Imagining Seamless Information Flow: Bridging the HIE Gap and Making Care Coordination Reality AJ Peterson: GM, CareConnect Larry Seltzer: GM,

Transcription

1 Imagining Seamless Information Flow: Bridging the HIE Gap and Making Care Coordination Reality AJ Peterson: GM, CareConnect Larry Seltzer: GM, CareManager Jerry Dolezal: CIO, Optum BH-Pierce County

2 Agenda Capabilities of the CareFrabric and how Netsmart is meeting Care Coordination requirements Industry Requirements around health information exchange Closing the loop between lab orders and results while improving efficiency and accuracy through automation What healthcare organizations have implemented in production environment to support health information exchange and care coordination Understanding how care coordination features are integrated into CareManager How integrated care will improve the quality of treatment for the consumer

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4 What is Health Information Exchange? The term "health information exchange" (HIE) actually encompasses two related concepts: Verb: The electronic sharing of health-related information among organizations Noun: An organization that provides services to enable the electronic sharing of health-related information Source:

5 Electronic Health Records & Health Information Exchange More than half of doctors now use electronic health records ACA envisions a system where records are electronic and can be readily exchanged among providers Important functions of health information exchange include: Promote coordinated care Improve safety Improve efficiency of care delivery Provide more complete patient record Reduce administrative costs and burdens Further communication between providers Promote use of data pooled across clients to improve outcomes Federal government has actually put in place incentives to promote the adoption and use of electronic health records Currently, behavioral health care providers aren t eligible for those incentives 5

6 Healthcare Landscape Complexity Hospital 1 Provider B Hospital 2 Provider A Syndromic Registry State Lab FQHC Reference Lab Health Home Immunization Registry HIE 1 HIE 2

7 Care Connect- What is it? CareConnect combines the body and the mind. Data is pulled from all sources to show a complete view of the client. (Data Exchange) CareRecords (myavatar, MIS, TIER, Insight,myEvolv) to communicate clinical data from the provider to another entity and back again. Security using encryption and rigorous authentication that protects the private health information of the consumer. Providers can send Continuity of Care Documents (CCDs), secure messages, referrals, or other consumer clinical data to participating organizations. Exchange data with an unlimited number of HIEs, hospitals, Health Homes, providers, RHIOs, etc. while maintaining a single connection Improve treatment outcomes through increased knowledge of a consumer s entire care plan

8 Beacon Community Netsmart Clients TIER, Avatar, Insight. MIS, Evolv Non-Netsmart EHRs Community Practice Lab Results Lab Orders Out Reportable Labs CCD & Referrals Immunization Syndromic Surveillance Federal Agencies Labs CareConnect Integrated Delivery System Health Information Organization Health Center Network Image Source: 8

9 Creating Simplicity Provider B Hospital 1 Hospital 2 Provider A Syndromic Registry State Lab FQHC Reference Lab Netsmart CareConnect Health Home Immunization Registry HIE 1 HIE 2

10 Lab Results & Order Interface Purpose Provide a Lab Interface which empowers our clients to receive their lab results electronically and upload them directly to the system seamlessly, when the order is placed in the CareRecord. Value CareConnect Labs reduces the cycle time and cuts the cost of delivery by reducing or eliminating the expense of paper, Tele-printer and courier distribution with our automated ability to integrate orders and results into the consumer s chart via the CareRecord.

11 Example Flight Path of a Lab Results/Orders Lab ABC Results Orders Netsmart CareConnect Results Orders Lab XYZ OrderConnect Orders Results CareRecord

12 HIE Query Infrastructure Five main concepts: 1. Community a tightly coupled group of sources of clinical information 2. Registry listing of all the documents in the community and what patient ID they belong to 3. Repository storage of the documents, can be one for the whole community or one at each source 4. Patient Identity Actor master person index 5. Gateway technology to talk outside the community

13 Query for Patient History HIE Patient Found Clinic CareConnect HIE Patient Not Found Patient Provider 1) Provider see s a new patient in the clinic 2) Provider sends out a patient discovery request for information about the patient 3) Sources that know the patient respond 4) Provider queries for patient clinical information 5) Sources respond with clinical document(s), typically CCDs HIE Patient Found BH Facility

14 HIE Model BH Avatar BH Avatar BH Avatar Primary Care BH Avatar CareConnect HIE BH Avatar HIE A Non-Avatar Hospital BH Avatar BH Avatar BH Avatar HIE B Clinic

15 HIE Connections 9 HIEs Live 5 HIEs in Development 6 HIEs in Planning 137 Hospital System 2,390 Provider Connections 14 Million Consumers

16 HIE Models Direct Connections CareConnect Referrals Transitions of Care Lab Results Immunization Registries Secure Messaging Distributed Consent..

17 1. Push Based Referrals and Transitions of Care 2. Increase Data to Include Behavioral Health Data 3. Implement Point of Care Consents for Query 4. Embed Netsmart into their Systems CareConnect

18 Larry Seltzer, Netsmart Jerry Dolezal, Optum BH CARE COORDINATION

19 Public Health Social Services Substance Abuse Population Health Analytics Claim Processing CareConnect Individual HIEs & RHIOs Primary Care Provider Management Care Management / Coordination Developmental Disabilities / Behavioral Health Primary Care

20 Provider Portal Individual Portal Consent Enrollment Assessments Coordination Plan Referrals Outcomes Analytics Outbound Claims Authorizations Inbound Claims Clinical Registries Provider Registry Treatment Guidelines Decision Population Based Support Evidence Utilization Management Case Management Clinical Research Individual Inpatient MH Facility CMHC Local Health Dept. Social Services Substance Use PCP Hospital Pharmacies HIEs Medicaid Medicare BC/BS MCO Insurance

21 Coordinated Behavioral Care Health Home Enrollment Demographics CBC Care Management Agencies Assessments Notes Care Planning Brooklyn Queens Manhattan Bronx Staten Island BH Provider(s) Inpatient MH Facilities Social Services Hospital(s) PCP(s)

22 Pilot Care Coordination Project Behavioral Health Physical Health Care Coordination Care Management Agency Care Coordination Plan Problems Objectives Interventions Healthix Health Information Exchange Care Coordination Care Management Agency Care Coordination Plan Problems Objectives Interventions CM CC Supporting workflow of Behavioral Health Supporting workflow of Substance Abuse Exchanging both Physical and Behavioral Health data Exchanging CDA electronically (Care Coordination Plan)

23 Washington State Health Home OPTUM BEHAVIORAL HEALTH

24 Optum Health Home Region 4 Region 5 Region 7 Seniors > 65 Behavioral Health Adult Chronic Physical Children Seniors > 65 Behavioral Health Adult Chronic Physical Children Seniors > 65 Behavioral Health Adult Chronic Physical Children CM Care Management Agencies by population Regions exist across Washington State CC Exchanging both Physical and Behavioral Health data All Care Coordination Agencies will utilize CareManager

25 MEDICAL HOME MODEL HEALTH HOME MODEL Focus on medical care coordination & community referrals Coordination of cross-system health care, long term care, behavioral health, & social service delivery Focus on payers High risk / high cost Medicaid & Dual population Includes all systems to facilitate care

26 THE GAME Overview of WA Health Home Allows the individual to be in control of improving their health & quality of life Get the right services PLUS at the right time & right place Provides the ability & supports to better manage their health Designed to address individuals with complex care needs

27 Fundamentals of WA Health Home Engagement High touch services Identify gaps in care Predictive Risk Intelligence System Self Manage Patient Activation Measure Health Action Plan Beneficiaries communication Care Transitions---Discharges from all Institutions

28 THE PLAYERS--BENEFICIARIES Available to all persons who have a chronic illness who are enrolled in Medicaid or Medicare/Medicaid. Who are at significant risk for health issues & have a PRISM score of 1.5 or higher. Who have had two or more hospitalizations in the last 15 months Identified Chronic List Mental health condition Substance abuse disorder Asthma Diabetes Heart disease Cancer Cerebrovascular disease Coronary artery disease Dementia or Alzheimer s disease Intellectual disability disease HIV/AIDS Renal failure Chronic respiratory conditions Neurological disease Chronic pain associated with musculoskeletal conditions

29 THE PLAYING FIELD -- Structure LEAD ENTITY Consists of networks of organizations that provide Health Home services An organization (like Optum) that is accountable for the administration of the Health Home Contracts with the State as a qualified Health Home Subcontracts with organizations that provide direct Health Home care coordination Administers the provider network CARE COORDINATION ORGANIZATION (CCO) Coordinates care & health promotion for Lead Entity Implements systematic protocols to ensure the beneficiary receives follow-up care after discharge Monitors care outcomes Ensures timely treatment & access to avoid unnecessary ED Optum s CCOs are: Multicare Health Systems Catholic Community Services Greater Lakes Mental Health Area Agency of Aging

30 HEALTH HOME LEAD ENTITIES HIGH COST / HIGH RISK POPULATIONS Broad-based regional provider networks Contracted to the State as a Qualified Health Home Subcontract with local/regional organizations that provide all Health Home coordination services Healthy Options Medicaid Managed Care Medicare/ Medicaid-Fee for Service (DUALs) Medicaid-Fee for Service CARE COORDINATION ORGANIZATIONS (CCOs) Conducts screenings for health risks & referral needs, education & coaching, assists with transition care, person-centered health action planning, facilitates communication across service providers. G O A L S Access to the right care at the right time & place Improve ability to self-manage chronic conditions Improve health outcomes Reduce avoidable costs Coordinate care across medical, mental health, chemical dependency & long term services & supports SERVICE DELIVERY SYSTEMS Primary Care Mental Health Chemical Dependency Hospitals Long Term Care

31 CareManager Deployment OPTUM Multicare Health System Catholic Community Services Greater Lakes Mental Health Area Agency of Aging INPATIENT MH FACILITY CMHA LOCAL HEALTH DEPT SOCIAL SERVICES SUBSTANC E USE PCP HOSPITAL, ED HIE (EDIE)

32 THE GAME The Innings HEALTH GOALS SET ENROLLED HEALTH ACTION PLAN SHARED WITH SVC PROVIDERS SUPPORT ATTAINING GOALS CARE COORDINATED PROGRESS MONITORED & PLAN UPDATED HEALTH IMPROVES GOAL EMPOWERED BENEFICIARIES WHO SELF-MANAGE THEIR OWN CHRONIC CONDITION Umbrella of integrated services For disadvantaged & chronically ill members of society Provides care coordination w/ community services Brings together silos of physical & behavioral health care Reduced duplication & fragmentation of care Improved outcomes & reduced costs

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34 HCA ELIGIBILITY LIST LOAD OPTUM NURSE COORDINATES SMART ASSIGNMENT CCO IMMEDIATE NOTIFICATION BENEFICIARY CCO CCO RECEIVES ASSIGNMENT NURSE CARE COORDINATOR ASSIGNMENT BENEFICIARY ENGAGED SURVEYS & ASSESSMENTS STRENGTH & OPPORTUNITY LIST CREATED CC COMPLETES HAP CC CARE REFERRALS CC DOCUMENTS CARE CC UPDATES HAP COORDINATED CARE CC ACTIVITIES DISCHARGE

35 BATTING AVERAGES Outcomes 1. Increase beneficiary engagement levels 2. Improve patient outcomes by mobilizing & coordinating primary medical, specialist, behavioral health, & long term care services & supports 3. Reduce preventable hospital admissions & re-admissions 4. Reduce avoidable emergency room use 5. Provide timely post discharge follow-up

36 BATTING AVERAGES Box Scores Payment Calculations Productivity Reports Health Home PLUS System QA Review UM Review Outcome Monitoring HCA State Reporting

37 Q & A For any questions about the webinar or issues accessing the slides and recorded presentation, feel free to Ben Jacoby, Marketing Programs Manager, Netsmart, at bjacoby@ntst.com