panel: transitions of care and adt (without rachel sherman)
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Connecting Michigan for Health 2013 http://mihin.org/TRANSCRIPT
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Using ADT Feeds to Promote Practice Transformation
June 5, 2013
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Who / What is CareBridge?
Currently support 6 Michigan Physician Organizations and 69 Primary Care Practices in the MiPCT program.
•Red = CIPA•Green = SPHN•Purple = WMPN•Blue = PMC•Yellow = OPNS•Light Blue = McLaren PHO
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Our Technology
• Standardize documentation.
• Scale best practices ADT Pilot.
• Enterprise level reporting use information to improve workflow and make comparisons.
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But Workflow is the KEY
• Technology supports efficiencies with communication, but the key is understanding how to most efficiently USE that information in a meaningful way.
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ADT Pilot
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The result: immediate notification of Inpatient, ER, Observation, SNF admissions from Spectrum Health.
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Meet the Practice Teams:
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Group 1
•3 practices, consisting of 13,000 MiPCT members (5.25 FTE need in Care Managers)•1 full time care manager hired end of January, 2013. •1 half time care manager hired mid-February 2013.•1 full time care manager hired end of May, 2013
Main Challenges:•3 different locations, with not enough FTE support.•New processes, new technology.
Group 2
•2 practices, consisting of 1,250 MiPCT members (1 FTE need in Care Managers)•1 full time care manager hired Q3 2012.
Main Challenges:•2 very different practices, with different technology and processes.•Need for info beyond what comes in the ADT feed.
Group 3
•2 practices, consisting of 8,000 MiPCT members (3.25 FTE need in Care Managers)•4 RNs fulfilling this need, with other duties in the practice.
Main Challenges:•RNs have responsibilities beyond MiPCT work.•Care Manager on maternity leave; just added another Hybrid Care Manager to support the process.•New processes and technology.
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Total Number of Notifications: Group 1
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Percent of Post-Admission Outreach: Group 1
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Total Number of Notifications: Group 2
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Percent of Post-Admission Outreach: Group 2
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Total Number of Notifications: Group 3
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Percent of Post-Admission Outreach: Group 3
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Post-Admission CN #1 - TopicCare Manager Office
Admission Month
Care Assessment
Note
Care Management
Refusal
Case Closure
Follow Up Note
Hospital Note
Initial/Yearly Assessment
Medical Neighborhood
Communication
Patient Education
Record Review
Telephonic Note
Transition Note
Group 1 Jan 1 35
Feb 3 1 112
Mar 1 1 3 86 2
Apr 1 3 1 96 3
Group 2 Jan 1 9
Feb 2 7 7
Mar 1 3 2 1 10
Apr 8 10 12
Group 3 Jan 8 2 10 13 14 4 25 5
Feb 8 7 13 6 1 1 1 14 12
Mar 3 8 2 6 4 8 39
Apr 11 1 1 1 19 14 19
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Record Review / Triage is the major activity for Groups 1 & 2, but Group 3 has a much larger variety of outreach types.
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Post-Discharge CN #2 - Topic
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Care Manager Office
Discharged Month
Care Assessment
NoteCase Closure Follow Up Note Hospital Note
Medical Neighborhood
Communication
Patient Education Record Review Telephonic
Note Transition Note
Group 1 Jan 4 4 9 8
Feb 5 1 22 7
Mar 2 1 5 3 14 11
Apr 3 1 4 3 13 30
Group 2 Jan 1 4 2 2
Feb 1 2 3 2 3
Mar 8 5 3 1
Apr 1 1 1 10 10 2 1
Group 3 Jan 3 6 7 2 1 12 2
Feb 4 3 5 17 6
Mar 2 5 2 2 12 13 4
Apr 3 8 14 6
After triage upon admission notification, the telephonic notes increase dramatically, and the variety of outreach is larger.
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Initial Lessons Learned
• Without the direct flow of information, we wouldn’t have been able to develop these processes.
• BUT, just having the information isn’t enough.
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Still Learning
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The technology allowed us to identify the opportunities in workflow.
Continuing to tackle complexity of integrating processes and patient information amongst care managers, offices, and hospitals • Expectations for follow up• Continuous improvement of workflow• Patient triage: knowing we can’t work with everybody, how
is this completed and documented?• Population management: Case load / frequency of follow-up • Collaborative ‘Lessons Learned’• ‘Value’ metrics in 2Q13: too much information is a bad thing.
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Next Steps• Refine current processes:– Triage & documentation of triage process;– Census and high ED utilization reports – i.e.
identifying which info is most useful for targeting appropriate patients.
• Begin to view transitions of care within the greater processes of the practice – instead of developing the process in isolation.– True population management focus.
• Prepare for expansion of the pilot to other hospital systems and other practices.
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April 12, 2013
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Main focus was to alert primary care physicians and care coordinators to relevant hospital admissions and to improve care coordination through the United Physicians Network
Project Components:◦ Establish Facility Census report for UP Primary Care
Physicians and Care Coordinators from: Beaumont, Crittenton and St. Joseph Oakland Hospitals Augment information with Discharge note
◦ Determine Primary Care Physician if no PCP is identified in ADT message by checking patient information against Patient-Physician attribution lists
◦ Pediatric program – use message to alter pediatricians so they can send CCD (via fax) to Beaumont Peds Unit
◦ Pass message on to MiHIN for St. Joseph Oakland
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Facility Census developed and live on UP portal
ADT feeds from Beaumont and St. Joseph Oakland live◦ Crittenton to go live June 4
ADT messages are being compared to patient – physician attribution and posted in Facility Census for PCP’s
Notification being sent to physicians in box
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# ADT messages◦ 175,000/mo – Beaumont (3 hospitals)◦ 6,250/mo - St. Joseph Oakland
Status of Initial roll-out◦ 213 physicians live◦ 15 United Physicians care coordinators
Roll-out plan for remaining physicians ◦ Approximately 2,000 physicians by end of
September
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ADT message is a standard message, not many issues with establishing feed from hospitals or integrating into structure◦ Other than prioritization
Issues◦ How do you determine which data to pull/filter?◦ Patient – Physician Attribution◦ Integration into practice work flow
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500 primary care physicians = 1.1 million patients in UP population
Participating Plans (attribution lists)◦ Plan Lists Used 106,000
<11% of population◦ Unused Plan Lists 183,000
Still only 26% of population
Needed to determine attribution from other sources◦ PMS feed◦ Registry Information◦ Other sources
◦ UP now has over 84% of patients attributed to a primary care physician
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Physician reaction upon receiving notification…◦ That’s great, what happened?◦ Some patients, it was immediately helpful, but for
many they needed more information
Establishing feed for discharge note to be sent at time of discharge◦ Working with Beaumont, St. Joseph Oakland and
Crittenton on Discharge summary feed
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Some offices have embraced immediately Most offices struggling with integration into
the office workflow
Establishing training to increase physician adoption◦ LEAN LITE
Focus on working with care coordinators or key person within each office
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Original Intent◦ Pediatricians who round on their own patients wanted
their office information better represented on the patient chart
◦ Upon notification of admit, Ped office to pull and send CCD to hospital PROBLEM – who receives the information and what
happens to it? Not consistently applied
New solution◦ Care coordinator in hospital
Key contact for staff Pediatricians Ability to pull/query Ingenium community record Receives CCD from physician office EMR
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Continue roll-out to physician community Add Discharge summary to enhance value
of information Emphasis on improving processes for care
coordination Pass messages to MiHIN
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Anecdotal now◦ YES◦ Pediatric use case◦ Practices assigning staff to oversee reports
What happened◦ Care coordinators
Work with hospitals and physician organization to track reports over time (re-admits, contacts, etc)◦ Do we have any of this information?