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Downstate New York Care Coordination Project September 16, 2013. Context. NYS Medicaid Health Homes have implemented (or are implementing) care coordination solutions to meet their near term requirements Each Health Home currently uses a separate care management system or EHR - PowerPoint PPT Presentation
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Downstate New York Care Coordination Project
September 16, 2013
Context• NYS Medicaid Health Homes have implemented (or are
implementing) care coordination solutions to meet their near term requirements
• Each Health Home currently uses a separate care management system or EHR
• In the Downstate NY region, there are many providers who are in multiple Health Homes and multiple RHIOs and their patients will cross borders
• If various care management tools do not support interoperability, providers may have to use 2 or 3 different systems and this is not sustainable
• Current state leaves untenable situation of no care plan interoperability
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Goals and Objectives• Develop consensus around functionality that would
enable enhanced care coordination, care plan management and interoperability across Health Homes and RHIOs through the SHIN-NY
• Align activity with developments at the national level• Develop Requirements to support the interoperability
and joint management of Care Coordination Plans across organizations
• Phase I implementation - Demonstrate the ability for two sites with two different care management tools to exchange Care Coordination Plans
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Requirements
• Enrollment of Health Home patients• Linking of patients and providers: care teams• Exchange of interoperable care plans• Clinical Event Notifications• Secure Messaging• Access to medical records for clinicians• Access to care plans for non-clinicians
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The DCC Workgroup agreed upon the following seven functions:
NY Downstate Pilot Participants5
Org. Name Type Vendor/ Type LCC Standards
Addiction Institute of NY- Methodone Mgmt Program Behavioral Health Netsmart Care Mgmt Care Plan
Addiction Institute of NY- Outpatient Treatment Program Behavioral Health Netsmart Care Mgmt Care Plan
St. Luke’s Roosevelt Hospital Acute Care Caradigm HIE/ Care Mgmt Care Plan
Continuum Health Home Network (CHHN) IDN Caradigm HIE/ Care Mgmt Care Plan
CHHN AIDS Service Center CBO Caradigm/ HealthIX HIE Care Plan
CHHN Americare Home Care Caradigm/ HealthIX HIE Care Plan
CHHN Argus Community CBO Caradigm/ HealthIX HIE Care Plan
CHHN Association for Rehab CM & Housing CBO Caradigm/ HealthIX HIE Care Plan
CHHN Beth Israel Medical Center Acute Care Caradigm/ HealthIX HIE Care Plan
CHHN Callen Lorde Community Health Center PCP Caradigm/ HealthIX HIE Care Plan
CHHN Dennelisse CBO Caradigm/ HealthIX HIE Care Plan
CHHN NADAP CBO Caradigm/ HealthIX HIE Care Plan
CHHN Project Renewal CBO Caradigm/ HealthIX HIE Care Plan
CHHN Puerto Rican Family Institute CBO Caradigm/ HealthIX HIE Care Plan
CHHN Ryan Health Center PCP Caradigm/ HealthIX HIE Care Plan
CHHN Services for the Under Served CBO Caradigm/ HealthIX HIE Care Plan
CHHN Westside Federation for Senior & Supportive Housing CBO Caradigm/ HealthIX HIE Care Plan
CHHN Institute for Family Health PCP Caradigm/ HealthIX HIE Care Plan
CHHN Isabella Nursing Home NH Caradigm/ HealthIX HIE Care Plan
• Care Coordination Plan (CCP) refers to a shared document that is used to track problems, goals, interventions and outcomes related to both clinical and social issues
• CCPs are a focus of collaboration for diverse care teams across organizations
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Care Coordination Plan (CCP) CollaborationWhat is a CCP?
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Care Coordination Plan (CCP) CollaborationUse Case
1. Author will create and edit the CCP in a care management tool that uses a national agreed upon structure for interoperable CCPs
2. Editor will view the CCP in their local care management tool, and suggest edits to the Author for review and approval. The Author retains editorial control of the CCP
3. Reader can view the most recent CCP in the RHIO, and provide comments to the Author through secure messaging
Iterative process based on interoperability standards
EditorAuthorv1
v1 edits
v1
RHIO
Reader
v1
View only
Healthix HEAL 17 – Project Highlights• Identified two sites with two different vendors to participate in Phase 1
implementation, both part of Continuum Health Partners• Addiction Institute of New York
• Methodone Treatment Program (Netsmart) • Outpatient Treatment Program (Caradigm)
• Held kick off meeting with stakeholders in early June• Agreed on Requirements and Phase 1/2 development• June – July: Design phase; engaged Lantana to align the data model
with proposed standard as closely as possible• July - August: Development, finalize draft data model for the standard
Care Coordination Plan with the LCC Standards Workgroup• September: Testing, Acceptance• October: Phase 1 Implementation, Evaluation
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