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PRISM
Predictor of mortality, re-admission developed by Dr. Cowen and Quality Institute at St. Joe’s
5 PRISM levels (1-highest risk, 5-lowest risk)Calculated on admission in the ED, in pre-op for
elective surgery at SJM Ann Arbor
4
% of Patients, 30 day re-admissions by PRISM score
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PRISM 2 & 3 patients account for 63% of all re-admits
5
Days to Re-AdmissionPRISM 1/2/3, Nov 2012 – June 2013
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Of all re-admissions, ~40% occur within the first 7 days
TOC Information Goals1. Provide care managers real-time
information on when patients are admitted and discharged
2. Provide risk scores to help care managers prioritize interventions
3. Integrate information into NextGen EMR to avoid multiple logins, screens, etc.
4. Store data to provide reports back to care managers and leadership
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Care Management Data Flow
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Database
ADT Feed
Risk Score (PRISM)
Care Manager
Panel
Reporting
Care Manager
Templates
Process Metrics
Outcomes Activity Panel Size
Data warehouse
Notification
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DischargeAdmit
NextGen Task
NextGen CM Panel
NextGen Task
NextGen Task
Next Morning
W/in 2 hours
NextGen CM Panel
W/in 2 hours
Next Morning
Next Morning
NextGen PAQ
24-48 hours
Admit Notification
Admit Notification D/C Notification
D/C Notification
D/C Notification
Discharge Summary
PCPPCP
Care ManagerCare Manager
Practice RNPractice RN
Next Morning
Next Morning
Call Center RN
Non-MiPCT referred to practice RN
NextGen Tasking
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Due date set based on protocol:•Follow up call within 24 hours•PCP appointment within 7 days
Flow of Patients in NextGen Care Manager Panel
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Patients move from Admit panel to Discharge panel when dischargedPatients move from Discharge panel to Active panel when enrolled
ReportingCare Management Dashboard
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Discharges % Enrolled% Seen by PCP w/in
7 daysDischarges % Enrolled
% Seen by PCP w/in 7 days
High Risk SJMHS MiPCT Discharges All SJMHS MiPCT Discharges
Metrics calculated bi-weekly by care manager
ReportingCare Management Dashboard
04/19/23
Panel Size Panel Size/FTE Encounters/FTE # Phone Calls # Face To Face Care Coord # Comp. Assm
Metrics calculated bi-weekly by care manager
Mercy Physician Community PHO• 145 Primary Care and Specialty Care
Physicians• 38 PCPs, 20 utilizing Crimson Care Registry• 6 MIPCT Practices• 3 Hospitals in St. Clair County, MI– St. Joseph Mercy-Port Huron, our affiliate– Port Huron Hospital, independent– St. John-River District
Discharge Process• St. Joseph Mercy Port Huron
– Daily feed through secure Trinity email system of all inpatient and emergency room discharges
• Port Huron Hospital– Daily feed through a secure web portal of all
inpatient and emergency room discharges
• St. John River District/Outlying Facilities– No current PHO process, though physicians
occasionally get their information through portals that they have access to individually.
Challenges We OvercameWorking with a “competing” hospital to
get data to promote better health in our community
Administrative burden of handling data in a timely manner
Training of offices on what to do with the data
Decreasing ED utilization for PCS diagnosis…a work in constant progress!
Internal PHO Process• Team Member accesses both files
and saves to our local drives in excel• Team Member separates each
physician onto its own formatted excel page by group• Physician group excel pages are
faxed or emailed securing to each office with DC for that day
Registry Component• Discharges for physicians on our
registry are added a service entry with a note by our Team• Physician office will then see the
service (ER or IP stay) and admitting diagnosis as well as dates of service
Care Manager Process• If office is a MIPCT office:–Complex Care Manager accesses the
excel file through the shared Trinity drives
–CCM makes the calls to patients who are DC from the hospital or ED
–Calls are logged on the log the Care Management Team uses
–Calls are logged in Crimson when there is a goal set or follow up needed.
Office Process• We train our offices to utilize these
lists and contact the patients to get them into the office.• Since many health plans incentivize
offices for seeing patients post IP stay, our offices really appreciate the daily lists
Findings/Quality
• We routinely track and share information with our Quality Committee and physicians related to time of day and insurance type.• Find that most are M-F 9AM-5PM• Most are Medicare • Diagnosis are Primary Care Sensitive
Time and Insurance September 2013
• 1435 ED Visits between SJMPH and PHH• 654 between hours of 9AM-5PM• 373 between hours of 5PM-9PM• 408 between hours of 9PM-9AM• 115 Uninsured• 246 Medicaid• 644 Medicare• 430 Commercial Insurances
MIPCT Success Story 162 year old female3 IP and 7 ED visits in preceding 12
monthsUCIDDM, CHF, COPD, O2
DependentInattentive Family
MIPCT Patient 1 Plan/SuccessMonthly PCP and Care Manager
MeetingsEducation re: signs and symptoms,
impending troublesLearned to anticipate illness and
contact PCP1 IP stay and 2 ED visits in last 12
months
MIPCT Success Story 228 year old female>25 ED visits preceding 12 monthsMany ED visits via ambulanceMinor medical historyAll ED visits were primary care
sensitive
MIPCT Patient 2 Plan/SuccessAccess to Complex Care ManagerMeetings every two weeksCalls from Care Manager each ED
visitClose working between PCP and
Care Mgr.3 ED visits in last 12 months
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