ESCO- Information Technology Requirements With An Example of Solutions Pramen Applasamy DCI Application Manager Doug Johnson, MD DCI Vice Chairman of the Board July 15, 2014
15-WEEK WEBINAR SERIES EVERY WEEK AT 2:00PM (EASTERN) WEEK 1 4.15.14 FIRST STEPS IN DECIDING WHETHER TO APPLY AND SELECTING LOCATIONS FOR ESCO WEEK 2 4.22.14 REVIEW OF THE REVISED ESCO RFA WEEK 3 4.29.14 ACCESS SURGEONS WEEK 4 5.6.14 ACCESS SURGEONS WEEK 5 5.13.14 MODEL OF CARE: CKD CARE COORDINATION WEEK 6 5.20.14 MODEL OF CARE: FIRST 120 DAYS WEEK 7 5.27.14 MODEL OF CARE: DECREASED HOSPITALIZATIONS WEEK 9 6.10.14 DEPRESSION WEEK 10 6.17.14 ESCO INFRASTRUCTURE WEEK 11 6.24.14 MEDICATION THERAPY MANAGEMENT WEEK 12 7.1.14 PATIENT ENGAGEMENT WEEK 13 7.8.14 CASE MANAGEMENT PLATFORM(S) WEEK 14 7.15.14 DATA INTEGRATION PLATFORM(S) WEEK 15 7.22.14 AUTOMATED MEDICATION THERAPY MANAGEMENT EVALUATION WEEK 8 6.3.14 MODEL OF CARE: END OF LIFE CARE
15-WEEK WEBINAR SERIES EVERY WEEK AT 2:00PM (EASTERN) WEEK 1 4.15.14 FIRST STEPS IN DECIDING WHETHER TO APPLY AND SELECTING LOCATIONS FOR ESCO WEEK 2 4.22.14 REVIEW OF THE REVISED ESCO RFA WEEK 3 4.29.14 ACCESS SURGEONS WEEK 4 5.6.14 ACCESS SURGEONS WEEK 5 5.13.14 MODEL OF CARE: CKD CARE COORDINATION WEEK 6 5.20.14 MODEL OF CARE: FIRST 120 DAYS WEEK 7 5.27.14 MODEL OF CARE: DECREASED HOSPITALIZATIONS WEEK 8 6.3.14 MODEL OF CARE: END OF LIFE CARE WEEK 9 6.10.14 DEPRESSION WEEK 10 6.17.14 ESCO INFRASTRUCTURE WEEK 11 6.24.14 MEDICATION THERAPY MANAGEMENT WEEK 12 7.1.14 PATIENT ENGAGEMENT WEEK 13 7.8.14 CASE MANAGEMENT PLATFORM(S) WEEK 14 7.15.14 DATA INTEGRATION PLATFORM(S) WEEK 15 7.22.14 ESCO Application Legal Requirements agreements, compliance plan
Agenda Goals Technology Plan Data Integration Platform Sandlot Solutions Current Status Detailed View of Data Integration Examples of other IT solutions Questions
Original Technology Goals
Integrated Care Technology Plan
Data Integration Vendors Considered Sandlot Mirth Covisint ISA Optum Intersystems Caradigm Most vendors $1,000,000 - $2,000,000 over 5 years
Data Integration Platform
Architecture and Data Flow
Detailed View of Data Integration
Expanding Plan to Other Dialysis Providers
Other Infrastructure Patient Engagement Evaluation Patient Outreach Case Management Platform Medication Therapy Management
Review Of ESCO Application In my opinion, it is important to have a plan in place for these areas to allow you to answer certain questions in the RFA, and for CMMI to see that you have the infrastructure in place to operate an ESCO
ESCO Application SECTION C QUESTION 23 Please provide a narrative description of the Applicant ESCO s plan for engaging with beneficiaries and their caregivers. At a minimum, please address the following: Shared decision-making Care transitions Beneficiary education about dialysis care and renal transplant options
C-23 Beneficiary Engagement The CC will use a 13-item PAM assessment, in addition to motivational interviewing, to assess the level of beneficiary engagement critical to shared decision-making. The PAM survey will be administered and a score determined every 90 days and at the time of any sentinel event. By continuously measuring patient engagement, the CC will identify opportunities to improve care for that patient as well as assess quality across groups of patients.
C-23 Beneficiary Engagement One of the tools used in facilitating and measuring the impact of the interaction between the beneficiary and the CC is RoundingWell software. RoundingWell will reach out to beneficiaries twice a week and ask them to complete a brief survey regarding their goals and action steps concerning topics recently discussed with the CC. The CC will be updated on the responses by beneficiaries and, based on this update, the CC can determine the next step to enhance beneficiary engagement in care.
ESCO Application SECTION D QUESTION 26 Please describe the Applicant ESCO s plan to achieve better health, better healthcare, and lower costs through integrated and coordinated care interventions. Please address the following in your narrative: The Applicant ESCO s use of interdisciplinary care teams to coordinate care for patients with multiple chronic conditions; The Applicant ESCO s methods and processes to coordinate care throughout an episode of care and during care transitions, such as discharge from a hospital or transfer of care from a dialysis facility to primary care providers and/or specialists (both inside and outside the ESCO); The Applicant ESCO s use of health information technology; The Applicant ESCO s strategies for improving beneficiary access to care; The Applicant ESCO s development and use of population health management tools; Please describe the Applicant ESCO s plan to incorporate medication management into its care coordination approach; and Additional specific care interventions and tools.
ESCO Application SECTION D QUESTION 26 Please describe the Applicant ESCO s plan to achieve better health, better healthcare, and lower costs through integrated and coordinated care interventions. Please address the following in your narrative: The Applicant ESCO s use of interdisciplinary care teams to coordinate care for patients with multiple chronic conditions; The Applicant ESCO s methods and processes to coordinate care throughout an episode of care and during care transitions, such as discharge from a hospital or transfer of care from a dialysis facility to primary care providers and/or specialists (both inside and outside the ESCO); The Applicant ESCO s use of health information technology; The Applicant ESCO s strategies for improving beneficiary access to care; The Applicant ESCO s development and use of population health management tools; Please describe the Applicant ESCO s plan to incorporate medication management into its care coordination approach; and Additional specific care interventions and tools.
D-26 Use Of Health Information Technology We will use our expertise to improve communication among ESCO partners. We are partnering with Sandlot Solutions to establish a Data Integration Platform, a key component of our HIT solution for the ESCO. Sandlot has extensive experience in implementing data integration platforms for Accountable Care Organizations (ACOs) and will use this in expanding its capabilities to the first specialty ACO. It will be used to create an aggregate view of patient data and to route data among providers. For providers who do not have the ability to interface directly, a web-based provider portal will be available.
D-26 Use Of Health Information Technology One technology that will be offered to beneficiaries is RoundingWell s patient engagement solution. Educational content, discharge reminders, and tailored messaging from clinicians are delivered to patients via Health Check-Ins. Patient responses are applied against proprietary algorithms to identify the early warning signs of risk. RoundingWell then delivers this information into clinician hands to enable them to take informed, clinically appropriate and cost-effective steps to manage a patient s health and avoid adverse events.
D-26 Use Of Health Information Technology The ESCO Assurance MTM program software is integrated directly with DCI beneficiary demographic, medical condition, laboratory and medication files. The MTM software creates an electronic therapeutic record, supports ICT practitioners providing MTM and provides Medicare MTM standard documents and reports.
ESCO Application SECTION D QUESTION 26 Please describe the Applicant ESCO s plan to achieve better health, better healthcare, and lower costs through integrated and coordinated care interventions. Please address the following in your narrative: The Applicant ESCO s use of interdisciplinary care teams to coordinate care for patients with multiple chronic conditions; The Applicant ESCO s methods and processes to coordinate care throughout an episode of care and during care transitions, such as discharge from a hospital or transfer of care from a dialysis facility to primary care providers and/or specialists (both inside and outside the ESCO); The Applicant ESCO s use of health information technology; The Applicant ESCO s strategies for improving beneficiary access to care; The Applicant ESCO s development and use of population health management tools; Please describe the Applicant ESCO s plan to incorporate medication management into its care coordination approach; and Additional specific care interventions and tools.
D-26 Population Health Management Tools The ESCO applies population health management tools in the context of preexisting individual interactions with ESCO members. DCI and RoundingWell developed a case management platform that enables the ICT and CC, as the primary coordinator of care, to identify at risk beneficiaries and opportunities to improve their care. The case management platform: Identifies all beneficiaries with certain high-risk comorbidities, including diabetes and heart disease Identifies all high-risk beneficiaries and all beneficiaries in a transition in care Assigns tasks or interventions, with automated deadlines, to the CC for implementation that will improve beneficiary care regarding high-risk comorbidities, transition in care, or other high-risk activities. Notifies the CC, with periodic reports to the ESCO management team, of those beneficiaries who did not receive the recommended interventions in a timely manner
ESCO Application SECTION D QUESTION 26 Please describe the Applicant ESCO s plan to achieve better health, better healthcare, and lower costs through integrated and coordinated care interventions. Please address the following in your narrative: The Applicant ESCO s use of interdisciplinary care teams to coordinate care for patients with multiple chronic conditions; The Applicant ESCO s methods and processes to coordinate care throughout an episode of care and during care transitions, such as discharge from a hospital or transfer of care from a dialysis facility to primary care providers and/or specialists (both inside and outside the ESCO); The Applicant ESCO s use of health information technology; The Applicant ESCO s strategies for improving beneficiary access to care; The Applicant ESCO s development and use of population health management tools; Please describe the Applicant ESCO s plan to incorporate medication management into its care coordination approach; and Additional specific care interventions and tools.
D-26 Medication Therapy Management All beneficiaries in the ESCO will receive MTM services. The ESCO MTM program is a beneficiarycentered and comprehensive approach to improve medication use via Comprehensive and Targeted Medication Reviews. The MTM program goal is to reduce adverse drug event risk and improve beneficiary adherence to prescribed therapies. The MTM program provides five core services to beneficiaries: monitor medication safety; optimize medication therapy outcomes; medication and chronic condition education; improve access to medications; and assist with care coordination.
ESCO Application SECTION E QUESTION 36 Please explain how the Applicant ESCO will provide high quality care to its beneficiaries while better managing prescription drug expenditures, including Part D expenditures. Please include any plans the ESCO has to partner with Part D plans while preserving beneficiary choice of Part D plans.
ESCO Application E-36 Reach MTM utilizes an interdisciplinary (nurse [RN], pharmacist [RPh], Nephrologist) approach using telehealth (video & phone) technology that facilitates MTM delivery. The principal RPh roles are to conduct comprehensive and targeted medication reviews, create intervention(s) for beneficiaries and providers, and generate beneficiary and provider medication reports. The principal RN roles are to facilitate RPhbeneficiary video conference and facilitate resolution of RPh recommendations with Nephrologists. Weekly interdisciplinary calls are conducted to determine MTM interventions outcome(s). Over the past year, Reach MTM provided services to nearly 400 ESRD patients and made 2857 recommendations to improve their care. Reach MTM recommendations addressed beneficiary medication cost/access issues or medication safety 22.4% and 77.6% of time, respectively. Only 4.3% Reach MTM recommendations were rejected by providers. Reach MTM CMR completion rate is 92.3%; well above national 11.4% average.
QUESTIONS??? Thank you!! pramen.applasamy@dciinc.org Doug.johnson@dciinc.org