 2012, building on Clinical Committee work, THINC convened 3 Hudson Valley HH Lead Agencies HITCH, an independent 501c3 developed by regional FQHCs to promote effective use of IT in the region, facilitated multidisciplinary workgroup to achieve consensus Create documented functional specifications to enable development of 17

18 Care Plan Development: Scope of Care Plan Collaboration Create a Bolt-On to THINC Clinical Viewer, to be developed by NYeC Quick, low-cost, limited to essentials; expected to evolve over time Not an EHR, not a billing system, not a care management system 18

19 Care Plan Development: Collaboration Administratively Effective Eliminate multiple data entry points across competing Health Homes Eliminate staff training on multiple systems Reduce costs associated with licensing multiple systems Ensure efficiency/consistency of software updates 19

20 Care Plan Development: Collaboration Focus on Users Recognize, but minimize duplicate data entry for care managers Foster use by medical providers who primarily use an EMR: 1-page Summary Care Plan Enable Care Managers to contact providers Learn from each other: workflow, patient challenges, staff skills 20

21 Care Plan Development: 4.0 System Features 4.1 Searching for and Finding Patients Collaboration Discussion Support assignment of HH patient to CM HH administrator role 4.2 Creating SCP Within a patient record, support certain elements being selectively entering from CV into SCP; enable overwriting of CV data 4.3 File Sharing and Attachments Support electronic storage of at least 10 intake assessment tools and respective results for up to 25 administrations 4.4 Discussions & Communication Enable CMs to pose questions to providers that appear when provider accesses summary page of SCP for patient Smart-Import function The assessments should appear as a tab on the SCP. Handle this with a comment to provider/pcp field 4.5 Data Display For patient problems, goals, and SMART goals, support display as summary with ability to easily access supporting detail. 21

22 Care Plan Development: Collaboration As part of Care Plan development process: Documented functional requirements provided to NYeC, who iteratively produced a full set of design slides Beta product developed Functionality can be deployed within Clinical Viewer to share clinical care plans among HIE users 22

23 ADDING BUSINESS FUNCTIONS 23

24 2013 Environmental Scan HH also requires business functions, i.e., to handle administrative data in a way that a system designed for clinical information cannot; similar to the difference between an EHR and a billing system. Examples include roster management, tracking billing triggers, and effecting payment. Funding pooled OMH TCM grant funds across region to support development of 24

25 The Hudson Center Not-for-profit, health care technology company, incorporated in 2005 Local Hudson Valley vendor, familiar with the needs of a range of stakeholders Historical understanding; linkage to a NYS managed care plan and CIDP provider Current understanding; remains up to date with ever changing rules, regulations and needs of the Health Home program 25

26 Hudson Center Overview Core competencies broad functional and industry knowledge agile software development methodology experience creating custom technologies for public benefits NY State and third party system integration system compliance with state and federal regulations as requirements are modified expertise in providing HIPPA compliant transactions 26

27 System Overview Insight Plus Web Based application with 3 modules Health Home Administrator Care Management Administrator Care Manager Designed to integrate with existing systems, built on the NYS model Collaborative design; involved Health Homes, Health Plans, Care Management Agencies & Care Managers 27

28 Insight Plus Interface with Clinical Viewer/HIE Goals Automate roster functionality Automate member tracking Reduce or eliminate double data entry Track Health Home CMART measures Manage billing to NYS and intra-agency Intuitive Care Plan development 28

29 Care Manager View Dashboard Reports View into Acuity Status of members; enrolled v. outreach Manage & Track ticklers Identify members without recent 29

30 Detailed Roster Management Document Outreach Document consent Complete required assessments Establish care team Establish & Share care plan 30

31 CURRENT STATUS 31

32 Insight Plus Roll Out Insight Plus goes live by year end 2013 Adheres to state HIT standards HIE Access Care Plan will be consolidated in a CCD A to enable access via the THINC HIE, estimated January 2014 A second phase with enhancements is contemplated Continued effort to work with all RHIOs throughout NYS 32

33 HIE/Insight Plus Integration Care Plan CCD from Insight Plus will be accessible here. 33

34 CHALLENGES AND SUCCESSES 34

35 Challenges and Successes Challenges Lack of infrastructure funding Uncertain state and national HIE environment Tight timeline: imminent distribution of Health Home patient rosters Transition from competitors to collaborators 35

36 Successes Challenges and Successes Think from the perspective of the stakeholder IT vendor with skin in the game Multidisciplinary, multi-stakeholder, regional collaboration to solve a common problem Transition from competitors to collaborators 36

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