8/28/2017

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Improving Financial & Clinical Performance Through

Health Information Exchange & Enhanced Transitions

LeadingAge NY 2017 Financial Professionals Conference

August 30, 2017

• Al Kinel: President Strategic Interests

• Travis Masonis: CIO Jewish Senior Life

• Cesar Perez: Sr. Account Manager Healthix (NYC RHIO)

• Jeff Norton: VP of Sales, SNF & ALF PointClickCare

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Agenda

▪ Measures Positively Impacted by HIE & ToCs

▪ Industry Actions to Utilize HIE to Enhance ToCs

▪ Perspectives of Jewish Senior Life

▪ Capabilities, Perspectives & Example from a RHIO

▪ Capabilities, Perspectives & Example from PCC

▪ Discussion: Barriers & Actions to Make a Difference

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CMS 5-Star Short-Stay Quality Measures

Source: Nursing Home Compare

Claims Based Measures

Measures:

• % Short-Stay Residents with 30 day Readmissions

• Hospital readmissions from SNF rehab

• Includes hospitalizations following SNF stay

• % Short-Stay Residents ED visit within 30 days

• Pop Health, Care Management, provider access

• Collaboration and use of telehealth

• % Short-Stay Residents Successfully Discharged to

Community

• MDS to identify patients discharged & claims

• Success: 30 days no hospital, SNF readmit death

Mechanics:

• Claims, in conjunction with MDS used to build stays

• Medicare FFS, soon to include Medicare Advantage

• Short stay residents following hospital stay

• Risk adjusted, based on claims, MDS & enrollment

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Hospital(s) Home Care / PGHD

Non-PCP Specialist

Urgent Care

CBOs / Social

Services

Labs, Rads, Geneticists

Behavioral Health

Disabilities

PT/OT

Community - PCMH

Transitions of CareWhere Information Gaps Appear & Compromise Care

SNF

Assisted Living

Inpatient Rehab

LTPAC

Health Home

PCP / FQHC

• Use Case 1:

– HOSPITAL to HOME

• Use Case 2:

– HOSPITAL to LTPAC

• Use Case 3:

– LTPAC to HOME

• Use Case 4:

– PCMH – PCP to Other

• Use Case 5:

– HOME to HOSPITAL

• Use Case 6:

– LTPAC to HOSPITAL

• Use Case 7:

– HOSPITAL to HOSPITAL

• Use Case 8:

– HOME to LTPAC

• Use Case 9:

– PROVIDER to BH/CBOs

• Use Case 10:

– Specialist to Specialist

Key Transitions

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Impact of Problems Associated with ToC

• 2001 Institute of Medicine (IOM) report, Crossing the Quality Chasm, described US

healthcare as decentralized, complicated, and poorly organized, noting “layers of processes

and handoffs that patients and families find bewildering and clinicians view as wasteful.”

• Health Affairs 2012: Inadequate care coordination, including inadequate management of

care transitions, estimated to cause $25 to $45 billion in wasteful spending in 2011 through

avoidable complications and unnecessary hospital readmissions.

• Commonwealth Fund 2013: Substantial proportion of readmissions caused in part by poor

discharge and transition planning and execution:

▪ ~ 20% hospitalized Medicare beneficiaries are readmitted within 30 days

▪ > 33% readmitted within 90 days

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Causes of Problems Associated with ToC

Source: Joint Commission Hot Topic in Health – Transition Planning 2012

• Communication: Providers do not effectively or completely communicate important information to each

other, the patient, or caregivers

Different Style / CultureNo Time for

Successful Handoff

• Patient Education: Patients or caregivers receive conflicting direction, confusing medications, and unclear

instructions about follow-up care. Patients may lack a understanding of medical condition or the plan

• Accountability breakdowns: In many cases, there is no physician or clinical entity that takes responsibility to

assure that the patient’s health care is coordinated across various settings and among different

Lack Standard

ToC ProcedureGap in Expectations

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Keys for Successful ToCs – More than HIE

• Right information, right time, right format…without extra noise

• Comprehensive Care Coordination, Health Coaching and PCMH Model

• Medication Management

• Effective Hand-offs to Providers and Social Workers

• Timely Post Discharge Follow-up

• Self-Management Care Plans with Patient Education and Clear Follow-up

• Identify and Provide Resources for Social Determinants of Care

• High Patient Satisfaction (correlated with lower 30 day readmit rates)

Sources:• Project BOOST (Better Outcomes by Optimizing Safe Transitions) – www.hospitalmedicine.org• Care Transitions Interventions (CTI) –www.caretransitions.org• CMS Community-Based Care Transitions Program (CCTP) – www.innovations.cms.gov/initiatives/CCTP/• Guided Care Comprehensive Primary Care for Complex Patients – www.guidedcare.org• Project RED (Re-Engineered Discharge) – www.bu.edu• State Action on Avoidable Rehospitalizations (STAAR) – www.ihi.org

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Partnering to Improve Transitions of Care (ToC)

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Hospitals & LTC/Home Health partners can jointly improve ToC effectiveness by

reviewing areas on both sides to change discharge planning, admit process & HIE:

• Improve Hospital-LTC ToC: discharge/admit▪ Screening and discharge efficiently getting patients to right facility

▪ Process & tools to provide LTC data needed to receive patient

• Collaborate After ToC: address patients & risks together▪ Process, tools, and alignment to identify patients at risk, gaps in care, actions to address

them, & means for team to communicate

• Improve LTC-Home ToC: discharge/admit▪ Discharge efficiently to home health agency, PCP, or both

▪ Process & tools to provide data and alert hospital

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Using IT & HIE to Improve Transitions of Care

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Process Technologies

Hospital Discharge Planning Care Management Tool - Creation of Care Plan

Risk Profile Scoring Tool

Referral Admin Process Discharge-Referral Process

LTC Admit Process

Metrics Reporting

Healthcare Information

Exchange (HIE)

Key Data from Hospital EMR in C-CDA

Transport Data (RHIO, DIRECT, Other)

Ability to Load Key Data in LTC EMR

Manage Patients at Risk Population Health – by payer, risk & other criteria

Dashboards & Rounding Tool with Alerts & Gaps

Telehealth: Surgeon, Care Team, Behavioral Health

LTC Discharge Process & HIE Key Data from LTC EMR in C-CDA

Transport Data (RHIO, DIRECT, Other)

Ability to Load Key Data in Home Health/PCP EMR

Transition

Of

Care

Transition

Of

Care

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LTPAC Attempting to Improve ToCs

S&I Framework - 2011

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Care Coordination Tool for ToC to LTC DataData Proposed to be Provided by Hospital Discharge

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DSRIP: Hospital Data that Facilitates LTPAC Care

Data Desired by LTPACRecipient Priority

Source Availability

Ease of Extraction

CDA Compatibility

Referrer Contact for Questions High High High Mod

02Sat High High High Mod

Detailed Pain Information High Mod Low Low

Detailed Functional and Cognitive Status High Mod Low Low

Pre-hospital admission meds High High High Mod

PT/OT care, abilities and willingness Mod High High Mod

Pressure ulcers / skin / wounds High High High Mod

Detailed Nursing Care: nutrition, hydration, devices, therapies

High High Mod Low

Advance Directives/MOLST High High Mod Low

Relative Notified of Transiton of Care? Mod Mod Mod Low

Vendor Supply / Info Mod Mod Mod Low

Notification regarding ToCs High High High N/A

FLPPS compared data requested by LTPAC to enable successful

transitions vs. ability to enable ToC to include additional data

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What do we have to do in our communities

to utilize HIE and other tools to improve

ToCs and enhance performance of SNFs and

Home Health agencies?

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Technology and Challenges to

Enable Better Partnerships for

LTPAC

Travis Masonis, CIO Jewish Senior Life

Overview of Jewish Senior Life

Comprehensive Portfolio CCRC/Lifecare Community

• SNF (362 Beds)

– short term rehab (68 beds, expanding to 88)

• Independent Living (90 Units)

• Assisted Living (78 Units)

• Adult Day Healthcare (85 slots)

• Outpatient Therapy Practice

• Companion Services

• Physician House Calls

• Alzheimer's Daytime Respite (Marian’s House)

1100 Employees including Therapy Department & Medical Staff

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Gather the data

• Gather what?

Referral Tracking

• Internal database measures– Response time

– Acceptance rates

– Referral patterns

– Diagnosis Classes

– Reason for bed denial

– Reason for bed refusal (by patient), where possible

• Curaspan– Similar metrics noted above

Understanding, managing, and improving LTPAC

performance as a partner receiving referrals

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Referral Tracking

• Allows JSL to understand mathematically

the shifts and trends in referral types:– Dx classes

– hard to place patients

– etc.

• More information = Better partnerships

Readmission Reduction

Tools/Analytics

• PointClickCare EMR

• eINTERACT

• Telemedicine (URMC Cardiac)

• Practitioner Engagement Mobile App for

providers

– Providers have more information at their

fingertips from the mobile device after hours

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Cost Accounting

• Measures activity based costs for the patient profiles.

Includes cost information pertaining to:

– Diagnoses (primary and comorbidities)

– Demographics (age, gender, etc.)

– Payor type

– Ancillary Charges

– Therapy Minutes

– Physician Visits

– LOS

• Shows value to referring hospital partners not only means

improving quality, but also reducing and controlling costs

– You can’t improve what you aren’t measuring

Inbound from RHIO

• RHIO to PCC• Lab

• Radiology

• CCD/CDA

– Perhaps ToC specific documents

• Value:

– Faster information at the provider’s disposal

– One system to log into

– Trend data over time

• Current status

– In the midst of build for Lab/Rad

– Still evaluating/planning CCD/CDA

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Outbound toRHIO

• PCC to RHIO• ADT

• Consents

• CCD/CDA

• Value

– Improved Care Coordination

– MyAlerts for both JSL and the community providers

• Current status

Discrete Data

• Discrete data is the enabler of interoperability

• Considerations when capturing data within the EMR:

– Usability

– Defined workflows/Standard Process for data entry

– Training

– Structured Progress Notes and Assessments

– Coded Dx’s on orders

– Up to Date Problem lists

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Opportunities/Challenges

• Telemedicine

• Advanced Data Sharing

– Targeted ToC documents, CCD/CDA consumption, global

readmission risk alerting

• Interoperability Costs and Complexity

– Hospital to RHIO to LTPAC partners.

• Predictive Analytics

• Biomedical/Telemetry Alerts for Readmission Risks

• Post-Discharge Monitoring (Wearables, Medication

Compliance, etc.)

• Clinical and Operational Integration Across

Organizations

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August 30, 2017

Improving Financial and Clinical Performance Through Health Information Exchange (HIE)

2

Table of Contents

▪Slide 3: What is HIE?

▪Slides 4 – 10: About Healthix

▪Slide 11: HIE Value

▪Slide 12: HIE Adoption Across NYS

▪Slide 13: Healthix Adoption in LTC

▪Slide 14: Barriers & Solutions

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3

What is HIE?

HIE

LTPAC

Lab & Radiology

Groups

Primary & Specialty

Care

HospitalsCommercial

Payers / Plans & Medicaid

Claims

Government / Public Health

Organizations

Behavioral & Community

Based Organizations

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About Healthix

Hundreds of healthcare

organizations at more than

1,500 facilities across New

York City and Long Island

participate in Healthix.

• Supplies secure data to improve healthcare quality, efficiency and effectiveness

• Provides a range of clinical information in real-time

• Facilitates care coordination

Healthix is the largest public

Health Information Exchange (HIE)

in the United States

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5

Healthix and the SHIN-NY

The SHIN-NY is

composed of 8 HIEs or

Qualified Entities (QEs).

The NYS DOH

establishes common

services, privacy and

security policies, and

technical standards for

interoperability.

When a user queries for patient data, Healthix automatically returns data

from both Healthix and the SHIN-NY.

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Role of Healthix in Exchanging Information

HEALTHIX

SHIN-NY

~ 500 Participants

~ 1,500 Facilities

PRIVATE HIEs

PRIVATE HIEsINCLUDE:• Health Plans• Large Provider

Systems • PPS • Pharmacies • More

eHealth exchange

and SHIEC

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7

Sources of Data

Hospitals Independent

Physician

Practices of

All sizes

Long-term

Care,

Nursing

Facilities

Behavioral

Health

Facilities

Federally

Qualified

Health Centers

(FQHCs)

Community

Based

Organizations

The breadth of data in Healthix is expanding in the number and type of contributors

63 213 123 57 35 30

Home

Care

Health

Plans

PPS

LeadsMedicaid

Health

Homes

Independent

Pharmacies

Independent

Labs &

Radiology

Centers

21

13 9 3 5 2

NYC

Correctional

Health

Services

All Other

Public HIEs

in New York

State

1 7

Medicaid

Claims

EMS

Veterans

Administration

In development

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Types of Data

▪ Demographics (Name,

Gender, DOB, Race,

Ethnicity, Language)

▪ Allergies

▪ Medications

▪ Medication Allergies

▪ Smoking Status

▪ Immunizations

▪ Encounters

▪ Observations

▪ Vital Signs (Hgt, Wgt,

BP, BMI)

▪ Pharmacy Fill Data

▪

In development

▪ Lab Tests, Values / Results

▪ Radiology Reports / Images

▪ Other Diagnostic Results

▪ Diagnoses

▪ Problem Lists

▪ Procedures

▪ Functional / Cognitive Status

▪ Care Plans / Team Members

▪ Discharge Instructions /Clinical

Summaries

▪ Advanced Directives

▪ Care Plans

▪ eMOLST

▪ EMS Run

Sheets

▪ Image

Exchange

▪ Medicaid

Claims Data

▪ Social

Determinants

of Health

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9

Healthix Core Services

PATIENT RECORDS SEARCHED VIA PORTAL

2,183CLINICAL SUMMARIES

DELIVERED

104,314CENs SENT TO:

ALL CLINICAL PROGRAMS

124,001CENS SENT TO:

PUBLIC HEALTH (NYSDOH)

361,593DIRECT MESSAGES SENT

9,568

MAY 2017

USAGEPatient Record Search:

Access to a more comprehensive patient profile statewide

Delivery of Clinical Summaries:

Ability to electronically deliver clinical summaries (CCD, C-

CDA) and lab results

Clinical Event Notifications (CENs):

24/7 Custom alerts provide real-time updates for patients in

care

Direct Messaging:

Secure HIPAA-compliant messaging

Predictive Analytics:

Assessing risk and managing patients to optimize care

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Uses of Healthix Data

▪ Accessing Patient Data in an Emergency Situation

▪ Managing Patients with Serious Medical Conditions using

Clinical Event Notifications

▪ Providing Transition of Care Documents for Physicians

▪ Supporting Secure Direct Messaging Between Providers

▪ Providing Alerts for Frequent Users of ED (3+ visits in 30 days)

▪ Facilitating Research using De-identified Data

▪ Connecting PPS Leads and Partners

IN DEVELOPMENT

▪ Delivering Alerts from Health Plans to Providers re: Gaps in Care

to facilitate care management

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11

NYS HIE Value Studies▪ In a study published in the Journal of the American Medical

Informatics Association, accessing the HIE within 30 days post

discharge from a hospital admission was found to be associated

with a 57% lower odds of same-cause readmission or approximately

605k in annual savings from averted readmissions.1

▪ In another study, published in the aforementioned research journal,

researchers found that compared to an ED setting without access to

an HIE, the setting with access to an HIE was associated with a 52%

and 36% reduction in the estimated number of laboratory tests and

radiology examinations, respectively.2

1 Journal of the American Medical Informatics Association, Volume 22, Issue 2, 1 March 2015, Pages 435–442, https://doi.org/10.1136/amiajnl-2014-0027602 Journal of the American Medical Informatics Association, Volume 22, Issue 6, 1 November 2015, Pages 1169–1172, https://doi.org/10.1093/jamia/ocv068

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HIE Adoption Across NYS*

*As of 06/30/17. Source: http://www.nyehealth.org/nyec16/wp-content/uploads/2017/08/SHIN-NY-Dashboard-for-July-2017-June-2017-Reporting-Period.pdf

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Healthix Adoption in LTC▪ Healthix has recruited approx. 60% of LTC facilities in target market

▪ Majority using SigmaCare or PointClickCare

▪ Developed streamlined models of integration with EMR vendors to

allow for standard implementations with minimal downtime

Optimal implementation of Healthix at LTC Organization

▪ 100 bed Facility in NYC using SigmaCare

▪ Bidirectional data exchange with Healthix

▪ Single Sign-On access within EMR

▪ Receiving Clinical Event Notifications (CEN’s) on patients post-

discharge

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Barriers and SolutionsBarriers

▪ Cost of interoperability

▪ EHR / Care Management Systems often charge customers an

integration fee along with ongoing maintenance fees

▪ HIE’s typically charge one-time integration fees

▪ Organizational commitment to change

▪ Workflow

Solutions

▪ Data Exchange Incentive Program (DEIP)

▪ Delivery System Reform Incentive Payment (DSRIP) Program

▪ Other value-based reform programs / initiatives

▪ Healthix provided training / education

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15

Contact Us

If you have questions, would like to see a demonstration or are interested in connecting with

Healthix

Cesar J. Perez646.619.6613cperez@healthix.org

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Enhancing Transitions of Care

Communication and collaboration

What Is Interoperability at PointClickCare?

Post Acute Care Providers

Hospital Systems

Insurance Organizations

Health Data Broker Systems

Patients

Families Home Care Providers

Care Providers

Interoperability is exchange of patient’s data between providers, institutions, 3rd party

vendors and with people within the patient’s circle of care.

Patients Circle Of Care Providers & Institutions Payers & Risk Bearers

ACO/Managed Care

Therapy

3rd Party Vendors

Pharmacy

Smart Devices .. Etc.

Data either moves point to point – direct integration from A to B, or through an

intermediary – HIE, RHIO, Repository (i.e. DIS), Exchange Provider

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Transitions Of Care

Seamless Transitions and Data Interoperability is key to provide the Highest Quality of Coordinated Care

Today

• Integrated Direct Messaging

• Direct Messaging Facilitated CCD and eINTERACT transfer form Exchange

• Patient death or discharge automatically sends the CCD to the local integrated HIE

Future

• Actionable CCD exchange and Service

• Data Insight Exchange

• Task and Alert Based notifications

• API Availability & 3rd Party Developer Program

CCD as a PDF is not Actionable

Challenges

HIE and Health System requirements vary greatly

from one another

Timing is very important

Identifying Patients and Users across systems

Need to share the “Right” information at

the “Right” time

EHR

Transitions of Care

• Stratis Health MN completed study of how electronic exchange of information benefited nursing homes and hospitals within a system through an HIE

• The nursing homes used the CCD and the eINTERACT transfer form to communicate during transitions of care.

• Included meeting with the ER receiving staff – admitted that they SELDOM IF EVER looked at paperwork from the home

o Time consuming

o Lack of consistency in aggregation and presentation of papers

o Found it easier to call and ask for the information rather than hunt through a package

• ALWAYS read the Transfer Form (current problem) and CCD (history)

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Managing High-Risk Patients

Identifying High Risk Residents

Client Specific

• Various risk assessment tools

o Elopement

o Braden

o Geriatric Depression Scale

System Tools

• eINTERACT

• POC – Advanced Reporting tools – AHRQ best practice toolset for

identifying risk of skin breakdown

• COMS**

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What is eINTERACT?

PointClickCare’s eINTERACT solution is a group of submodules designed to improve the

identification, evaluation, and communication on changes in resident status so that hospital

readmissions can be avoided. The solution includes the following components:

• eINTERACT Stop & Watch Alerts

• Real time alerting of changes from the norm through POC

• eINTERACT Change In Condition Alerts, Change In Condition Assessment & SBAR

Summary

• Assists in the identification of residents that SHOULD be transferred to hospital and

improves communication between practitioners and the facility

• eINTERACT Transfer Form Assessment

• Ensures communication of condition to hospital is complete and when combined with

CCD provides current and historical data for evaluation and treatment (continuity)

• eINTERACT QI Tools

• Identify gaps in process at both the resident level and the facility

eINTERACT: Tools and Integrated Care Team Process

Transition of Care – CCD and eINTERACT form sent via IDM

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• AHRQ Safety Program for Nursing Homes: On-Time Prevention Program

integrates clinical reports (Advanced Reporting) into PointClickCare workflow

using daily care capture through POC to identify residents at risk for developing

pressure ulcers and support clinical decisions to decrease those risks.

• Reports use POC data which identify changes which put residents at risk for

skin breakdown: incontinence, decrease in nutrition, changes in skin condition

and weight loss or gain and combinations thereof.

• When integrated into daily care, homes are seeing reduction in skin breakdown

of up to 25%.

• Benefits were initially identified using paper processes – not unlike eINTERACT

– and replicated in study from 2015-2016 that replicated benefits in HIT.

Advanced Reporting (AHRQ OnTime Reports)

The entire program and resources can be found at: http://www.ahrq.gov/professionals/systems/long-term-care/resources/ontime/pruprev/index.html

How to track, report and make

advancements in QMs that can

increase bottom line

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How to demonstrate quality & reporting

Embedded Analytics tools that allow you to have oversight of organization performance concerning:

• Readmissions

• Clinical Key Performance Indicator (CKPI)

• Quality Measure (QM)

• Quality Indicator (QI) outcomes.

System allows drill down to specific time frames, residents, units.

Readmissions (non risk adjusted) provides real time data by hospital, resident, location and time frame.

Reporting and insights

Instant access to:

Interactive dashboards at the

corporate, facility, and

resident levels for

Readmission, QM/QI and

CKPI data.

PointClickCare Analytics

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How does your organization benefit?

• Increase Corporate Oversight – Gain increased visibility with multiple tiers of

reporting, with interactive dashboards available at the corporate, facility, and

resident levels to quickly identify discrepancies and outlier facilities, saving you

time and reducing unnecessary hospital readmissions.

• Improve Quality of Care – Identify your highest acuity population as well as

which residents are triggering negative outcomes and are at risk for readmission,

enabling you to take immediate action and minimize risk.

• Enhance Problem Solving Capabilities – Conduct detailed root-cause analysis

and prepare responsive improvement plans, boosting overall corporate

performance and your reputation.