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All In Project Showcase Webinar Developing Data Systems for Care Coordination Using Patient-Centered Approaches August 30, 2017 2:00 p.m. – 3:00 p.m. ET
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We are All In ! BUILD HEALTH CHALLENGE COMMUNITY HEALTH PEER LEARNING PROGRAM Funded by 10 national & local funders (including Advisory Board, de Beaumont NPO: AcademyHealth, Washington DC Foundation, the Colorado Health Funded by the federal Office of the National Foundation, The Kresge Foundation and Coordinator Robert Wood Johnson Foundation) 15 former grantees 18 implementation and planning grantees DATA ACROSS SECTORS FOR HEALTH THE COLORADO HEALTH NPO: Illinois Public Health Institute in FOUNDATION: CONNECTING partnership with the Michigan Public Health COMMUNITIES AND CARE Institute Funded by the Colorado Health Foundation Funded by the Robert Wood Johnson Foundation 14 grantees 10 grantees
All In: Data for Community Health 1. Support a movement acknowledging the social determinants of health 2. Build an evidence base for the field of multi- sector data integration to improve health 3. Utilize the power of peer learning and collaboration
Speakers Aaron Seib CEO, National Association for Trusted Exchange (NATE) George Klauser Nate Tyler Rahel Berhane, MD Medical Director, Children’s Executive Director, Altair Chief Strategy Officer Accountable Care Organization Simply Connect Comprehensive Care Clinic
Data for Community Health- Patient controlled aggregator Lessons and Challenges Rahel Berhane, MD Children’s Comprehensive Care Clinic Austin, TX August 30, 2017
Children’s Comprehensive Care Primary Care Health Home for Children with Complex Chronic Conditions ▪ Integrated Medical and Behavioral Health ▪ Habilitation – Physical, Occupational, Speech ▪ Integration with School ▪ Care giver support
Challenges ▪ Previous experiences of coordinating care across entities proved very expensive and inefficient ▪ Ideal design of care delivery requires moving from care coordination to care integration – across business entities in different sectors ▪ Care integration (which includes process and workflow integration) is not possible without data integration
Challenges • Health care delivery system relegates patients to passive recipients of care • Health care technology shortcomings inhibit engagement • Fragmented stories – data siloes • Information overload • Institutional culture – Data blocking • Privacy – Legal hurdles
Vision Design a community health data ecosystem ▪ Enables participatory care ▪ Allows for integrated ‘story’ to enable workflow integration from multiple entities ▪ Avoids documentation burdens ▪ Utilizes Human Centered Design principles throughout
Children’s Comprehensive Care Project Goal: Design a patient controlled application linked to a common data platform to serve the clinic, the MCO and at least two additional community organizations providing services for children with complex medical/behavioral issues. Community Goal: Build a prototype and demonstrate a use-case for a data ecosystem that leads to a measurable increase in engagement and communication by both service providers and families.
Partners and Stakeholders ▪ Technology Partners ▪ Theresa Neil Strategy and Design ▪ Cloud Forest Solutions ▪ Stakeholders ▪ Parents of children in CCC clinic ▪ Providers and case managers at CCC ▪ Managed care Organizations (Superior, BCBS) ▪ Community (AISD; Family Resource Center) ▪ School nurses ▪ DME/Home health/Therapy agencies
Day 1: Family Perspective
Day 1: Family Perspective
Day 2: Extended Care Circle Perspective
Day 4: Family-Provider Relationship
Some Insights and Themes ▪ Only the family knows the full story ▪ Convoluted systems &poor technology increase gaps ▪ Trust e rodes when families are not well understood ▪ Parents long for s o m e semblance of normalcy ▪ Mobility and ease of entry will aid adoption
Data Flow Schema
Prototype
Future State Next three months ▪ Develop modules for DME, Home health and Therapy ▪ Integrate data from MCO databases ▪ Pilot on 200 patients Next six months (Pending funding) ▪ Integrate data from EMRs (Common Well) ▪ Larger pilot (600 patients)
Lessons • Design presupposes a cultural shift- where providers actively seek the patient’s direct voice into the story • Design most suited for value based payment systems – not traditional fee for service care • Uncertain future – for experimentation on delivery service reform • Funding challenges
How to Successfully Engage the Community in Care Coordination George Klauser, Executive Director Altair Nate Tyler, Chief Strategy Officer, Simply Connect
Topics • What do we mean by community? • Review tactics to engage the community and discuss examples • Recommendations • Open Discussion
What do we mean by Community?
Engagement Tactic: Add Value - Facilitate Access to Information Patient/Person Receiving Services Significant Gaps, Inconsistencies and Lag in Communications Care Team Lacks Definition [Many silos of information with little access] Only Events that could lead to a fine are reported Exploitation Hospitalization Abuse ER Visit
Engagement Tactic: Add Value – Access to Information Patient/Person Receiving Services Event Driven Bi-Directional & Actionable Clearly Defined Care Team Communications [With a PHR] Clearly Defined Events Hospitalizatio Assess. Risk Illness Accident Life Events Gen. Change Med Errors Adv. Reaction n Behavior Abuse Srvc Barrier Aggression ER Visit Exploitation Injury Depression Chng
Engagement Tactic: Relieve a Pain Point or Barrier to Service Information on Non-Emergency Medical Specialists Transportation
Leverage tools to provide support to natural supports and coordination staff
Access to Support Currently, easy upstream interventions go under utilized because people don’t: – Know who to call. – Don’t want to bother someone. – Don’t understand that there is a problem.
Engagement Tactic: Fill a Gap Poor medication adherence results in $290 billion of avoidable costs in the health care system. Network for Excellence in Health Innovation (2011). Bend the Curve: A Health Care Leader’s Guide to High Value Health Care. A ccessed May, 2014.
Nearly one in five Medicare patients discharged from a hospital — approximately 2.6 million seniors — is readmitted within 30 days, at a cost of over $26 billion every year. James, J (2013). Medicare Hospital Readmissions Reduction Program. Health Affairs Health Policy Brief. Accessed May, 2014
1.5 Million preventable medication-related adverse events each year
Engagement Tactic: Education & Change Management • Ensure each stakeholder group understands the ‘why’ • Demonstrate the wins for each group required to take action
Staff Training DirectCourse
Engagement Tactic: Show the Impact/Outcomes
Recommendations • Talk to your eHR Vendor • Talk to your HIE Vendor • Find a care management tool that meets your needs and is interoperable
Connect with Us! ▪ Visit our website: allindata.org ▪ Sign up for our online community: allin.healthdoers.org ▪ Follow #AllInData4Health on Twitter ▪ Sign up for news from All In ▪ Contact information for speakers ▪ George Klauser: George.Klauser@lssmn.org ▪ Rahel Berhane: rxberhane@seton.org
Next Steps ▪ Share your feedback Please complete the evaluation survey following the webinar ▪ Resource list, slides, and recording will be posted Available online at allindata.org/resources
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