Health Care Delivery System Transformation …the Adirondack Experience www.facebook.com/adirondackhealthinstitute www.adirondackhealthinstitute.org
Today’s Panelists Colleen Florio, PhD, Director Brenda Stiles, RN Care Team Manager, Medical Home Kati Jock, Director Strategic Planning & Network Development
Today’s Agenda Adirondack Population Issues ADK Region Medical Home Pilot Health Home ACO DSRIP & the “Performing Provider System”
Mission: To promote, sponsor, and coordinate initiatives and programs that improve health care quality, access, and service delivery in the Adirondack region. www.facebook.com/adirondackhealthinstitute www.adirondackhealthinstitute.org
Adirondack Population • Older than State Average • Poorer than State Average • Greater Chronic Disease Burden • Rural & Mountainous – Travel – Communication
Multiple HPSAs: PC, Dental, MH
Collaboration = Key
ADK Region Medical Home Pilot Goals • Improving Physician Satisfaction and Retention • Improving the patient experience of care (including quality and satisfaction) • Improving the health of the populations • Reducing the per capita cost of health care IHI Triple Aim Plus
Transforming Care in the Adirondacks Case in Brief: Adirondack Medical Home Pilot • Five-year pilot to generate health care value in Adirondack region of Northern New York • Key objective is to transform physician practices into NCQA recognized medical homes • Launched in January, 2010; previously codified by New York state legislature in 2009 • Supervised by both New York Department of Health, Department of Insurance http://www.adkmedicalhome.org/ 4 Business Confidential: Not for distribution without permission of AHI
Engaging a Multitude of Stakeholders Pilot Includes Government and Commercial Payers Providers Payers 97 physicians and All 7 commercial payers, 127 MLPs spanning Medicare, Medicaid 33 individual practices Adirondack Medical Hospitals Patients Home Pilot 7,000 Square Miles 5 hospitals and health Population 200,000 7 eMR Vendors systems 105,000 patients Regional Health Information Organization Attributed (RHIO)
HIT Infrastructure Clinical Transaction Content ADT, Meds, Lab/rad/departmental reports (HL7 content) Health Clinical summary info (C32 content) Plans Claims data flow Web application Payer Data EHR Data Access to web viewer Warehouse Warehouse( Treo QDC) Clinical quality Clinical care Claims portal portal portal 45 Specialty 33 Primary Care 2 GFH Specialty Health Plans 3 PPSOs 5 Hospitals Providers Practices Practices
Total Attributed Patients 104,022 & Pod Specific Resource Distribution Resource: 8 Sites •1 RN Care Manager •2 Dieticians •2 Patient Educators Pod #1 Resource: 26 sites •1 Pharmacist •16 RN Care 14,065 •1 Information Tech Managers Pod #3 •2 Social Workers 57,024 •4 Administrative Resource: 16 Sites •1 Pharmacist Pod #2 • 6 RN Care Managers 32,933 • 1 Peds Health Coach • 3 Administrative • 2 Transition Care • 2 Patient Navigators
Implementation Issues Data Practices Utilization • “Clicks” • – Timeliness • Practice Resources – Pricing – Workflow – Unpaid Claims – Remediation • Clinical – Report Creation – 7 eMR vendors – Data Analysis, IT – RHIO • Attribution – Standards? – Effort – Remediation – Gaps – Consent • Products – Trigger • Changing Insurance
Health Home Care Management • “a care management service model whereby all of an individual’s caregivers communicate with one another so that all of a patient’s needs are addressed in a comprehensive manner” http://www.health.ny.gov/health_care/medicaid/program/medicaid_health_homes/
AHI Health Home Service Providers Transitioning TCMs Patient-Centered Medical Homes • Citizen Advocates Hudson Headwaters Health • Mental Health Association in Essex Network County Champlain Valley Health Network • Essex County Mental Health Services • Warren-Washington Association State ICMs for Mental Health Saint Lawrence Psychiatric Center • AIDS Council of Northeastern NY Capital District Psychiatric Center* • Behavioral Health Services North • Glens Falls Hospital*
AHI Health Home Patients Served 2014 Average Members Per Care Management Agency Month: January- May 2014 AIDS Council of Northeastern New York 60.4 Behavioral Health Services North 302.6 Champlain Valley Health Network 42.8 Citizen Advocates/Northstar Behavioral Health 312.6 Essex County Mental Health Services 33.8 Glens Falls Hospital N/A* Hudson Headwaters Health Network 394.4 Mental Health Association of Essex County 65.4 Warren-Washington Association for Mental Health 92.8 Grand Total 1304.8 * Glens Falls Hospital will be merging with AHI's Health Home effective 7/1/14. In May 2014, Glens Falls Hospital had 230 members. Number excluded from Grand Total.
Data Drives Triple Aim • Improving the health of Quality populations. Patient • Improving the patient experience of care, including access to care Experience and satisfaction with their care. Cost • Improving efficiency & reducing the per capita cost of health care. Savings
Data Uses • Share pertinent patient information with other providers to improve health outcomes and reduce redundant or unnecessary services (interfaces, RHIOS, shared care plans, etc.) • Monitor progress toward utilization, clinical quality and patient experience goals • Determine success of new initiatives such as Care Management and Transition Care • Identify patients who may benefit from a focused intervention • Identify unaddressed barriers to care including psyco- social determinants
Transparency Performance Dashboard Workgroups on The Hweb - Chronic Disease http://hweb/Departments/home.cfm?Me Pediatric nuID=5136&OldCFID=178261 Prevention Network Quality Advocacy/Advisory Measures Pediatric Quality Measures Patient Satisfaction Utilization Measures Provider Level Reports
Patient Centered Primary Care A Team Based Approach Brenda Stiles, RN CDE Care Team Manager Northern Adirondack Medical Home September 22, 2014
Engaging a Multitude of Stakeholders Adirondack Medical Home Pilot Participants Pilot Successfully Includes Wide Range of Payers, Providers Providers Payers 97 physicians and All 7 commercial payers with 127 mid-levels spanning Medicare, Medicaid 33individual practices Adirondack Medical Home Pilot Hospitals Patients 5 hospitals and health systems 105,000 patients 3
Key Requirements to Join Pilot Committing to Substantial Practice Redesign Major Changes in Practice Operations and Investments Accept Implement Adopt Implement Achieve medical home recognition assignment same day access e-prescribing evidence-based as patients’ system care (level 2 or level 3) personal provider Create disease Coordinate care Join regional Participate in quality management across continuum health measurement and information improvement exchange activities
Practice Transformation Practice Change Team Based Care Person Centered Medical Home Primary Care Provider & Patient/Family Disease Access to care Management 24/7
25 Transitional Care Supports Improving Patient Outcomes and Reducing Hospital Readmissions RN meets Medication RN provides RN Care Manager Work with patient review daily patients in reconciliation with 48-72-hour and PCP to ensure hospital for pharmacist phone call or admissions & that follow-up introduction of dedicated to home visit for readmissions to appointment determine those supports Medical Home follow-up occurs 7 – 10 days available patients patients at post discharge highest-risk
Adult Mental Health Transitional Care May 2014 Health Home Care Manager began providing transitional care supports to all patients discharged from Adult Mental Health Unit Follow up call to ensure patient was able to obtain medications, transportation to follow up appointments, etc. Ensure that Primary Care Provider aware of the recent hospitalization, along with medication changes
Health Home Care Management An Evolving Role
Pediatric Transitional Care
Pediatric Mental Health Transitional Care March 2014 Medical Home Team began providing transitional care supports to children and families discharged from the CAMU 72 patients have received transitional care supports 31 active patients currently receiving supports CAMU Transitional Care 80 72 70 60 50 41 40 31 30 20 10 0 Total Admissions Closed Active
Readmission Rates All Medical Home Primary Care Providers Patients discharged from CVPH and Alice Hyde Medical Center May 2011 - Readmission Rate – 14.9% Readmission Rates Total Patients 9.50% 997 Year 8% Total 1439 Average 7% 1546 Q4 9% Q4 339 4% 470 2014 2013 Q3 7% Q3 299 2012 8% 372 11% 514 Q2 6% Q2 478 7% 444 8% 483 Q1 9% Q1 323 7% 260 0% 5% 10% 15% 0 500 1000 1500 2000
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