Date: Monday, Apr 8, 2013 Time: 9:30 AM - 12:30 PM

1. Date: Monday, Apr 8, 2013 Time: 9:30 AM - 12:30 PM • These presenters have nothing to disclose Using Quality Improvement and Health IT Innovations to Transform Care in the Primary Care SettingThe Greater Cincinnati Beacon Collaboration

2. Session Objectives • After this session, attendees will be able to: • 1.) Learner will understand the use of Health IT tools to catalyze quality improvement work in a primary care setting • 2.) Learner will be able to discuss the intersection of quality improvement and Health IT in meeting the requirements of a Patient Centered Medical Home. • 3.) Using the Transformation Equation, the participant will be able to identify a component(s) of the equation as a starting point for transforming care in their own setting

3. An Overview of the Greater Cincinnati Beacon Collaboration Pattie Bondurant DNP, RN Gina Carney

4. Greater Cincinnati Beacon Collaboration (GCBC)

5. Why is technology critical to improving health and health care? • “Information is the lifeblood of medicine. We are only as powerful as the information we have, whether we are a nurse practitioner, a physician, or a respiratory therapist.” Dr. David Blumenthal, former National Coordinator for Health Information Technology

6. Patient Care is at Stake • More than 40 percent of outpatient visits involve a transition of care • 1 in 5 discharged Medicare enrollees are readmitted within a month – most are preventable • Referring physicians receive feedback from consultants 55 percent of time • Physicians make purpose of referral clear 74 percent of time

7. Incomplete Knowledge of Diabetes and Asthma Care Quality: Data exists in silos – need more complete data for improvement No single health system, hospital or practice has complete view of patient care Many gaps in information, data sharing only partially electronic Preventable ED visits: Patients need appropriate primary care rather than emergency care Hospital Readmissions: Hospitals will be challenged on reimbursement for readmissions – big financial impact Patients need appropriate primary care to prevent readmission Transitions in Care: PCP lacks information from patient’s hospital visit Specialists lack most current information from PCP Case for Intervention

8. GCBC Adult Diabetes ProjectWhat does success look like? Goals: 5% improvement in overall D5 composite score (Registry or EHR-MU Stage 1) Reduction of ED/Admissions by 10% (ED/Admit Alerts) 80% of Beacon adult PCP practices will achieve at least Level II recognition . 10% Improvement in Aggregate Culture Survey Scores

9. GCBC Adult Diabetes ProjectClinical Transformation Results/Progress To Date • 100% of Beacon adult PCP practices achieved Level III recognition, the highest possible distinction • Achieved 10% Improvement in Aggregate Culture Survey Scores • Interim results (2010- 2011) 7% Increase in Beacon Cohort III teams, 3% Increase in Beacon QID5 teams

10. Transforming Healthcare Pattie Bondurant DNP, RN Gina Carney

11. Transformation EquationWhat Did We Learn?

12. Patient Centered Primary CareExtreme Makeover Uncoordinated care Over-loaded schedule Physician & practice-centric Arbitrary quality improvement projects Lack of clear leadership & support Team-based approach Open access Patient engagement & empanelment Data directed quality improvement efforts Engaged leadership

13. Using the NCQA Framework

14. Emphasizing Sustainable Change

15. HITECH: Policy Framework Better care for individuals, better health for populations, and lower per-capita costs. IHI-Triple Aim Initiative

16. Meaningful Use & Incentives • The 2009 ARRA/HITECH Act authorizes incentive funding for health care providers who demonstrate “meaningful use of health information technology.” • The federal government will pay eligible professionals that meet meaningful use (MU): • Up to $44K under Medicare or • Up to $63,750 under Medicaid • Eligible hospitals can receive millions. • Payments come in 3 Stages – with increasing requirements.

17. Stages of Meaningful Use *Indicates “payment year” in which each Stage is first introduced. Actual compliance timeframe depends on an EP’s first payment year.

18. Quality Reporting: Monitoring Progress

19. HealthBridgeHealth Information Exchange • In operation since 1997 as a 501c3 Not for Profit • One of the nation’s largest, most advanced and successful health information exchanges • One of only a handful of HIEs nationwide with a sustainable business model • Provide HIE services for Greater Cincinnati and four other HIEs – Dayton HIN, CCHIE, HealthLINC, NEKY RHIO, Quality Health Network • What Does an HIE Do? • Delivers 3-6 million clinical messages PER MONTH; • 2011- more than 60 million messages; • 3+ million unique patients, 50 total hospitals, 7500 physicians

20. Two Remedies for Better Information • Like any good transportation system, our health information system must have two parts to work well: HIT = health information technology (e.g., EHR) + HIE = health information exchange and interoperability But the business case for HIT and HIE in health care is challenging.

21. ED/Admission Alerts • Goal: reduce readmissions and prevent subsequent ED visits by enhancing the delivery of better coordinated, preventive care in the primary care setting • Process • Electronic Alerts triggered on registration at ED or hospitalization • Alert sent through HealthBridge to Primary Care Physician (PCP) • Alerts are Patient Centric-alerting PCP where the patient presents for care, anywhere in the region • Practice intervenes – schedules follow up appt. w/patient, informs of same day/open scheduling for future, get copy of discharge

23. ED/Admission Technology Data Elements of ED/Admission Alert

24. Direct with PDF Attached ED/Admission Alerts

25. ED Alerts Project University Internal Medicine - Pediatrics Experience Jonathan “JT” Tolentino, MD Assistant Professor of Internal Medicine and Pediatrics University of Cincinnati

26. UC Internal Medicine-Pediatrics Clinic at Hoxworth • Hospital-Based Clinic • Combined faculty-resident teaching and private practice • NCQA Level III-Certified Patient Centered Medical Home. • Many unique challenges associated with combined practice. • Diverse payer mix – 60% Medicare/Medicaid, 25% private, 15% indigent care

27. Clinic Characteristic • Team: • 35 Attending providers and resident providers assigned to one of five nurses for care management/coordination • 10 additional faculty preceptors present one half-day per week for teaching • Medical Assistants – Clinic triage and immunization • Clinical Support staff - patient scheduling and referrals • Electronic Medical Record • GE Centricity EMR, not integrated with inpatient Lastword • Transitioned in July 2012 to EPIC outpatient and inpatient • ED/inpatient notification available for those admitted to UC Health facilities

28. Problem Definition • Lack of meaningful data • No process to systematically identify patients visiting the emergency room • Inconsistent process

29. Understanding our problem:Patient Visits to the ED Patient discharged from hospital Patient visits the ED Patient admitted to the ED Patient admitted to the hospital Patient sets follow up visit Admit? Y N Patient follows up at MP Clinic Patient discharged from the ED Patient sets follow up visit

30. Our process failures Patient visits the ED Patient admitted to the ED Patient discharged from ED Patient sets follow up visit Patient follows up at MP Clinic • Patient/family does not call • Office unaware of need for follow up • Home care services unaware of need for follow up • Patient visits a non-UC Health ED • ED seen as primary provider for acute illnesses • No appointment available • Clinic closed • Pt’s vague understanding of ED visit • Late follow up • Incomplete or delayed ED visit information • Inability to communicate with ED provider • Incorrect PCP identified by ED or patient • PCP not notified of the ED visit • ED visit occurs during non-clinic hours • PCP contact “non-critical” to the ED visit • No notification to the PCP’s office • Vague discharge instructions • Despite PCP notification, support staff/nurse not instructed to set follow up • Information overload • Delayed notification of ED visit to PCP

31. Recognized Barriers System Created Implications of the System Inconsistent practices and processes Lack of reliable information Lack of coordination Ineffective follow up appointments No tools or processes to coordinate care and uncover gaps • > 45 providers • Multiple hospitals and hospital systems • Incomplete or missing medical records • Teaching practice – trainees at different levels of experience and understanding • Diverse payer group • Provider-centered decision making model

32. Task 2: Create a High Level Transformation Process Outline • Identify Stakeholders: • - • - • - • Example: Process Outline: • - • - • - Action 3 Action 1 Action 2 Kick Off Convene Stakeholders Aim Statement and Charter Develop Your Process Map

33. Task 2: Create a High Level Transformation Process Outline Action 2 Action 3 Action 1 Kick Off Convene Stakeholders Develop Your Process Outline Aim Statement

34. Task 3: List Challenges in Your Transformation Equation

35. ED Alerts Post Intervention University Internal Medicine - Pediatrics Experience Jonathan Tolentino, MD Assistant Professor of Internal Medicine and Pediatrics University of Cincinnati

36. Objectives for the UC Med-Peds ED/Admit Alert Project • Characterize the use of emergency services by patients with diabetes • Develop a system that coordinates care after an emergency department visits in an environment with multiple providers • Develop clinic infrastructure to divert emergency department visits for non-emergent illnesses

37. Our Approach using the Transformation Equation Data Empanelment Empanelment Team Development Empanelment Meaningful Tools Data Empanelment Meaningful Tools Data Team Team Development

38. Empanelment • Our patients with type II diabetes that are at high risk for complications will need close follow up after a visit to the emergency room for a diabetes-related visit. This risk stratification strategy will not include patients who are in the emergency room and admitted to the inpatient unit for a diabetes-related issue. • N=125 (out of 435 total)

39. Team • Clinical Support Staff • Medical Assistant • Nurse • Physician • Clinic Manager • System developed to empower support staff and MAs to become the key drivers to the success for care coordination. • Who is your “keystone?” “Scope of training” vs. “Scope of ability”

40. Developing Tools for Success Diabetes-related ED visit is defined as a patient whose diagnosis description/chief complaint transmitted through the ED alerts system includes any of the following: Hyperglycemia, Elevated Blood Sugar, or High Blood Sugar Out of medications or in need of medication refills Infected foot or lower extremity Hypoglycemia or low blood sugar

41. Our Johari Window* • “Ignorance is bliss”: • Moving out of the unknown. * Luft, J.; Ingham, H. (1955). "The Johari window, a graphic model of interpersonal awareness". Proceedings of the western training laboratory in group development (Los Angeles: UCLA).

42. One Patient’s Story

45. Feedback • MD experience • Positive, noted opportunity to reach out to patients who have not been seen in a while • Notification of patients admitted helpful, especially when admitted to non-UC Health hospital • MA and CSC experience • Easy to use algorithm, no issues with determining which patients need to be called • Highest volumes on Mondays • Difficulty getting records from some health systems • RN team • Positive – able to help manage patient team • Some difficulty getting records from health system with multiple hospitals • Uncertainty of follow up needed for patient who have been admitted • Late adopters – CSC and MAs were our earliest adopters

46. Our Lessons • ED alerts coupled with a simplified algorithm empowers our nursing, MA, and CSC staff to assist MD/providers in decision making • Coupling point of care information, meaningful use, and a simplified algorithm is easily adaptable to chronic care management of many diseases • Limitations with current point of care information – ED visits vs. inpatient visit. • Adding decision support for with risk stratification allows for additional empowerment of decision making. • Some elements may not be in our control - Not all patients are willing to make a follow up appointment, even after reaching out to them.

47. Our Lessons • Practice transformation is possible if all aspects of the transformation equation is addressed. • We just now beginning to understand the process and our patients • Backing into optimized system of care – cannot always go in without the data. • Only 16% of our diabetic patients use emergency care services for diabetes-related reasons • Over 30% of our diabetic patients were going to other health systems – what are we missing, what didn’t we know before.

48. Questions • Beacon web page • www.healthbridge.org/beacon • Social Media • Twitter: http://twitter.com/healthbridgehio • Facebook: http://www.facebook.com/pages/Cincinnati-OH/HealthBridge/128672340540952 • LinkedIn: http://www.linkedin.com/company/healthbridge_3 • YouTube: http://www.youtube.com/user/HealthBridgeHIE Thank You……….