Advancing Care Coordination and Integration between ...

[Pages:4]Advancing Care Coordination and Integration between Community Health Centers & Hospitals to Achieve the Triple Aim

Project Summary: ALLIANCE FOR RURAL COMMUNITY HEALTH (ARCH)

Project Lead: Carol Mordhorst Phone: 707-462-7264

Email:carolmordhorst@

1. Project Goal: To advance care coordination and integration between community health centers and hospitals to Achieve the Triple Aim. This project will build IT interfaces and infrastructure needed to improve quality and cost effective services as well as to support ARCH member clinic's participation in high risk/high cost patient care management (including Partnership Health Plan's programs and/or other care coordination/care management initiatives). The focus of this project (the Linking II Project) is to create IT and workflow solutions to facilitate better care coordination among member clinics and Adventist Health hospitals. Once created, this IT and workflow infrastructure will allow expansion of care coordination/care transition activity between other ARCH clinics and Adventist hospitals.

2. Project Rationale/Needs Statement: The primary care safety net in rural Mendocino County continues to struggle with effective exchange of health information between providers as well as during transitions of care for our patients. While all ARCH members utilize an Electronic Health Record, each clinic is at a slightly different stage in the meaningful use of its EHR.

This is an important issue for ARCH and the broader community of providers which includes our member clinics, private practitioners, specialists, and hospitals. Transmission of hospital records effectively into clinic EHRs is critical for treatment planning and data reporting, now required of all ARCH members due to meaningful use and patient centered health home standards. ARCH's member clinics provide care to more than 50% of the county; 57% of whom have incomes at less than 200% Federal Poverty Level (FPL).

In comparison, there are three hospitals that provided inpatient services for 6,650 discharges, surgical services to 2,372 inpatients and 6,513 outpatients, birthing services for 1,066 infants, and 42,370 emergency services. Current processes allow record transmission only during clinic business hours and there is no capacity to meet the need of the hospital for 24/7 access. Hospital staff needs access to primary care records, especially for the low income, vulnerable population of ARCH's member clinics. With over 15% of the population being elderly and approximately 40% having income at less than 200% FPL, there are significant health disparities present including heart disease, chronic respiratory disease, and cancer. Mendocino County is ranked 43 out of 58 counties for all three diseases in 2012.

As a result of these health care siloes, we are mired in a system with redundant diagnostic tests, treatment delays, poor care coordination, and serious treatment mistakes; all leading to frustration, high costs, and poor health outcomes for our patients. Sources: US Census 2010, CA County Health Status Report, and OSHPD reports.

3. Description: The Linking II Project

Is this a new project, a pilot or expansion of an existing program? This project is an expansion of an existing program. Previous efforts were to connect Mendocino Coast Clinics with Mendocino Coast District Hospital and the Veterans Administration.

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The Linking II Project is the logical next step in ARCH's evolution of supporting and strengthening its members' capacity to provide access to quality health care and to evaluate data. Through the continuation of ARCH's work in health information exchange, vital clinical content will be securely available at the point and time of care for our patients. This information will transform our currently siloed practices into an efficient integrated delivery system which can actually reduce inappropriate emergency utilization and inpatient re-admissions; effectively meeting the goals of the Triple AIM for better care, better health, and lower cost.

4. Project partners and roles: The Alliance for Rural Community Health is the project lead and partners include the ARCH member clinics and the Adventist Health System including Ukiah Valley Medical Center and Howard Memorial Hospital. Adventist Health and their two hospitals will provide staff and support to achieve interoperability with their IT system. Some of the member clinics staff or technical support consultants will work with the hospitals to achieve the interoperability with their clinic EHRs. Some ARCH members will not be connecting with Adventist Health, but will participate in the learning sessions, training to improve data collection and analysis and discussions to improve communication and data exchange whether it be by use of technology or systems redesign.

5. Do you have health plan partners? If yes, what is their role? Partnership Health Plan of California (PHC) has provided baseline information on its enrollees. Furthermore, PHC has offered to assist with special data reports to support the evaluation of the project.

6. Describe your target population

How do you define your target population? The target population is the entire patient populations at the clinics.

What data/algorithms will be used? Due to the fact that we have baseline information specifically on the Partnership Health Plan of California (PHC) enrollees, we will be using them as an indicator to measure improvement in data sharing, utilization, reducing costs and improving the patient experience.

7. What is your intervention or model to be implemented?

Part of the purpose of the data exchange is for the clinics to receive timely information from the hospital for patients that have been admitted or utilized the emergency department. Each clinic is encouraged to contact their patients after discharge to reconcile medications, provide them with a follow up appointment and educate them about clinic hours of operations to encourage the patient to seek care at the clinics rather than the emergency department. Accurate data collection for labs, radiology and other hospital based services will help to avoid unnecessary duplication of tests and services.

Roles/types of staff involved both at hospital, clinic, and health plan. Clinic staff involved may include the IT staff, Electronic Health Records staff, quality improvement staff and clinical staff if needed. The hospital staff will include the IT departments and others as needed or appropriate. The health plan staff will include the district office of Partnership Health Plan and the Quality Improvement staff of PHC. PHC has committed to assisting with special data reports to measure the outcomes for this project.

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8. How is data sharing done? (Please describe both low and high tech approaches you will use for data sharing). This project will include building interfaces between the clinics and the hospitals. In addition, it may include the implementation of a secure e-mail system to allow for data sharing between the clinics and the hospital but will also allow for sharing information with other providers such as specialists.

When/how often is data shared? There are 8 member clinics of ARCH and each are in different situations. Some have access to a provider portal to obtain certain hospital services results while other reports are received by fax. A couple of the clinics have a unidirectional interface in place to receive lab results but more work is needed to transport additional reports such as radiology and discharge reports. All clinics desire to move to bidirectional interfaces with Adventist Health so lab and x-rays may be ordered and the reports received electronically. Some clinics also have remote access to the hospital system that collects the emergency department and admission/discharge reports while others do not.

What type of staff is involved in data sharing among project partners? Currently, most of the data sharing involves the medical records staff, care coordinators, EHR staff, medical assistants and quality improvement staff. IT staff or consultants have been involved in previous interface efforts.

9. List outcomes you will measure: a) Triple Aim measures: - Health/utilization: - Cost of care: - Patient experience: 1. Daily count of AHS discharge summaries received at ARCH member clinics for clinic patients treated at AHS 2. Daily count of Continuity of Care records sent to AHS from ARCH member clinics 3. Health/utilization outcome metrics will focus on the impact of effective HIE on the following: Reducing inpatient days Reducing readmission rates within 30 days of previous discharge Reducing avoidable emergency department visits for Medi-Cal and identified high risk patients at ARCH member clinics

b) Other outcomes?

1. Bi-monthly meetings of ARCH Quality Improvement Committee (serving as the stakeholder committee for the Linking II Project)

2. Progress of key activities and completion within scheduled due dates 3. Reflective staff interviews at participating facilities to determine further workflow

optimization opportunities (both technology and non-technology), and to gather anecdotal observations on the relative clinical value of the Linking II Project.

10. Goals you aim to achieve by April 2015:

1. By May 31, 2014, complete a project plan to support interface development between ARCH members and Adventist Health Systems.

2. By August 31, 2014, complete purchase and installation of interfaces and begin technical assistance to ARCH members and Adventist Health Systems.

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3. By December 31, 2014, complete successful tests of exchanging clinical data between ARCH members and Adventist Health Systems.

4. By February 28, 2015, complete an evaluation of the interface services between ARCH members and Adventist Health Systems; document best practices discovered during the project; and complete dissemination of results plan.

5. By March 31, 2015, complete assessment of next level of HIE needs for ARCH members.

6. By April 30, 2015, apply and integrate interfaces into a care coordination pilot with 100 Partnership Health Plan patients at one or more ARCH clinics.

7. By June 30, 2015, participate in two web-based and two in-person meetings as part of a Foundation-sponsored learning community.

11. Do you anticipate any challenges?

Health information technology planning and deployment projects between unaffiliated entities continue to carry risk of unanticipated outcomes. Some of the significant challenges anticipated as well as some of the lessons learned from the initial Linking Project include the following:

1. Software upgrades often result in a need to re-map exchanged health information. 2. Reporting requirements continue to evolve resulting in an ongoing evolution of health

information needing to be exchanged. 3. Technology continues to evolve resulting in opportunities to further improve integration

platforms. 4. Despite strong leadership at participating facilities, excellent clinical sponsorship, and an

appropriate software design; resistance to workflow change among facility staff and/or staff turnover may disrupt adoption. 5. Currently, there exists a misalignment of the timing for Meaningful Use incentives for primary care providers and hospitals resulting in a prioritized need for one partner which isn't necessarily as prioritized by the other partner. 6. The paradox of change: if the use of HIE services to integrate a safety net primary care practice and the ED is too successful, it may reduce the overall need for diagnostic testing or ED services, resulting in reduced net revenue for the hospital partner, a risk borne entirely by the hospital.

12. What would you like to learn about/discuss at the first in-person Learning Session?

1. Because we have five different EHRs in place (Next Gen, E Clinical Works, Cerner, RPMS and Practice Fusion) it would be helpful to know if any other projects have information on interface challenges/solutions.

2. Sharing of best practices on data sharing (electronic data sharing and systems flow).

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