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Mile High Health AllianceCORHIO Solutions in Focus:
Patient Event Notifications High Utilizers Sub Group
March 22nd, 2017
Mark Carlson
CORHIO Overview
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Mission, Vision, Values, Goals
Working Statements
© 2016 CORHIO – All Rights Reserved – CORHIO Proprietary – Not For Redistribution
Mission CORHIO empowers people, providers, and communities
by providing the information they need to improve health
Harnessing the power of data for health and vitalityVision
Delivering with Integrity and Accountability
Building Community through Collaboration
Pursuing Innovation with Determination
Deliberately Creating a Fun and Respectful
Environment
Values Making a Commitment to Excellence through Life-Long Learning
Products, Services, Trust: CORHIO will be a trusted provider of
technology and services that advance the Triple AimGoalsEmployer: CORHIO will be an employer of choice
Sustainability: CORHIO will continually seek new ways to
recognize the value of its assets
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CORHIO By the Numbers
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61Hospitals Connected
(11 more underway)
4,300+ Providers Connected
(9,900+ total users)
4,000,000+ Patients in the
Community Health Record
Last updated 3/13/17
CORHIO empowers people, providers, and communities by providing the information they need to improve health.
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Banner Health System
• Banner Fort Collins Medical Center (4/2015)
• East Morgan County Hospital (8/2012)
• McKee Medical Center (8/2012)
• Northern Colorado Medical Center (8/2012)
• Platte County Memorial Hospital, Wyo (3/2016)
• Sterling Regional MedCenter (8/2012)
• Torrington Community Hospital, Wyo (3/2016)
• Washakie Medical Center, Wyo (3/2016)
HealthONE Health System (12/2014)
• North Suburban Medical Center
• Presbyterian/St. Luke’s Medical Center
• Rocky Mountain Hospital for Children
• Rose Medical Center
• Sky Ridge Medical Center
• Spalding Rehabilitation Hospital
• Swedish Medical Center
• The Medical Center of Aurora
Centura Health System (10/2011)
• Avista Adventist Hospital
• Castle Rock Adventist Hospital
• Littleton Adventist Hospital
• Longmont United Hospital (12/2011)
• Mercy Regional Medical Center
• OrthoColorado Hospital
• Parker Adventist Hospital
• Penrose Hospital
• Porter Adventist Hospital
• St. Anthony Hospital
• St. Anthony North Hospital
• St. Anthony Summit Medical Center
• St. Catherine’s Hospital, Kansas (09/2014)
• St. Francis Medical Center
• St. Mary-Corwin Hospital
• St. Thomas More Hospital
Connection dates in parentheses
Last updated 3/13/17
Hospitals – Connected
CORHIO empowers people, providers, and communities by providing the information they need to improve health.
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SCL Health System (Exempla) (5/2014)
• Good Samaritan Medical Center
• Lutheran Medical Center
• Saint Joseph Hospital
Children’s Hospital (12/2012)
• Anschutz Campus
• Uptown Denver Campus
• North Campus, Broomfield
• South Campus, Highlands Ranch (1/2014)
• Children’s at Parker Adventist Hospital
• Children’s Urgent & Outpatient, Wheat Ridge
• Children’s At Memorial Hospital, Co Springs
Boulder Community Health (2/2011)
• Boulder Community Hospital
• Boulder Community Foothills Hospital
Connection dates in parentheses
University of Colorado Health System
• Grandview Hospital
• Medical Center of the Rockies (12/2011)
• Memorial Hospital Central (7/2012)
• Memorial Hospital North (7/2012)
• Poudre Valley Hospital (12/2011)
• University of Colorado Hospital (6/2013)
Independent/Other Hospitals
• Conejos County Hospital (9/2014)
• Craig Hospital (7/2013 query only)
• Estes Park Medical Center (8/2014)
• Evans Army Community Hospital (11/2016)
• Melissa Memorial Hospital (10/2014 query only)
• Mt. San Rafael Hospital (8/2015)
• Pagosa Springs Medical Center (10/2015)
• Parkview Medical Center (4/2012)
• Prowers Medical Center (11/2016)
• San Luis Valley Regional Medical Ctr (8/2011)
• Yuma District Hospital (4/2016 query only)
Last updated 3/13/17
Hospitals – Connected (continued)
CORHIO empowers people, providers, and communities by providing the information they need to improve health.
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Independent Hospitals
• Animas Surgical Hospital
• Arkansas Valley Regional Medical Center
• Colorado Plains Medical Center
• Denver Health & Hospital Authority
• Kit Carson County Memorial Hospital
• Lincoln Community Hospital
• Rio Grande Regional Hospital
• Southwest Memorial Hospital
• Spanish Peaks Regional Health Center
• Valley View Hospital
• Wray Community District Hospital
Last updated 3/13/17
Hospitals – In Process to Connect
CORHIO empowers people, providers, and communities by providing the information they need to improve health.
Patient Event NotificationsSolutions to support interventional models of care and care management
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Problem Statement
Supporting Value Based and Population Health Models
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Traditional model for exchange/sharing of clinical data does not, alone, meet the requirements of emerging care management / ACO models of care:
• Patient/population centric care management is not as effective in a provider based routing model
• Need visibility into utilization based on real time notifications of access to services
• Identify and support the most vulnerable in a managed population
• Claims data does not support interventional care management• Patient engagement 3 months+ after encounter does not impact immediate cost and
patient need
• Inform analytics and interventional models to impact cost
Solutions in FocusCORHIO Intelligence Services
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Collaborations with community organization's helped CORHIO to develop new data offerings for the community:
• Patient Event Notifications – reports built using ADT data from the HIE
• Clinical Event Notifications (2017) –reports built using clinical data from the HIE
• Quality Reporting (2017) – reports for specific quality measurements
• Custom Report Development (2018) – new reports to meet a specific business and/or clinical need
CORHIO Intelligence
Services
Patient Event Notifications
Clinical Event Notifications
Quality Reporting
Custom Report
Development
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Patient Event Notifications (PEN):
• CHP provides current member file
• Inbound Admissions, Discharge and ED messages are matched
• Care managers use for patient follow up
• Information also captured to identify trends in access by members
Solution continuedThe foundations…
Patient Event Notification
How it Works
© 2015 CORHIO – All Rights Reserved – CORHIO Proprietary – Not For Redistribution 12
Laboratory
Radiology
Practice EHRs
Panel / Attribution
File
Patient Event
Notification
eMPI
Daily PEN Report
(Excel or CSV)
Real Time NotificationsCare Management SW
IP / ER Admit and Discharge (ADT)• Patient Demographics• Admitting / Discharge Dx• Location of Service• Treating Facility• PCP
ADTs
Patient Event Notifications
Report Example
Case Studies:Learnings / Challenges /Outcomes
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Requirements informing the deliverables…
• Developed customized reports using HIE data to improve pay-for-performance KPI for post-partum check-ups.
• Developed quantitative A1C report including values for diabetes management to monitor compliance and disease management.
• Developed report to identify dual Medicare/Medicaid patients to build required care plans within required CMS timeframe.
• Enrich daily notifications with Risk Scores to enable prioritization or engagements and follow-up.
Solutions In FocusPilot with Community Health Partnership (CHP)
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• Cost savings and care manager workflow efficiencies correlated with the utilization of HIE for data analytics (details pending)
• Less reliance on multiple solutions/sources to achieve key performance indicators that are difficult to meet with the inherent lag in claims data
• Foundational component necessary for true continuum of care coordination
• Real-time patient event notifications supports timely follow up and engagement
Outcomes: Community Health Partnership (CHP)
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EXAMPLE: Medicaid and Medicare ID numbers across the MME roster to identify dual eligible patients (SCP requirement)
RESULT: Increased visibility from 10 to 300 patients in the first month of production.
• Significant increase in meeting Care Plan requirements for MME
Outcomes: CHP
10Patients
300Patients
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• EXAMPLE: Post-Partum KPI requires 30-day check
• RESULT: L&D Report enable timely outreach to ensure mom get’s the indicated Post Partum assessment (performance improvement measurements in process)
Outcomes: CHP
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• Continue community HIE deployment efforts with CORHIO
• Advance technology development partnership with CORHIO
• Data Quality
• Incorporate all tools into a Community Care Coordination tool
• Client Track: Real Time Data Delivery
• Support the use of community and practice analytics
• Tools for utilization and care management reporting
Conclusion: CHP
FullWell (CHN) Problem Statement
Supporting ACO’s
In 2014 CHN created care coordination teams to manage the care of high-needs patients across the network’s at-risk populations.
The Challenge:
• CHN started the first iteration of this work with a daily hot spotter report on ACO attributed patients utilizing Centura facilities. However….ACO patients also receive care from non-Centuraproviders
• The health system needed a way to collect real-time utilization updates from out-of-network hospitals.
Solution in Focus
FullWell / CHN
In order to successfully support chronically ill patients, CHN leadership recognized the importance of providing its care coordination teams with access to real-time data on ED use, hospital discharges, and other utilization.
• In 2016, Centura partnered with CORHIO to gain real time access to ADT data from every connected hospital in the state
• CHN leveraged its Salesforce care coordination platform to automatically create unique identifiers for each of its 150,000 ACO patients.
• CHN has customized its Care Coordination software to create a visual timeline for each patient, which is auto-populated with the encounter data from CORHIO, including notification date, type, and facility.
• CHN has 15 RN care coordinators who each receive approximately 50 to 75 patient notifications each week, having about 300 patients on service at any given time.
• CORHIO notifications are assigned to coordinators based on the patient’s PCP, as coordinators are aligned with primary care practices within a given geographic region.
Outcomes To Date
FullWell / CHN
• Within one of its smaller commercial ACO populations, CHN has had a 0% hospital readmission rate for over 12 months.
• CHN has also seen a reduction of 5-13% in emergency department utilization which the organization attributes to the care coordination program.
• CHN’s providers have been very pleased with the COHRIO integration.
• Turnover rates for nurse care coordinators are very low, in part attributed to the flexibility and ability to provide proactive care coordination/management.
• Primary care physicians appreciate the real-time utilization data and the hands-on assistance of care coordinators, viewing them as part of the practice care team.
Other Participating Organizations
Clinica:
• Has realized a 400% increase in post-discharge outreach and engagement ensuring indicated follow up care is scheduled and care plan created
DoD:
• “Military health care providers and clinical “care navigator” staff have been able to reduce the time they spend tracking down patient information from civilian providers, increasing satisfaction.”
Innovage:
• Hard data being gathered but anecdotally: “Our users are really thrilled with the ADT information they now receive, to the point that any interruption in our messages is upsetting for them…”
