Tools for Change: CNY Cares

Population Health Analytics

• Cassie Breen, IT Interface Analyst

• Kris Hebert, IT Systems Analyst

• Michele Jacobson, Project Manager of Data & Performance

• Karen Joncas, Project Manager

• Ebony Pengel, Training Manager

CNY Cares Team

Agenda

• Population Health Management (PHM) Overview

• How IBM Watson Health Can Help• Enterprise Performance Manager (EPM)

• Phytel Outreach (Formerly Known as Engagement Manager)

• Integration Update

• Use Cases• External Data Request Process

• Future Content

PHM Overview

CNY Cares PHM Overview

• A comprehensive approach to identifying gaps in care, filling those gaps, improving outcomes, aligning physicians, coordinating care, and optimizing efficiency.

What is Population Health Management (PHM)?

• Delivery of evidence-based care to patients with clinical, social and behavioral need

What does PHM Enable?

• IBM Watson Health

• Unite Us

What tools are available for PHM?

CNY Cares PHM Tools

IBM Watson Health

Enterprise Performance

Manager (EPM)

Phytel Outreach

Unite Us

CNY Cares Population Health Management Tools

EPM

Measure• NYS VBP and DSRIP measures • Results display by

organization, site, and provider

• Multiple attribution models• Benchmarking• Quality Metrics

Registry• Customizable Patient Lists• Shareable Worklists

Phytel Outreach

Automated Outreach• Connect with patients by

phone, text, or email

Patient Registries • Build using practice

management data and evidence based protocols

• Identifies care gaps and patients in need of services

Quality Improvement• Measure results of the

outreach

Unite Us

Community Based Referral Management Platform• Closed loop referrals• Social and behavioral needs

assessment and care triage• Reporting on service

outcome, program efficacy, and quality

How IBM Watson Health Can Help

Enterprise Performance Manager (EPM)

VBP Readiness Measures, metrics and registries using all consented community data will

allow your organization to have superior insight when negotiating VBP

contracts

Patient List Generation Registries allow your organization to find custom patient cohorts

Care Opportunities Virtual patient chart, measures and registries will allow your organization to

actively identify patients in need of care, or avoid redundant care

Data Governance Aggregation and standardization of data will allow your organization to see

documentation inefficiencies in your own data

Phytel Outreach

Improve quality of care Enhance both chronic and preventive care

Reduce variances in care

Improve financials Optimize staff time

Boost quality-based payments

Support NYS PCMH Patient Engagement

Lower administrative costs Increase efficiency and productivity

Reduce expensive manual errors and oversights

Opportunity for NCQA auto-credit for patient engagement

Improve patient engagement Strengthen the patient-provider relationship

Promote a positive patient experience

Integration Update

Partners

Phase 3 Partner Integrations: Source System Status

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Hospital Primary Care CBO Health Home SNF Rehabilitation Pharmacy

Completed In Process

Phase 4 Additional Integration Partners

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CBO Primary Care

Making IBM Watson Health

Work for You

Why Consent Matters – Shared Community Data

• Use Case #1: John Doe goes to Best Primary Care in Syracuse, New York for

Primary Care Services and Behavioral Health North in Oswego, New York

• As part of pre-visit planning at Best Primary Care, Dr. A, John’s PCP, discovers that

John has been diagnosed with Schizophrenia at Behavioral Health North and has

been taking an antipsychotic medication utilizing IBM Watson’s Virtual Chart

feature

• John has not been receiving the appropriate screenings at either location and has

a history of cardiovascular disease

• Based on the evidence in the virtual chart, John now needs a Diabetes Screening

and a LDL-C test

Note: All Medicaid Claims data is Pre-Consented Data

IBM Watson Use Case Scenarios – EPM – Measure

• Use Case #1: Controlling Blood Pressure

• Numerator: Number of people whose blood pressure is adequately controlled

• Denominator: Number of people ages 18 to 85 years who have hypertension

• Use Case #2: Adult Access to Preventive or Ambulatory Care

• Numerator: Number of Adults who had a visit during the MY

• Denominator: Number of Adults ages 20 – 44 as of June 30 MY

Result: IBM Watson Health will produce non-adherent lists indicating

individuals who may need interventions

IBM Watson Use Case Scenarios – EPM – Registry

• Use Case #1: Creating a Registry of Individuals who have not been seen in the

past year and who do not have a visit scheduled

• Use Case #2: Identification of patients who are diagnosed with diseases but have

not had an annual physical using either “Patient Panel” or “Chronic Conditions”

Registry• Diabetes

• Hypertension

• Hyperlipidemia

• Use Case #3: Identifying eligible individuals who have not had a Mammography

Screening in the past year• Ability to set age parameters to meet your needs

Note: Worklist enables users to create custom registries and share them

amongst other users in their organization

Custom Reports – Emergency Department Visit Counts by

Language• Catholic Hospital System consists of 4 hospitals

• Each hospital has their own EMR (4 EMRs) and

• Each hospital has Primary Care Practices that have their own EMR (4 EMRs)

• Total of 8 EMRs

• Catholic Hospital is unable to view their data all in one system but needs to

understand the demographics of the patients utilizing their Emergency Departments• Catholic Hospital System needs to know how many ED Visits are occurring from refugee

patients, based on language spoken

• Catholic Hospital System contacted CNY Cares to create a custom report utilizing the

integrated IBM Watson Health Data

• CNY Cares was able to provide Catholic Hospital System with the number of patients

utilizing the ED across all 4 hospitals in a single year based on the language spoken

giving them insight into data that was previously unavailable

External Data Request Process

• CNY Cares has the ability to create custom reports to fit your organization’s unique

needs• Utilization

• Demographics

• Attribution

• In order to request a custom report from CNY Cares, please email info@CNY

Cares.org with the subject “Data Request”

• Once received, CNY Cares will evaluate the request by determining whether or not

the appropriate legal agreements are in place, feasibility (if appropriate) then will

assign data sources and timeframe

• Any questions that arise at CNY Cares will be communicated to the partner

• Results will be delivered securely to the partner via CNYCare’s sFTP site

Future Content

EPM – NYS Value Based Payment (VBP) Measures

In addition to the currently available DSRIP Measures available in EPM, CNY

Cares will be adding the following VBP Measures to the platform:

Planned Value Based Payment (VBP) Measures Adolescent Well-Care Visits Chlamydia Screening in Women Prenatal and Postpartum Care

Annual Dental Visit Comprehensive Diabetes Care - Eye Exam (Retinal) Performed

Use of Spirometry Testing in the Assessment and Diagnosis of COPD

Breast Cancer Screening Comprehensive Diabetes Care - HbA1c Poor Control (greater than 9%)

Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents

Cervical Cancer Screening Comprehensive Diabetes Care - Medical Attention for Nephropathy

Well-Child Visits in the First 15 Months of Life - Six Visits

Childhood Immunization Status: Combo 3 -DTAP, IPV, MMR, HiB, HepB, VZV, PCV

Immunizations for Adolescents: Combo 2 -Meningococcal, Tdap, and HPV

Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life

Additional Custom Reports

• CNY Cares will unveil additional reports in the future to help understand and

improve:

• Network Performance

• Quality

• Program Assessment

• CNY Cares Partner Collaboration

• Service Utilization

• Population Stratification

• Social Determinants of Health

CNY Cares Contact Information

• Enterprise Performance Manager – Michele Jacobson: michele.jacobson@CNY Cares.org

• Phytel Outreach – Karen Joncas: karen.joncas@CNY Cares.org

• Training – Ebony Pengel: ebony.pengel@CNY Cares.org

• System Integrations – Cassie Breen & Kris Hebert: cassie.breen@CNY Cares.org;

kris.hebert@CNY Cares.org

• Account Coordination – Brian Moran: brian.moran@CNY Cares.org

• Corrective Action Plans/Security – Rachel Sheley: rachel.sheley@CNY Cares.org

All Contact Information is also listed on CNY Cares’ Website under “Contact Us”

Questions?