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MiPCT/CCM Spotlight ADT Alert and workflow Training for Care Managers and PO/CCM Leads January, 2014. AGENDA. Brief Spotlight Overview of “Phase One” Member List Functionality “Phase Two” ADT Alert Briefing Care Management Workflows Prompt action on Transitions of Care - PowerPoint PPT Presentation
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MiPCT/CCM Spotlight ADT Alert and workflow Training for Care Managers and PO/CCM Leads
January, 2014
AGENDA
1. Brief Spotlight Overview of “Phase One” Member List Functionality
2. “Phase Two” ADT Alert Briefing
3. Care Management Workflows▫ Prompt action on Transitions of Care▫ How ADT alerts can be used to prioritize
and manage your caseload
3
Spotlight Overview
What is the MiPCT Spotlight Offering?
A way for Care Managers to receive
web-based access to MiPCT member
lists with near real-time alerts when
patients are hospitalized or discharged
where available.
.
5
Spotlight Data Security• External security audit review performed in 2012 with
CynergisTek and subsequent review planned for 2013 upon CCM Version 2 rollout completion
• Annually CTC undertakes:▫ Risk analysis of the company, our processes, assets,
applications, data (under a NIST 800-30 based risk management program)
▫ Review of all our policies and BAAs internally and with lawyers▫ Disaster recovery test▫ External network/application security tests
• Worked with Healthcare Law Consultancy (CCM) to address new HIPAA omnibus regulations (September 2013)▫ Policies in place and updated as HIPAA regulations change to
address things such as security breaches including notification to affected parties.
6
Phase 1: MiPCT Member Lists via CTC Spotlight
7
Phase 1: New Member Alerts via CTC Spotlight
8
ADT Availability
9
•Through partnership with MiHIN, MSMS, and others
•Leverages MiHIN/CareBridge ADT work
•Expands ADT availability with additional feeds with prioritization of ADT feeds of greatest value to MiPCT practices
Spotlight Leverages ADT Access
ADTs Available Q1 2014
Facilities included in the first set of ADT feeds for MiPCT patients with hospitalizations or ED visits:
• Beaumont▫ Working on identifying individual facilities
• Henry Ford Health System▫ Macomb to start▫ Wyandotte and Main campus to follow
• Trinity
Admission, Discharge, Transfer MiPCT Data Flow and Progress
Over half of our POs participate in the Crimson Care Management (CCM)/MiPCT partnership• Care managers now receive member lists electronically via a web interface• ADT notifications being added
Phase 2: Admission/Discharge AlertingPatient Admitted Email Alert
Phase 2: Admission/Discharge AlertingPatient Discharged Email Alert
Phase 2: Admission/Discharge AlertingPatient ER Visit Email Alert
15
Phase 2: Admission/Discharge Alerting
Alerting – Acknowledge via emailLogin to Spotlight
Alerting – Acknowledge via emailClose Alert
Admission/ER Visit Information
Discharge Dispositions:
20
Care Management Workflows
St. John Providence, Partners in CareMiPCT-P.O.- Soft launch Partner
CTC/ADT alert only process flow
developed by:
Transitions of Care Best Practice Workflows
Care Manager (CM) ADT alert workflows:
•Associated with corresponding faxed patient information.
•Associated with CM electronic access to patient record.
CM Workflow for Inpatient Alert
CM Workflow for Discharge Alert
Best Practice Transitions of Care Process: Practices with Care Team Connect(CTC) and Admission, Discharge and Transfer(ADT) Feeds
Care Manager receives Alert in CTC: Responds within 24-48 hours of receiving the alert
Patient Transfer to Long Term Acute Care, Rehabilitation, or Skilled Nursing Facility
Patient Discharge
CM enters assigned patient list. Locates patients name. Receives hospital name and
pertinent information.
CM enters assigned patient list. Locates patients name. Receives hospital name and
pertinent information.
CM reviews patient EMR/discharge summary to determine the name of the facility patient was
transferred to. CM reviews patient EMR/discharge
summary.
CM contacts facility Case Manager or Social Worker for TOC call.
CM records receipt of CTC Discharge alert and communication with facility Case Manager or
Social Worker. Record plan for anticipated discharge as well as anticipated timeline for CM
follow up in CTC and patient medical record (EMR or paper chart).
CM records receipt of CTC Discharge alert and communication with patient or
caregiver. Record initial care management plan and anticipated timeline for CM follow up in CTC and patient medical record (EMR
or paper chart).
CM contacts patient for TOC call.
CM places patient name on CM schedule
for follow up.
When the CM does not have access to the hospital record: · Arrange to receive daily faxes of pertinent patient information (admission history and physicals for
admissions and discharge summaries for discharges).· Contact the inpatient case manager to arrange receipt of the needed patient medical information
(admission history and physical, discharge summary, medication list and any other information needed to arrange and provide appropriate follow up care).
· Contact the patient or care giver if unable to determine the patient’s disposition.
Patient discharged to home
Fax from hospital
Access the hospital EMR
Fax from hospital
Access the hospital EMR
CM Workflow for ED Alert
ADT Alerts Best Practice Process
• The following steps are completed by the CM 24-48 hrs. after alert notice.
• Acknowledge receipt of admission, discharge or ER alert from CCM.
• Investigate patient change in status and determine care management intervention.
• Document receipt of alert, intervention(review of EMR and follow up with facility contact, patient and physician) and planned follow up with patient in EMR.
Transitions of Care Integrated Workflow
(displays inpatient, discharge and ED flows in one screen)
Best Practice Transitions of Care Process: Practices with Care Team Connect(CTC) and Admission, Discharge and Transfer(ADT) Feeds
Care Manager receives Alert in CTC: Responds within 24-48 hours of
receiving the alert
Patient Inpatient
Admission
Patient Transfer to Long Term Acute Care,
Rehabilitation, or Skilled Nursing Facility
Patient Discharge
CM enters assigned patient list. Locates
patients name. Receives hospital name and
pertinent information.
CM reviews patient inpatient information
CM contacts hospital
Inpatient Case Manager
CM records receipt of CTC Admission alert and communication with IP Case Manager. Record
plan for anticipated discharge and timeline for CM follow up in CTC
and patient medical record (EMR or paper
chart).
CM places patient name on CM schedule for
follow up.
CM enters assigned patient list. Locates patients name. Receives hospital name and
pertinent information.
CM enters assigned patient list. Locates patients name. Receives hospital name and
pertinent information.
CM reviews patient EMR/discharge summary to determine the name of the
facility patient was transferred to.
CM reviews patient EMR/discharge summary.
CM contacts facility Case Manager or Social
Worker for TOC call.
CM records receipt of CTC Discharge alert and
communication with facility Case Manager or Social Worker. Record
plan for anticipated discharge as well as
anticipated timeline for CM follow up in CTC and patient medical record (EMR or paper chart).
CM records receipt of CTC Discharge alert and
communication with patient or caregiver.
Record initial care management plan and anticipated timeline for CM follow up in CTC and patient medical record (EMR or paper chart).
CM contacts patient for TOC
call.
CM places patient name on CM schedule for
follow up.
CM places patient name on CM schedule for
follow up.
When the CM does not have access to the hospital record: · Arrange to receive daily faxes of pertinent patient information (admission history and physicals for
admissions and discharge summaries for discharges).· Contact the inpatient case manager to arrange receipt of the needed patient medical information
(admission history and physical, discharge summary, medication list and any other information needed to arrange and provide appropriate follow up care).
· Contact the patient or care giver if unable to determine the patient’s disposition.
Patient discharged to home
Fax from hospital
Access the hospital EMR
Fax from hospital
Access the hospital EMR
Fax from hospital
Access the hospital EMR
ADT/CTC Summary of Key Points• Alerts need to be acknowledged on a timely basis
throughout the day to minimize multiple alerts on the same patient. (i.e. admission alert that is not acknowledged by the time of discharge will generate another alert -> discharge alert)
• When acknowledging an alert by email, click on “view care plan” button once logged in CTC. Clicking “close” will remove alert from your home page and require you to look up patient by name. ( Patient hospitalization report is being developed via CTC website to see patient TOC activity.)
• It is recommended that review of the discharge disposition code be incorporated into your process.