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Insight Driven Health
Albany Medical Center Hospital DSRIP Clinical Integration Strategy
CI CCM Overview Training Session September 26, 2016
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Agenda
Topic Detail Time Facilitator
Welcome • Training Kick-off 1:00-1:05 Dr. Manjunath
Introduction • Review agenda, objectives, and ground
rules 1:05-1:10 Tara Foster
Background • Discuss why we are here and where
we’ve been 1:10-1:20 Tara Foster
Care Coordination Model • Review the CCM Framework,
Elements, Processes, Functions and & Protocols
1:20-1:40 Dr. Manjunath
Clinical Integration Process and Elements
• Deeper dive into ED Process Flow • Deeper dive into ToC in Community
Setting 1:40-2:00 Dr. Manjunath
Tools and Templates • Review all tools / templates • Deep dive into Care Plan
2:00-2:10 Tara Foster
CI CCM – Future State • Case of John Doe 2:10-2:15 Dr. Manjunath
Q & A • Questions and Answers 2:15-2:30 Team
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Introduction Ground Rules
• Ask questions: There are no stupid or unimportant questions!
• Be courteous:
• We will mute your lines during the presentation.
• Enter any questions into the chat box or email us at
• Within 24 hours, please email confirmation of your participation in today’s meeting with your name, title, and the organization you are representing.
• Keep things moving: We will Parking Lot items that are off topic or require offline follow up due to limited time in session; keep the objectives of the session and agenda item in mind throughout the discussion
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Upon completion of this training session, participants will be able to:
• Describe the vision, framework and key elements / assumptions of the care coordination model
• Identify the high level care coordination process flows and the technology that support the process
• Identify points of communication and elements for data exchange to further coordinate transitions of care
• Identify the tools and templates which will be used to facilitate care coordination and transitions of care
• Understand the roles of the interdisciplinary care team members
• Understand the patient navigator role and identify key components and functions
Introduction Training Objectives
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Background
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“Change almost never fails
because it's too early. It almost
always fails because it's too late.” ~ Seth Godin
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Background Case Management and Care Coordination
CM is the process of consistently managing the quality, cost and delivery of care / medical services across the care continuum
The goal of acute CM is to improve a patient’s health status, and achieve / enhance appropriate utilization of acute, post-acute, and community-based care
Case Management (CM)
Source: American Case Management Association, Agency for Healthcare Research and Quality
CC is the organization of patient care activities between two or more contacts involved in a patient's care to facilitate the appropriate delivery of services
The goal of CC is to meet and communicate the patient’s needs / preferences at the right time to the right people to guide care delivery
Care Coordination (CC)
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Background DSRIP Mission and Milestones
Reduce avoidable ED use and inpatient admissions by 25%
Improve key population health measures
Minimize the system-wide cost of care by transitioning to a Value-Based Payment system
Provide a community-based approach to care through the integration of services
AMCH DSRIP Mission
PPS Care Transitions Strategy
Training for providers and operations staff across settings
DSRIP Milestone Requirements Benefits
follow-up appts. and PCP alignment
patient satisfaction
Communication / staff experience across PPS affiliates
cost in ED / IP / PC / BH
avoidable readmissions / admissions / ED visits
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Background Development of the Clinical Integration Care Coordination Model
The CI CCM was developed through a collaborative effort by PPS stakeholders and includes standardized, timely and effective processes and guidelines to drive enhanced care coordination
Current State Assessment
Identified areas for improvement to guide CCM development
Identified PPS stakeholders and governance model
Gained understanding of current CM / CC processes across PPS
Reviewed 109 documents and interviewed
81 people from 20 Affiliate organizations
CI CCM
Researched care coordination leading practices, tools / protocols
Future State Design
Consolidated input into future state processes, tools and protocols
Conducted five (5) 4 hour workshops with Leads, PMO and SMEs
Work group included 30 representatives
from 12 organizations
CI CCM Development Process
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Background Current State Assessment Findings
Key Themes across PPS
Behavioral Health challenges Inconsistent communication across the care continuum
Fragmented CC functions / processes
Limited data exchanged
Limited availability for placements / services
Social barriers to care
A B C
D E F
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Process flows, Visio diagrams, and other products contribute to the package of CI future state design assets. These tools and documents will be used to support the implementation of the CCM
Background Summary of Future State Assets
Process Flows and Protocols for Key Functional Areas: • Include high-level process, the task and associated steps, type
of data collected, timing, and system used • Flows Include: ED / Obs. / hospital admission, Discharge (DC)
to home, home health, SNF/Rehab, BH OP and IP; and Transitions in the Community Setting
Technology Alignment to Processes: • Visio diagrams map the user workflow to data, system /
technology enablers and integration layers • Triggers / alerts and communication / data sharing points are
highlighted
Tools and Templates: • Defined and standardized essential elements of patient CM
assessments, engagement / care plans, risk stratification tools (LACE in acute, adapted rubric in community setting)
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Clinical Integration Care Coordination Model (CI CCM) Overview
DY2 DY3 DY4 DY5
2016 2017 2018 2019
AMCH PPS Projects Q1/2 Q3/4 Q1/2 Q3/4 Q1/2 Q3/4 Q1/2 Q3/4
2.a.i Create an IDS
2.a.iii Health Home At-Risk Intervention Program
2.a.v Medical Village/Alternative Housing using existing Nursing Infrastructure
2.b.iii ED Care Triage for At-Risk Population
2.d.i Patient Activation Activities to Engage, Educate and Integrate At-Risk Population
3.a.i Integrate Primary Health and Behavioral Health
3.a.ii Behavioral Health Crisis Stabilization Services
3.b.i Evidence-based strategies for Disease Management in High Risk Populations
3.d.iii Evidence-based Guidelines for Asthma Management
4.b.i Promote Tobacco Use Cessation
4.b.ii Increase Access to High Quality Chronic Disease Prevention (Cancer)
Key
Required in 6 Months
Priority Long-term
AMCH has chosen 11 projects from the menu of interventions provided by New York State; the CI CCM strategy is foundational to the AMCH projects outlined below
Clinical Integration Care Coordination Model (CI CCM)
Current State:
• Experiences headache, blurred vision and concerns of a stroke
• Dial 911 and is transported to ED by ambulance
• ED staff determine hyperglycemia, secondary to medication non-
adherence
• Daily meds changed to include insulin, briefly counseled on self-
injection and sent home with recommendation to f/u with a PCP
• Several weeks later, John is readmitted with the same condition
due to lack of timely access to PCP & ongoing confusion regarding
the appropriate use of multiple medications
Patient Name: John Doe Age: 44 Years Insurance: Medicaid
Current State: Fragmented Care
Medical History: • History of uncontrolled Type II Diabetes Mellitus,
Hypertension • Lacks transportation to visit PCP, Language challenges • Medication non-adherence • Two prior hospital admissions within the preceding 6
months
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CI CCM guiding principles will serve as the foundation to achieve the PPS goals and should be continuously revisited throughout implementation and adoption of the model
CI CCM Context - Guiding Principles
1. CC extends to all patient settings including hospital / ED, post acute care, PCMHs, and community based organizations across the PPS
2. CC functions / processes focus on coordination across the continuum based on leading practices
3. CC is a both proactive and reactive continuous improvement model in its approach to facilitate patient care delivery / coordination across the continuum
4. Effective CC ensures appropriate care, at the right time, in the right setting, at the right cost, to the right patient taking into account that there is no “wrong door” for any patient
5. CCM is sustained by a leveraged, collaborative interdisciplinary care team with staff operating within their license / skill level to support functions / processes
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CI CCM guiding principles will serve as the foundation to achieve the PPS goals and should be continuously revisited throughout implementation and adoption of the model
CI CCM Context - Guiding Principles
6. CC will focus on patients identified through stratification and predictive modeling based on risk domains such as health status, utilization, social determinants and engagement level to identify risk and opportunities
7. CC includes real-time, ongoing active communication and data sharing where technology is a key enabler to facilitate efficient and effective communication / coordination
8. CI CCM leverages existing community based organizations (i.e. health homes, home care agencies, etc.)
9. CI CCM aligns with elements, goals and requirements of PCMH, Health Home, DSRIP, and leverages care coordination leading practices / expectations
10.CI CCM is centered around the patient through patient engagement and patient activation (i.e. leveraging Patient Navigation (PN) and PAM tools)
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CI CCM Framework: Overview Model Framework
Readmissions Management
Technology Enablement
Leveraged Care Team
Centralized Functions
Performance Management
Collaborative, patient-focused
interdisciplinary team
Centralized PPS services in support of regional
CC / CM affiliates
Real-time data and reporting
Standardized information sharing across PPS
affiliates
Standard ToC processes
Risk Stratification
Patient Engagement /
Care Plans
Standard Assessments
Patient Navigation & Engagement Fu
nct
ion
s, P
roce
sse
s &
Pro
toco
ls
Fou
nd
atio
nal
C
om
po
ne
nts
Integrated Care Coordination Across the Continuum of all Care Delivery Settings
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End-Of-Life Care
CI CCM Framework: Care Continuum Focus Continuous Cycle of Care
Acute Rehab /
Skilled
Nursing
Home Care
Preventative / primary care
Stability / Acute / Post Acute Care
Behavioral
Health Care
Community-
Based
Organizations
Substance Abuse
Treatment
Urgent Care
Primary /
Specialty Care
Long-Term Care
ED / Hospital
Care
CI CCM emphasizes care being delivered in a continuous cycle across care delivery settings, with the majority of services and care being provided in the community
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CI CCM Framework: Care Coordination Elements Care Coordination Across Community and Acute Settings
Key Elements of Community CC
Standard risk stratification
Target high / moderate risk patients
Weekend and evening coverage / access
Engagement with Community Health Workers / Peer Coaches
Automated risk identification
100% case review
ED coverage
Optimized staffing
Timely DC planning
Engagement with Patient Navigators*
Key Elements of Acute CC
Text
Common elements:
Standard CM assessment elements
Standard pt. engagement / care plans elements
Proactive ToC communication
Readmission management interventions
*Official title of staff in patient navigation / non-clinical role subject to change pending hospital partner consensus
CI CCM aligns to CC leading practices and incorporates standard essential elements for effective CC across the continuum, as identified by PPS stakeholders
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CI CCM Framework: Foundational Components
Leveraged Care Team
CCM Leveraged Interdisciplinary Care Team
Each unit will work as a team to achieve a successful CCM with a leveraged care team that may include:
Social Workers Work directly with pts addressing individual, family and social issues
Patient Navigators* / CHW Non clinical team members who
work with the care team and pts to remove non-clinical barriers to care
Physicians / Advanced Practitioners Clinical lead manages medical
treatment and identifies on going medical needs
BH / MH Staff Provide consultation /
interventions for episodic / ongoing and/or acute BH needs
Case Managers / Care Coordinators Assess, evaluate, plan, coordinate
services and pts to right level of care based on current / on going care needs
Nurses Manage pt needs and deliver pt
care / treatment. Identify need for CM / SW and wider team input
*Official title of staff in patient navigation / non-clinical role subject to change pending hospital partner consensus
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CI CCM Framework: Foundational Components
Leveraged Care Team: Patient Navigation
• The goal of PN is to assist Case Mgr / Social Workers in identifying and managing non-clinical barriers
• IP / OP / PCP PN processes incorporate the Pt. Navigator into the care team
• Pt. Navigators* collaborate with the care team and focus on addressing non-clinical ToC / DC planning challenges
• Requires consistent / frequent collaboration, communication, and escalation policies
Patient Navigators / CHW
Support & monitor care plan
Identify & remove barriers
Determine required services
Outreach
CULTURAL / HEALTH LITERACY
Awareness / understanding
Language / ethnic preferences
Holistic needs
Barriers to Accessing Care
FINANCIAL
$$$
Coverage for care
Out-of-pocket expense(s)
Rx set-up / refill / financing
Limited / no financial resources
LOGISTICAL
PCP alignment
Transportation assistance
Child care coordination
Temporary residence required
COORDINATION AND EDUCATION
Support to manage complex BH / physical conditions
Educational services
Community services
*Official title of staff in patient navigation / non-clinical role subject to change pending hospital partner consensus
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CI CCM Framework: Foundational Components Centralized Functions
Administrative Support
Tracking / reporting Key Performance Indicators (KPIs)
DOH reporting
Contract Support
Cost analysis and financial needs
Training Support
Develop standard PPS training materials / job aids / tools
Conduct training
Provide coaching / monitoring
IT Services / Support
Technology system use standardization
Data management
IT support services to facilitate interoperability
Centralized CM Support
Assess and provide CCCM services as appropriate
Refer patients to CC services
CC support:
− Post DC calls
− Patient reminders
− Schedule appts.
− Enrollment in programs
Patient Navigation services :
− Transportation / housing
− Financial
− Managing resources on-line
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CI CCM Framework: Functions, Processes and Protocols Integrated CC / ToC: Readmission Management
Readmission Management
Readmission risk level can guide specific actions / strategies for acute DC and community CM
Support from / collaboration with primary health care teams is integral in minimizing ED attendance and reducing readmissions
CI Work Group identified specific questions /
information to ask pts. who have been readmitted can help inform DC planning
Example
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CI CCM Framework: Functions, Processes and Protocols Integrated CC / ToC: Standard ToC Processes
Standard ToC Processes
Flows include high-level process, the task and associated steps, type of data collected, timing, and system used
Developed flows include:
ED / Obs. / hospital admission
Discharge (DC) to home, home health, SNF/Rehab, BH OP, and BH IP
Transitions in the Community Setting
Discharge Planning Process Flow
Dat
a La
yer
IP –
Use
r Fl
owTe
ch/S
yste
m L
ayer
Inte
gra
tio
n L
aye
r
Post-clinical Review Planning
Complete pre-discharge
assessment / reviews and
identify post-discharge needs
3.1
Review holistic patient picture
3.2
Determine discharge
disposition and risk level (LACE)
3.3 3.4
Alerts / TriggersLegend: Communication / Data Sharing
End ED, Observation or
Inpatient Process
Start Discharge to Home process
Level of Care Determination
Start Discharge to Home Health process
Start Discharge to PAC facility process
Start Discharge to BH IP process
Start Discharge to BH OP process
1. ADT (A:1,3)2. Notes (A:2,4)
C
1. Patient hx2. Care plan3. Pt. demo4.Assessment
A
1. InterQual / Milliman
B
iStop
1. ADT (A:2,3)2. Notes (A:1,4)
C
1. Notes2. Patient hx3. Pt. demo4.Assessment
A
1. InterQual / Milliman
B
1. ADT (A:1)2. Notes (A:2-4)
C
1. Patient hx2. LACE score3.Assessment4. ToC
A
1. InterQual / Milliman
B
1. ADT (A:1)2. Notes (A:2-4)
C
1. Patient hx2. LACE score3.Assessment4. ToC
A
1. EMR
B
1. ADT (A:1)2. Notes (A:2-4)
C
1. Patient hx2.Assessment3. ToC
A
1. EMR
B
Hixny
Example
Technology enablers (e.g. Hixny alerts) are
mapped to various steps and events in the
process flows
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CI CCM Framework: Functions, Processes and Protocols Integrated CC / ToC: Risk Stratification
Risk Stratification
LACE will be used in the acute setting to inform post-DC admission avoidance actions depending on readmission level (low, moderate, or high)
An adapted* existing evidence-based risk stratification tool, which includes health status, social support and utilization domains, will be used in the PCP setting
*Adapted from American Academy of Family Physicians and Camden Coalition of Healthcare Providers
Example
The LACE Score involves risk assessment based on
LOS, Acuity, Comorbidities and ED usage
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CI CCM Framework: Functions, Processes and Protocols Integrated CC / ToC: Patient Navigation & Engagement
Patient Navigation* & Engagement
CI Workgroup agreed upon standardized non-clinical tasks eligible for PN consultation and care team contributions
PNs and CHWs will help patients address barriers to care, such as logistics (e.g. transportation) and financial (e.g. insurance application) challenges
Example
CHWs connect pts. with community resources
PNs support the CM/SW with
administrative work
*Official title of staff in patient navigation / non-clinical role subject to change pending hospital partner consensus
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CI CCM Framework: Functions, Processes and Protocols Integrated CC / ToC: Care Plan
Patient Engagement / Care Plan
Patient Care Plan is intended to be fluid and focused on patient engagement, priorities, and goals
Care Plan should be reviewed / amended at ToC as the patient moves through the care continuum
Affiliates can leverage Hixny to enable visibility into care plans across LOC and settings
Example
PPS CI Care Plan consistent with Health Home
requirements
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Example
CI CCM Framework: Functions, Processes and Protocols Integrated CC / ToC: Standard CM Assessments
Identifies essential information (e.g. health status, cognitive, cultural / language barriers, etc.) required to holistically review and manage the patient
Assessments should be reviewed and refreshed as needed as the pt. moves through the care continuum
Standard CM Assessments
Defined essential element of information to capture
and review
Further explanation / definition for appropriate
implementation
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Clinical Integration (CI) Functions, Processes and Protocols: Examples
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Available Process Flows and Protocols
CI Functions, Processes & Protocols Summary of Future State Assets
Process Flows and Protocols for Key Functional Areas Define CC functions, tasks and guidelines for CM and ToC
Include high-level process, the task and associated steps, type of data collected, timing, and system used
Process flows created:
1. Emergency Department 2. Observation Status 3. Inpatient Admission 4. Clinical Review Planning and Execution 5. Discharge Planning and Transition of Care to:
Home / OP / PCP Home Health SNF/Rehab IP Behavioral Health OP Behavioral Health
6. Transitions of Care in Primary / Community Care
Protocols and Functions Defined: Readmission Management Patient Navigation
Example tasks, data and technology functions
Review in Today’s Session
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CI Process Flows: Example Emergency Department (ED) Process Steps
Context:
CM in the ED commences post triage
Triage nurse will use an Emergency Severity Index (ESI) or Trauma Acuity Score algorithm which yields rapid clinical stratification of patients into 5 groups, from level 1 (most urgent) to level 5 (least urgent)
Triage to include questions to trigger need for CM or PN (eventually an auto alert based on risk)
Triage would also identify if the patient has a primary BH need and triage accordingly
Hixny / Other alert based on event trigger
Triage
Intake Prioritize pts. to be
seen
Review pt. information
Clinical review /
Identify LOC
Collaborate with pt. and
family
Start Obs Process
Start IP Admission
Start DC Process
1.1
1.2
1.3
2.1 Report out
to Care Team
2.2
2.3
Pre-patient review Patient assessment and review
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CI Process Flows: Example ED Process: Patient Triage, Referral & Patient Review Requirements (1/2)
ED1 Tasks/ Steps: Referral & Pre Patient Review Requirements Data Technology
ED 1.1
Case Manager reviews worklist / ED tracker and / or alerts to prioritize pts. Target time ≤ 30 mins: • Responds to alert/ notification to confirm referral received • Referrals for pts. with following triggers (eventually automated): no PCP,
frequent flyer, has specialized care plan, non-compliant, readmission (LACE score)
• ED registrations • Readmissions • Alert / Triggers
• EMR • Hixny
ED 1.2
Confirm with ED physicians / nursing staff the pts. to be seen and any pertinent information: • Identify needs for LOC / DC plans / other issues • Seek info on plan, clinical milestones and options • Review medical and nursing notes • Identify behavioral health needs; consult as needed
• Medical and Nursing records
• Care plan
• EMR
ED 1.3
Review pt. social information where possible prior to meeting the pt.: • If pt. a readmission review previous DC plans • Contact previous / community CM for key information / input • PCMH and Health Home will send / warm handoff relevant pt. information
• Previous history • Care plan • Contact person
at CBO / PCP
• HARP* info if applicable
• Hixny • EMR
Level 1 & 2 pts. receive immediate emergency care with Level 3-5 prioritized based on urgent or primary care needs. Triage to include questions to trigger need for CM or PN needs (eventually an automatic alert based on risk) Triage would also identify if the patient has a primary BH need and triage accordingly. Once the pt. has left the waiting room EDs provide designated exam rooms and areas for different diagnostic populations. This is where the Case Manager would begin the initial pt. review and assessment.
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CI Process Flows: Example ED Process: Patient Assessment & Review (2/2)
ED2 Tasks/ Steps: Patient Assessment & Review Data Technology
ED 2.1
Ascertain with ED care team if pt. diagnosis / plan requires an acute admission: • Case Manager and Nursing to use standardized assessment tools • Conduct initial clinical review to determine appropriate LOC based on pt. status
/ plan of care (Milliman/ InterQual) • Identify initial DC plan / options and any potential risks and barriers to DC • Obtain an accurate and complete list of the patient's medication
• Review med list for indicators of high risk and involve Pharmacist/MD in review
• Current history • Previous history • Shared care plan • Pt. information • Assessments • Review summary
• InterQual/ Milliman
• EMR • Hixny • iStop
ED 2.2
• If pt. confirmed for admission by medical team, identify appropriate LOC status (inpt. / observation status). Case Manager completes handover/ report to inpt. CM staff
• If pt. does not require an acute admission, identify treatment / care needs, appropriate LOC, services requirement.
• Discuss with care team the post DC plan • Depending on post DC plan incorporate PN / Other
• Medical notes • Diagnostic
results
• InterQual/ Milliman
• EMR
ED 2.3
Collaborate with pt. / family / other to identify home environment, social needs, ability to care for pt. (self-care / with support): • If recent visit - reason for presentation • Set goals agreed upon by the pt. / or family and physician for the treatment
needed in the ED and beyond DC - build upon prior plan, document and share with rest of care team
• Identify services currently used • Identify additional services required short term and medium term
• Medical notes • Diagnostic
results • Patient
information • Assessments • Shared care plan
• InterQual/ Milliman
• EMR • Hixny
Begin Discharge Planning and / or ToC Process (specific to pt. discharge disposition or inpatient / observation needs)
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Context:
CI Work Group defined the recommended steps and care coordination / communication points required for transitions in the community
Information will need to be shared and actions taken in a timely matter to successfully transition pts.
Clinical Integration Processes and Elements Transitions in the Community
Hixny / Other alert based on event trigger
Make Referral
Schedule appt. /
open case
Send relevant pt. information
Confirm receipt / request addt’l
Pre-visit planning
4.1
4.2
4.3
4.4
Appt. reminders
4.5
Ref
erri
ng
/ D
isch
argi
ng
Org
aniz
atio
n
Rec
eivi
ng
Org
aniz
atio
n
Meet / evaluate / treat pt.
4.6 4.7
Address other needs / eligibility
4.8
Update care plan / risk
strat.
4.9 Share
relevant info w/ Care
Team
4.10
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Transitions in Community Setting Referrals and Discharges amongst PCP, OP, Specialist and CBOs
COMM 4
Tasks/ Steps: Transitions in the Community Setting • Data • Technology
COMM 4.1
Make referral • Org. staff or pt. may initiate appt. scheduling • Consider cognitive functioning (e.g. intellectual disabilities, TBI, dementias, etc.), as
well as communication (not the same as language) and physical barriers to accessing healthcare services wherever applicable
• Referral • Care team • Encounter Hx
• EMR • CM • Scheduling
COMM 4.2
Receiving Organization: Schedule appt. / open case (as applicable) • Expected that the receiving organization: Hold “Frozen” slots for high risk pts. who
require an expedited appt. • Availability of NP / PA for hospital follow-ups • PCP walk in / evening hours available • 24/7 hotline to field questions and prevent unnecessary ED visits
• Patient Hx • Pt status • Assessment • Care plan • Services • Care team
• EMR • CM
COMM 4.3
Send relevant pt. information • H&P • Medical indications • Medication list • Problem list • CM Assessment • Care plan • Pt’s ongoing education needs
• Patient Hx • Pt status • Assessment • Care plan • Services • Care team
• Scheduling • EMR • Hixny
COMM 4.4
Confirm receipt of documentation / follow up as needed • Future appts. • EMR
COMM 4.5
Pre-visit planning • Review documents and medical history • Huddles, interdisciplinary team meetings (e.g. PCP and BH embedded together)
• Patient Hx • Pt status
• EMR
COMM 4.6
Offer Appt. reminders • Future appts. • EMR
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Transitions in Community Setting Referrals and Discharges amongst PCP, OP, Specialist and CBOs
COMM 4
Tasks/ Steps: Transitions in the Community Setting Data Technology
COMM 4.7
Meet / evaluate / treat pt. • ID need for Intensive CM, condition / disease management, and medication
management • Risk stratify • Pt engagement and education (e.g., lifestyle choices, self-mgmt.)
• Patient Hx • Pt status • Assessment • Care plan • Services • Care team
• EMR
COMM 4.8
ID and address other needs or program eligibility • Identify other CM / Service providers / Medicaid programs (e.g. Catholic Charities,
Health Home) and share relevant visit information in timely fashion • Determine Health Home eligibility & initiate referral as appropriate • Coordinate with other community Case Managers • Identify / Refer to APS / CPS • Communicate / coordinate with Mobile Crisis / outreach services • Expedite PCP alignment for care needs • Pt. Navigation services to support non-clinical barriers
• Services • Encounters • Eligibility
• EMR
COMM 4.9
Update Care Plan / Risk Stratification (as applicable) • Patient Hx • Pt status • Assessment • Care plan • Risk strat
• EMR
COMM 4.10
Share relevant follow up / results information • Share results of visit / service / report / consults with referring affiliate / organization
(follow up to close the loop)
• Patient Hx • Pt status • Assessment • Care plan • Services • Care team
• EMR • Hixny
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Technology Alignment Case Study of Alerts / Triggers
X
ED Visit Discharge /
Transitions of Care
Observations &
Inpatient Care
Currently available functionality: Future: Additional community-based alerts
PCP / Specialist
Visit
Notified that patient presented in the ED
Notified that patient has been DC and accesses data: • Encounter hx • Working dx • Care plan, needs
Notified that patient has been admitted and accesses data: • Working dx • Care plan
Notified of completed visit and accesses data: • Care plan, needs • Assessments • Risk score
Notified of significant changes to pt. records and accesses data: • Encounter hx • Assessments • Service assessments
CO
MM
UN
ITY
ALE
RTS
*
AC
UTE
IP /
ED
A
LER
TS ED CM notified and
accesses data: • Care plan • Previous summaries • Risk scores
IP CM notified of admission and accesses data: • Patient hx • Care plan • Risk scores
CBO Affiliate
Visit
* Alert received by community care team members (e.g. PCP, Community CM, MCO CM, etc.) Note: List of accessible data are examples, not complete
38
CI CCM Framework: Foundational Components Centralized Functions
Administrative Support
Tracking / reporting Key Performance Indicators (KPIs)
DOH reporting
Contract Support
Cost analysis and financial needs
Training Support
Develop standard PPS training materials / job aids / tools
Conduct training
Provide coaching / monitoring
IT Services / Support
Technology system use standardization
Data management
IT support services to facilitate interoperability
Centralized CM Support
Assess and provide CCCM services as appropriate
Refer patients to CC services
CC support:
− Post DC calls
− Patient reminders
− Schedule appts.
− Enrollment in programs
Patient Navigation services :
− Transportation / housing
− Financial
− Managing resources on-line
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Identify eligible patient (PMO, ED/Hospitals,
Other Providers, CBOs)
• Clinical Assessment • MAPP • Salient • EHR • Payer data • PHM Analytics
Create referral
CCCCM* Entity
PMO Database
Determine Attribution
Centralized Care Coordination Care Management Proposed Process Flow (1 of 2)
CCCM* – Centralized Care Coordination Care Management
40
PMO Database
Determine Attribution
AMCH PPS
Patient ?
CCCCM to notify referring entity No
CCCM Needs Assessment
Yes
Linkages to Current or New PCMH
- HH* CM Provider if HH or HHARI** eligible
- Other CBOs for CCCM
Centralized Care Coordination Care Management Services
* HH – Health Home ** HHARI – HH At-Risk Intervention Project
Centralized Care Coordination Care Management Proposed Process Flow (2 of 2)
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Tools and Templates
42
Tools and Templates Applying Tools and Templates in Practice
Tool / Template Usage / Purpose Setting
InterQual / Milliman Standard tools used to assess and support level of care and appropriate utilization; used at admission, throughput and discharge
Acute
Patient Activation Measure (PAM)
Survey used to gauge health and health care involvement / participation Acute and Community
LACE Score
Evidenced-based, standard tool used to assess risk of readmission; used at admission, throughput and discharge to guide DC decisions
Acute
Risk Stratification Tool (Primary Care)
Standard tool, adapted from Camden Health and American Academy of Family Physicians, used to inform and support CM and pt. interventions
Community
LOCADTR 3.0 Standardized tool used to determine the most appropriate LOC for a client with a substance use disorder
Acute and Community
Medicaid Health Home Eligibility
Criteria used to identify if pt meets Health Home criteria and agrees to referral Acute and Community
CM Assessment Standard list of questions / data points to gather and review for each patient throughout the care continuum; allows for holistic assessment of pt.
Acute and Community
Patient Engagement / Care Plan
Patient centered care plan for care across the continuum, accessible by all CMs, providers and care coordination team members
Acute and Community
Transition of Care Summary
A summary care record related to each transition of care or referral of a patient to another setting of care or provider of care
Acute and Community
The CI Work Group and other PPS governing bodies decided on the use of the following standard tools to support care coordination in various settings
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Patient Engagement / Care Plan (1 of 2) Assumptions, Considerations and Implications
• Simple and concise plan that is practical and patient-focused
• Living document that changes as the patient changes
• Aims to engage a patient / caregiver at a specific moment in time, and identifies their goals
Assumptions
• Patients may need to prioritize their needs due to impacts by social barriers (e.g. housing)
• Make the patient the owner of their care plan using their own words and open ended goals
• Frame goals so that they feel achievable; piecemeal the steps required to achieve the goal
Considerations
Implications
• Training: Ability to train (e.g. motivational interviewing) those interacting with Pts, and taking ownership of patient care plans
• Technology: Ability to track changes in the care plan and share it across the continuum
• Technology / Training: Ability for PCPs to view the care plan and train on its goals / content
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Diagnosis
Pt’s perception of diagnosis
Health literacy level
Caregiver involvement
Support / resources available*
Functional needs*
Prescriptions
Patient Goals (1-3 goals max)*
Specific CM activities / time frame / interventions*
Referrals made (where / when / with whom)
Follow-up appts. scheduled (where / when / with whom)
List of key providers involved in Care Plan*
Patient’s signature documenting agreement with Care Plan *
Patient Engagement / Care Plan (2 of 2) Essential Elements to be Captured and Shared
*NYS Health Home requirement
Include: • Priorities • Ability to self manage • Preferences / strengths • Barriers to goals • Target dates / times
Patient Goals
Care Plans should be completed at the first identification of need, in any setting, for moderate / high risk patients and shared via Hixny during transitions
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Care Coordination - Future State
Current State:
• Experiences headache, blurred vision and concerns of a stroke
• Dial 911 and is transported to ED by ambulance
• ED staff determine hyperglycemia, secondary to medication non-
adherence
• Daily meds changed to include insulin, briefly counseled on self-
injection and sent home with recommendation to f/u with a PCP
• Several weeks later, John is readmitted with the same condition
due to lack of timely access to PCP & ongoing confusion regarding
the appropriate use of multiple medications
Patient Name: John Doe Age: 44 Years Insurance: Medicaid
Current State: Fragmented Care
Medical History: • History of uncontrolled Type II Diabetes Mellitus,
Hypertension • Lacks transportation to visit PCP, Language challenges • Medication non-adherence • Two prior hospital admissions within the preceding 6
months
• If existing patient of PPS, may call Care Management Operations
(CMO), if not dials 911
• If he calls CMO, either referred to PCP or sent to ED based on triage
• If he dials 911, he is transported to ED by ambulance
• PCP and ED care coordinator will receive alerts for John’s ED visit
• ED staff determine hyperglycemia, secondary to non-adherence, treat
with insulin and change daily meds to include insulin
• ED team provides education and management of DM and
comorbidities
• ED care coordinator meets with John, schedules next day visit PCP and
arranges transportation
• ED care coordinator will forward care plan/discharge notes to PCP and
CMO
Patient Name: John Doe Age: 44 Years Insurance: Medicaid
Future State: Coordinated Care – ED Care
Medical History:
• Experiences headache, blurred vision and concerns of a
stroke
• John receives assistance from a community care coordinator
from the CMO for linkages to PCMH, transportation, and access
to medications.
• John is seen by his PCP and their team for follow-up assessment,
appropriate medication management, care plan development,
self-management support using shared-decision making tools,
and referral to community-based resources for ongoing support.
• PCP team sends the updated care plan and prescription
notification to CMO.
• Pharmacy fulfills the prescription and notifies CMO.
• CMO follows up with Juan if he fails to pick up his prescription
and provides ongoing support for a period of time.
Patient Name: John Doe Age: 44 Years Insurance: Medicaid
Future State: Coordinated Care in a PCMH & the Community
• John’s CMO team schedules his PCP visits on a regular basis.
• John’s PCP discovers John’s smoking history and notifies the
CMO team to update the goals and advises lifestyle changes.
• CMO team schedules visits with DM educator/smoking
cessation.
• John is able to track his weight, glucose goals, and blood
pressure using home-based equipment and communicate the
results to the PCP team via the Patient Portal.
• CMO team schedules Home Care and other community based
appointments, as needed.
Patient Name: John Doe Age: 44 Years Insurance: Medicaid
Future State: Prevention of Secondary Complications
