using healthix to support dsrip: opportunities and...

Using Healthix to

Support DSRIP:

Opportunities and

Challenges

February 25, 2016

1

Contents

1. Community Care of Brooklyn Overview (2 – 5)

2. Healthix Enablement of CCB IT Strategy (6- 13)

3. Challenges (slide 14)

4. Discussion

Community Care of Brooklyn

2

• Maimonides Medical Center = PPS Lead and fiduciary

• Maimonides Performing Provider System (Maimonides PPS) = a broad

network of health and social services providers, Brooklyn-based

community groups and others

• Community Care of Brooklyn (CCB) = the name of the Maimonides PPS

• CCB is not a separate entity; it is established via Master Services

Agreements (MSAs) between CCB Participants and MMC

• Includes 3,000 providers (including 1,100 primary care physicians) and

more than 300 partner organizations including 6 hospitals, 8 FQHCs, a

number of community-based organizations, other entities

• Governance through committee structure, with consensus-based

approach to decision-making

• Maimonides Central Services Organization (CSO) = team providing

management services to support CCB

CCB Governance Structure

October 2015

Finance Committee

CMS

Information Technology Committee

Care Delivery & Quality

Committee

CCB Executive Committee Nominating Committee

NYSDOH

Maimonides (Fiduciary) Maimonides CSO

Workforce Committee

Compliance Committee

Community Engagement Committee

3

CCB Initiatives / DSRIP Projects

Initiatives Descriptions / Participant Types Status

Create IDS (2.a.i) Overarching, cross-cutting work that will support multiple DSRIP projects, achievement of overall DSRIP goals

Ongoing

Reduce 30-day readmissions (2.b.iv)

Hospital-based program focusing on identifying patients at risk for readmission, effecting linkages to primary, specialty care and social services as appropriate

Launched with key Participants, ongoing rollout

ED Triage (2.b.iii) Reducing the number of low-intensity ED visits; requires availability of accessible PCP services, urgent care, care management and social services support

Launch underway, ongoing rollout

4

CCB Initiatives (continued)

Initiatives Descriptions / Participant Types Target Launch

PCMH + (2.a.iii – HH at risk, 3.a.i – integration of behavioral health and primary care, 3.d.ii – home-based asthma care, 3.b.i – management of cardiovascular disease, 3.g.i –palliative care)

Ensure that PCPs achieve required level of Patient Centered Medical Home (PCMH) designation; early focus on Federally Qualified Health Centers (FQHCs), free-standing Diagnostic & Treatment Centers (DTCs) and larger physician practices

Launched with key Participants, rollout ongoing

Population Health: HIV Access to Care (4.a.iii)

Citywide effort; NYCDOHMH serving as

lead; work focused on ten (10)

interventions to improve screening and

early access to care

Planning underway

Population Health: MHSA (4.c.ii)

Citywide effort; target population is

youth and young adults (ages 12-25);

focusing on school-based health services

to improve MHSA identification and

linkages to care

Planning underway

5

6

CCB IT Strategy

Leverage and build upon previous local, NYS, and

Federal investments in Health IT:

Scale and adapt to the MMC PPS the proven and compliant Care

Coordination platform, available via the internet and interoperable

with Healthix/SHIN-NY, that was established and enhanced by MMC

as part of the HEAL, Health Home, and CMMI HCIA Programs.

Expand and enhance the use of MU certified EHRs for core clinical

data capture and exchange, and promote connectivity to the

Healthix/SHIN-NY infrastructure and participation in state-wide Health

Information Exchange (as a verb) for all Participants in the PPS.

Promote and leverage current and future NYS Health Information

Exchange infrastructure, data, and services including Healthix, the

SHIN-NY, MAPP, Salient analytics, etc.

0

500

1,000

1,500

2005 2006 2010 2011 2012 2014 2015

Jan. 2010: HEAL 10 MMC received funding to develop MHH model and HIT infrastructure; seven stakeholders and South Beach Psychiatric enter into HEAL contracts to

improve care for schizophrenics

2006: Co-location of primary care & behavioral health services at

South Beach

Oct. 2010: Development of

Mental Health Home Standards completed

Jan. 2011: HEAL 17 MMC received additional funding; five stakeholders

added and diagnoses expanded to include

schizoaffective disorder, bi-polar disease and serious

depression

Dec 2011: Health Home MMC designated as

Medicaid Health Home (Brooklyn Health Home), receiving PMPM fee for

IT-enabled, comprehensive care

management

July 2012: HCIA MMC received CMS Health Care Innovation Award to enhance HIT functionality, develop care management

training program and migrate from fee for

service to total cost of care payment model

Care Coordination Platform – GSI Health

Care Coordination Platform

Car

e C

oo

rdin

atio

n

Pla

tfo

rm

Care

Co

ord

inatio

n

Platfo

rm

Speciality Physcians

SHIN-NY/BHIX

SHIN-NY/BHIX

SHIN

-NY

/BH

IXSHIN-NY/BHIX

SHIN

-NY

/BH

IX

SHIN-NY/BHIX

Payer

Homeless Shelters

Correctional Services

Supporting Housing

Organizations

Peer Advocacy

FamilyIntensive Care Management

Providers

SPOA

Public Health Authorites

OASAS/Addiction Services

Social Service Provider

Case Management

Home Care

Patient

Care Manager

Care N

avigator

Psychiatrist

Pri

mar

y C

are

Ph

ysic

ian

Therapist

Soci

al S

erv

ice

s

Specialists

Social Se

rvices

Specialists

2005: BHIX Consortium of

hospitals, nursing homes, home

health providers & insurers

establish BHIX with HEAL NY

funds.

Jan. 2014: HARP Pilot MMC, Brooklyn Health

Home, FEGS and Healthfirst initiate HARP Pilot, integrating a payer into the care model in a

meaningful way

April 2014: DSRIP planning begins. MMC

and Steering Committee of partners organize Community Care of

Brooklyn.

April 2015: DSRIP Q1 begins.

Community Care of Brooklyn initiates

first DSRIP projects

MMC Technology for Population Health

7

8

Adapt PPS Model from BHH Model

Key Feature of the BHH

model: Virtual co-location of providers

and services enabled by

health IT and coordination

of services

9

Care Coordination, Communication, and

Reporting

User Interface/ Dashboard

Platform

Enrollment

Care Teams

Apps

EHR EHR

EHR EHR

Alerts

Messages

Coordinated Care Plan

Patient Engagement

Population Manager

SHIN-NY

Patient Summary/ CareBook

© 2015 GSI Health LLC. All rights reserved. GSI Health LLC and the GSI Health logo are registered trademarks of GSI Health, LLC. All other trademarks are the property of their respective owners.

GSIHealthCoordinator Clinician Engagement

Healthix CCD data

combined with Care

Coordination data

One page summary view

depicting patients history and

current

medical/behavioral/social

issues

Access to platform from MMC

ED EHR system (July)

Continuous care

documentation


10

GSIHealthCoordinator Operational Reports

Assessment Report

Encounters Report

Care Teams Report

Care Plan Issues Report

Healthix Alerts Report

Gaps in Care Report

11


GSIHealthCoordinator Mobile App

Ability to View and Send Messages

Notification for new alerts and messages

Same view and functionality as GSIHealthCoordinator

App available in App Store and Google Play

12


Healthix CENs

(Alerts)

Healthix HISP-HISP

Direct Messaging

Healthix CENs Brooklyn Health Home received Alerts from 25 Healthix connected facilities. Please see the list below for count of Alerts of all types since 9/27/2015, a weekly average of 364.

Facility Total Alerts

Beth Israel Kings Highway 74

Beth Israel Petrie Division 38

Brookdale University Hospital and Medical Center 1179

Forest Hills Hospital 13

Franklin Regional Hospital 16

Good Samaritan Hospital Medical Center 3

HHC Correctional Health Services (Rikers Island) 34

Jamaica Hospital Medical Center 5

Jewish Home Lifecare 1

Kingsbrook Jewish Medical Center 142

Lutheran Medical Center 1028

Maimonides Medical Center 919

Mount Sinai 63

Mount Sinai Sant Luke's Hospital 18

Nassau University Medical Center 1

New York Hospital Medical Center 5

New York University Medical Center 68

NYP/Columbia 30

NYP/Cornell 43

Richmond University Medical Center 30

Roosevelt Hospital 23

Staten Island University Hospital 17

SUNY Downstate 162

The Brooklyn Hospital Center 523

Wyckoff Heights Medical Center 1761

13

Challenges • Funding – CRFP Funds for EHRs and Healthix Connectivity

• Confusion - swirl of vendors, solutions, and mandates • Care Coordination, Predictive and other Analytics, Patient Engagement/Activation,

SMS Text Based Messaging, etc.

• Example - Options and/or Mandates re Care Coordination / Care Plan • My local EHR or Care Plan

• PPS(s) Care Plan(s)

• Planned Healthix Care Plan

• NYS DOH Care Plan (MAPP - Curam)

• Where do I invest my time and money?

• What is the data of record?

• What will really be required and/or provided and when?

• NYS (and national) Consent Policy • Opt-Out vs Point of Access vs Community Wide vs Program Consent

• SAMHSA Requirements and Possible Changes

• Availability and Utility of NYS Claims (MCD/PHI) Data • Channels – Direct vs. MAPP Salient vs. Curam vs. Healthix

• Technical Security and Process Requirements

• Practicality – I can have it, but how can I use it?

14

Discussion

Questions

and

Comments

15

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