UTILIZING ADT NOTIFICATIONS TO SUPPORT POPULATION HEALTH MANAGEMENT 2015 Michigan Rural Health Conference, April 20, 2015

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1 UTILIZING ADT NOTIFICATIONS TO SUPPORT POPULATION HEALTH MANAGEMENT 05 Michigan Rural Health Conference, April 0, 05 Paula Hedlund, Chief Innovation Officer Anne Levandoski, Chief Quality Officer The Overriding Issue to Solve Address Risks Associated with Transitions of Care How do we get information that an unplanned event has occurred? How do we know if discharge instructions are being followed, especially around medications? How do we know if discharge planning is appropriate and reasonable? How do we know what the patient s care plan is, especially to home? Upper Peninsula Health Plan Landscape FAST FACTS 08,000 people, 6,77 sq. miles Represents 5% of the Michigan land mass and only % of the population 5 Facilities ( Critical Access Hospitals) 00+ Provider Clinics Skilled Nursing Facilities 0 different Ambulatory EHR Vendors and 5 Facility EHR Vendors

2 UPHP Population Overview Over 50,000 members: Michigan Medicaid Medicare Special Needs Plan & Advantage MiCHILD Healthy Michigan Plan MI Health Link Duals Demonstration Project UPHP Challenges. Limited visibility to hospital admissions until claims data was received Process to follow-up on members consisted of phone calls No notification requirement for care transitions to post acute settings UPHP Challenges Economic Issues. People/Process Issues Technical Readiness Issues UPHP is 00% at risk for these patients Quality of care for patients Contractual issues specified post-discharge follow-up obligations

3 Scope of Alert Rules How often do we need to send alerts? Who needs to get which alerts? Which high-risk patients? How do we get the alerts delivered? Distribution Frequency How often do case managers need to be notified of each event type (admission, discharge, ED visit)? Distribution Who needs to get the alert? Which alerts will be actionable for each end user? Frequency Focus on Patients Which populations are at the most risk? Which populations can alerts have the biggest impact? Delivery How do we get the right type of alert to the right person? What alert types need almost immediate attention and which ones are informational? Focus on patients Introduce Technology Real Time Alerting ADT Case Manager ALERTING ENGINE Rules Based Logic Customizable Filters DISTRIBUTION Direct Message Daily Digest Application Feed Secure FTP ACRs File - Members to be monitored - Caregivers ALERT Specific Action Plan For a non-ed admission alert: Begin the transition-of-care process by contacting the patient or guardian and discharge planner in the facility and sending the medication list to facility. For ED admission alert: Monitor ED admit, contact member with multiple ED visits and discuss concerns and possible alternatives for care. For a Discharge alert: Contact member to discuss plans for discharge, request discharge instructions and medication list and perform follow-up calls with members one to two days post discharge.

4 Results Increased efficiencies Reduction in phone calls to track down information Timely Care Engagement with 75% of patients within hours, remaining 5% discharged on a weekend within days. Potential Cost Savings Identification of high ED utilizers, patients with readmission risk The Right Alerts to the Right People More effective communication instead of waiting for claims data to determine outcomes Where We Are Heading with Alerting Capabilities MDS ADT CCD ALERTING ENGINE ALERT Risk based analysis of future members by product line New High Value Average cost per ETG (episode treatment group) Diagnosis Based Alerts Service Frequency Based Alerts Calculation of High/Med/Low Alert Care Coordinator Primary Care Provider Ancillary Organizations The Aftermath Lessons Learned Real-time alerts can be overwhelming. Send fewer, but more high-value alerts. Specify the risk attributes to more closely define the population. Make sure care coordinators know what to do with alerts modify workflow.

5 Take Aways This is a real world implementation that, when implemented thoughtfully, actually delivers on the cliché that the right information to the right caregiver at the right time Using Alerts in a meaningful way is very achievable Be ready for the technology don t be afraid to turn it on jump in and try it; you have to be people process ready, but you also have to test it real time in your own environment Next Steps Increased collaboration with facility discharge planners Assist clinics to develop ADT workflow Increase provider awareness of Medicare transition-of-care expectations What to Consider in an Alerting Solution Connectivity in an expansive network Real-time Risk Rating Flexible Methods of Distribution Flexibility in Determining and Planning for Frequency 5

6 Questions 6