john rugge, m.d adirondack health institute · 2011-02-10 · adirondack region medical home pilot...
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Adirondack Region Medical Home Pilot
John Rugge, M.D
Adirondack Health Institute
Patient-Centered Primary Care Collaborative
February 10, 2011
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Demographics
� Population ~ 200,000
� Micropolitan (2)/Rural/Frontier
� Second to SW Florida in Age
� Unusual and Stressed Economy
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The Emerging Adirondack Crisis
Departure of Primary Care Providers
Low Pay Long Hours Grinding Work
Destabilized Health Care System
Hospitals Specialists
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Crisis Response: The Providers
Adirondack Health Institute (AHI)
Private Practices FQHC FQHC Look-Alike Hospital Clinics MSO PHO
Project Manager: Dennis Weaver, M.D. EastPoint Health
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Crisis Response: NY State
Rural Health Network Designation
Antitrust Protection for AHI
Adirondack Medical Home Pilot
2009 NYS Budget Antitrust Protection for AHI/Payers Enhanced Medicaid Payments
Civil Service Commission Empire Plan
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Crisis Response: The Payers
� Blue Shield of NENY
� CDPHP
� Empire Blue Cross
� Excellus
� Fidelis
� MVP
� United Health Care � Medicaid � Medicare
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Crisis Response: The Community
� New York State Association of Counties (NYSAC)
� Adirondack Health Summits (07 & 09)
� Local, State, Federal Officials
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Pilot Goals
� Improve Clinical Outcomes
� Control Health Care Costs
� Improve Provider and Patient Experience
� Enable Retention and Recruitment
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Pilot Design
Care Coordination Pods
Plattsburgh – Integrated Hospital System
Saranac - PHO
Lake George - FQHC
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Pilot Terms
� Five-Year Demo: 2010-2014
� Readiness Assessment & Work Plan: 1/10
� E-Prescribing: 7/10
� Level II NCQA Recognition: 2/11
� “Crossover” Point: Year 3
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Pilot Financing
Enrolled Patients
One E&M Visit in Previous 24 Months Household Members
Continue Existing Reimbursement
Add $7 pmpm
Care Coordinating Teams Physician Compensation
Data Sets
Consider Additional Incentives in Out-Years
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Pilot Data
Focus on 3 Clinical Conditions
Shared Performance Standards
Pooling of Data
Providers and Payers RHIO HEAL - 10
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Pilot Oversight
Governance Council
NYSDOH as Voting Chair
8 Providers (Including MSSNY)
8 Payers
Non-Voting Participants
NYSAC, Legal Staff, Consumers, Public Health, Employers, Service Organizations, Invited Experts
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Pilot Budget
Developmental Investment
$ 85,000 HRSA Project Planning $ 540,000 HRSA Project Development $3,000,000 MSSNY Reg. Pod Capacities $7,000,000 HEAL 10 Electronic Connectivity $8,000,000 Providers Matching Commitments
Operating Revenue/Expenses
$55,000,000 (Estimated) Five Years
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Dennis Weaver, M.D. EastPoint Health
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Physician Practice Support Organizations: “Pods”
Patient identification and payment coordination
Data aggregation and analysis reporting
Quality improvement activities
Chronic disease management • PharmD, Social Worker, Disease Management Nurse
• Care coordination / Case management
• Disease registry management
Transitions of Care
• Hospital to home to primary care
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Clinical Process Flow
Patient ID
and
Stratification
Patient
Outreach
Patient
Follow-up
Clinical Encounter Physician
Clinical Encounter
Non-physician
Patient
Monitoring
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Pilot Participation Requires Measurement
Access to care
Clinical Quality - Evidence based guidelines • Adult – Diabetes / Hypertension / Coronary Disease
• Pediatric – Childhood Obesity /Asthma / Prevention
Efficiency
• Inpatient bed days / ER visits / Formulary compliance
• Risk adjusted total cost
Health Plans & Providers will utilize the same measures!!!
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Abstract View
Payor Data
Warehouse
Health
Plans
6 Hospitals 33 Primary
Care Practices 3 PPSOs
Claims
portal
Clinical quality
portal
Clinical care
portal
ADT, Meds, Lab/rad/departmental reports
(HL7 content)
Claims data flow
Access to web viewer
Web application
Clinical summary info (C32 content)
45 Specialty
Providers Health Plans
2 GFH
Specialty
Practices
EHR Data
Warehouse
(QDC)
Clinical Transaction Content
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Hospital-to-HIXNY Practice-to-HIXNY HIXNY-to-practice HIXNY-to-QDC
• ADT
• Lab/path/micro
results
• Imaging reports
• Current and
prescribed
medications
• Departmental reports
(availability may vary
by hospital)
• Discharge summaries
• NA • C32 content will be
available to Practice
EHR’s for consumption
• EHR vendor
consumption
capabilities are vendor-
specific
• Lab/path/micro results
• Imaging reports
• NA
Note: C32 content for
Practice-to-HIXNY
exchange is per HITSP
harmonized standard.
HIXNY version may
differ slightly.
• NA • Patient demographics
• Language spoken
• Health care provider
info
• Health insurance info
• Allergy/drug
sensitivity
• Problem/condition
• Medications
• Pregnancy
• Information source
• Advance directive
• Immunizations
• Vital signs
• Results
• Encounter type
• Procedures
• Social history
• Comment
• Plan of care
• Family support
• C32 content / HIXNY
Patient Record
• Available through
HIXNY portal
• Patient
demographics
• Language spoken
• Health care provider
info
• Health insurance
info
• Allergy/drug
sensitivity
• Problem/condition
• Medications
• Pregnancy
• Information source
• Advance directive
• Immunizations
• Vital signs
• Results
• Encounter type
• Procedures
• Social history
Clinical Transaction Content Detail
ADT, Meds,
Lab/rad/
departmental
reports
(HL7 content)
Clinical
summary info
(C32 content)
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Cyndi Nassivera-Cordes, RN, CRM
Hudson Headwaters Health Network
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Using Technology to Assist Transformation
� E-prescribing
� Population Management
� Transition Care/Care Management
� Increased Efficiencies � Automated Reminder/Results Calls � Centralized Referrals � Centralized Document Management
� Others in Discussion (Centralized Prescription Refills, Prior Auth, Telephone Triage, and Appt Scheduling)
� EMR Templates � Quality Measurement and Improvement
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E-Prescribing
� Pilot Practices E-prescribing at rates>90% by July 2010
� Most E-prescribing Systems Include Safety and Efficiency Alerts
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Using Systems for Population Management
� Practice Management System Identifies Patients With Upcoming Visits/Important Conditions/Conduct Outreach prior to visit
� Determine Who Would Benefit from Care Management
� Next Step - Incorporate Clinical Details from the EMR to Increase Efficiency
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Using Systems for Population Management
Chronic Condition Flow Sheet � Automatically Pulls in Pertinent Medication and Co-morbidity Information
� Manages Historical Clinical Information
� Outlines Patient’s Goals and Progress
� Patient Self-Management Support Tool
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Using Systems for Population Management
Automated Patient Communication
� Reminder Call/Appointment Tickler
� For Preventive Care Visits/Tests and Follow-up Care for a Chronic Condition
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Preventive Service Clinician Reminder
� Age-Appropriate Screening Tests and Immunizations built into EMR Templates
� Risk Assessment/Social History Based on Age
� Specific Assessments built into Social History Templates (BHS, Cage and Smoker’s Questionnaires)
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Continuity of Care
Transition Care Program
� Hospital Provider Can Access Outpatient EMR
� Follow-up Outpatient Visit Scheduled Prior to Discharge
� Patients Who Can Benefit From Transition Care Coordination (Coleman Model) Identified Prior to Discharge
� Program Reinforced by Hospital Provider
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Continuity of Care
Transition Care Program
� Medication Reconciliation Completed on the Medication List in the Patient’s EMR
� Transition Care Coordinator Documents Patient Interaction in the EMR
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Test Tracking
� Efficiencies in Notifying Patients of Normal and Abnormal Test Results
� Results Call/Patient Portal
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Measures of Performance
� Measure Adherence to the Pilot’s Evidence-Based Treatment Guidelines
� Diabetes � Hypertension � CAD � Preventive Services (pap smear, mammogram, colonoscopy)
� Can be Reported at Multiple Levels � Patient
� Provider
� Health Center
� Network
� Pod
� Pilot