HIE-Enabled Data Sharing Between Hospital and Home Care Providers to Improve Patient Care

Within Bundled Payment Context: a Case Study

Katie Mullaly MS, RN NYULMCAmy Weiss PT, DPT VNSNY

Agenda

1. About Visiting Nurse Service of New York 2. About NYU Langone Medical Center3. Bundled Payment for Care Improvement Initiative4. Evolution of Data Exchange5. Results6. Challenges to Date7. Closing Thoughts

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• VNSNY is the largest not-for-profit home healthcare organization in the United States

• About 65,000 patients under direct or managed care on any given day– Care for more than 35,000 patients daily in all five New York City boroughs

plus Nassau, Suffolk and Westchester Counties– Manage the care of more than 30,000 VNSNY CHOICE Medicare and

Medicaid Health Plan members

• 17,000 employees including almost 2,000 Registered Nurses and Licensed Practical Nurses

• 2,276,690 total paraprofessional (clinical) visits in 2013• Clinical staff speak 50+ languages• The operational scale to successfully implement quality care

innovations across the care continuum

About VNSNY

Working on Your Own, You Cannot Achieve the Innovation Demanded in Today’s Healthcare

Environment

About VNSNY:Partnership as a Solution

Working in Partnership, We Can Innovate and Succeed!

About VNSNY:Partnership as a Solution

About VNSNY:Our Partners

Large Academic Medical Center

Integrated Delivery Systems

Teaching Hospital

Specialty Hospitals

National Disease Specific

Foundations

Sub-acute Care Facilities

Local Community

Hospital

Account Care Organizations

Federal + State Institutions

National + RegionalInsurance Providers

Physicians

Rehabilitation Centers

Proof of Concept Build Coalition Create Unified Programming

Create Clear Criteria for Success

About VNSNY:Partner Process

Needs Assessment

COLLABORATE1Partnering

ALIGN2Create Value

SOLVE3Evaluate

MEASURE4

NYULMC: ABOUT US

• An integrated academic medical center.• Comprised of four hospitals• 1,069 licensed beds• 39,000 patient admissions• 670,000 outpatient visits

NYU LANGONE MEDICAL CENTER NYU FACULTY GROUP PRACTICE & NYUPN, CLINICALLY INTEGRATED NETWORK

• Physician owned and operated NYUPN Clinically-Integrated Network, LLC comprised of:

• 800 voluntary physicians • 1400 Faculty Group Practice (FGP) physicians • 130,000 lives in commercial ACO contracts

• NYU FGP annual volume of patient visits is 2M

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RECOGNIZED FOR CLINICAL EXCELLENCE AND QUALITY

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NYULMC’s Road to Payment Reform & Network Integration

2008

2010

2011

2012

2013

2006Conceptual Planning of Clinically Integrated Network and Health Information Technology Strategy

Selection of Epic as Enterprise-Wide EMR

• ACA enacted• Creation of Payment Reform Steering Committee

• Medicare released the Bundled Payment Request for Application• Selection of NYULMC’s Health Information Exchange (HIE)

• Creation of NYUPN Clinically Integrated Network• NYULMC is selected as a demonstration site

• Creation of Bundled Payment Steering Committee• Jan – Go-live with BPCI Phase 1• Oct – Go-live with BPCI Phase 2 • Oct – Go-live with Cigna Collaborative Accountable Care Shared Savings arrangement

BPCI: Bundled Payments for Care Improvement (Medicare demonstration project)

2014• Apr – Go-live with United ACO Shared Savings arrangement• Evaluate additional episodes• Jul – Go-live with Aetna ACO

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Selecting Episodes

What we considered

• Strong clinical leadership• Defined, discrete clinical

episodes• Relatively predictable

Clinical opportunity

• High volume• Procedure-based • Attractive to Medicare

Financial opportunity

Total Joint Replacement• 469-470 Major joint replacement of the lower

extremity• 800 Medicare cases annually• 31 physicians; 55% employed / 45% voluntary

Spinal Surgery• 459-460 Spinal fusion (non-cervical)

• 235 Medicare cases annually• 18 physicians; 56% employed / 44% voluntary

Cardiovascular surgery• 216-221 Cardiac valve

• 260 Medicare cases annually• 8 physicians, 100% employed

What we selected

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Overview of Bundle Payment For Care Improvement Initiative

Medicare Bundled Payments for Care Improvement

• Payment for episode of care defined by hospital admission in select DRGs for Medicare FFS patients

• Four models1. Retrospective acute care hospital stay only 2. Retrospective acute care hospital + post acute care (30 or 90 days)3. Retrospective post-acute care only4. Prospective acute care only

• All providers paid traditional FFS rates

• Total Medicare cost for episode compared to historical baseline

• Savings go to provider organization after discount; provider repays if exceeds historical baseline

• Quality measures

CMS Demonstration for Episode Based Payment Models

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What is Included in the Model 2 Target Price?

Home Health Agencies

Outpatient Therapy Services

Skilled Nursing Facilities & LTACH

Inpatient Rehab

Hospital

Surgeon

Physician Visits (surgeon and other)

Any services during the 90-Day Post-Acute Period

such as…

Consulting Physicians

Readmissions (to NYU or others)

DMEPart B Drugs Outpatient Services

Lab Services

Anesthesiologist

Any services during the Acute Staysuch as…

Any services that roll into the Index Admission through the current IPPS 72-hour rule such as…

ED Visits

Days 91-120

CMS will be monitoring the period immediately following to ensure that services are not being shifted outside the bundle.

NYUHC will be financially responsible if such behavior is observed and may be removed from the program.

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Post Acute Goal – Improved Outcomes and Patient Experience NYULMC Post-Acute Partners

Home Health Facilities1. Visiting Nurse Service of New York Home Care CHHA2. Village Center for Care CHHA3. Revival Home Health Care4. Jewish Home Lifecare Long Term Home Health Care

Skilled Nursing Facilities1. Village Center for Care, Manhattan2. Gouverneur Healthcare Services, SNF, Manhattan3. Jewish Home Lifecare, Manhattan, Bronx, Westchester4. Mary Manning Walsh, Manhattan5. Terence Cardinal Cooke, Manhattan6. Haym Salomon Home for the Aged, Brooklyn7. Cobble Hill Health Center, Brooklyn8. Clove Lakes Rehabilitation Center, Staten Island9. Trump Pavilion for Nurse Rehab at Jamaica Hospital, Queens

NYULMC clinicians and staff selected facilities based on a set of rigorous quality and care coordination criteria, taking into account existing clinical relationships, patient geography, and physician discharging preferences.

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Episodes of Care InitiativeWays to Improve Quality and Efficiency

• Reduce readmissions • Reduce LOS• Reduce implant, supply, or drug costs• Reduce OR time • Alter discharge patterns to more cost-efficient settings• Decrease excess utilization (e.g., consults, ancillary tests)

Quality improvements and efficiencies will benefit all patients, regardless of payor.

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Staffing

Care Coordination Staffing – Dedicated to Bundled Payment• Clinical Care Coordinators (CCC) are the “General Manager” of the 90-day episode

• Help answer questions and facilitate communication with providers• Receive regular updates on patient progress• Help ensure follow-up visits with surgeon and PCPs

• 5 RN FTE Clinical Care Coordinators manage 1,200 patients • Preoperatively 1 CCC : 20-25 patients • Inpatient 1 CCC : 4-6 patients • 90-days post-discharge 1 CCC : 50-60 patients • Annual staffing ratio 1 CCC : 240 patients

Program Staffing – Support all Population Management Initiatives• The Network Integration and Payment Reform team consists of:

• MD Executive Sponsor • RN Senior Director of Clinical Operations• RN Director of Clinical Care Coordination • RN Manager of Clinical Care Coordination• Director of Program Implementation• Manager of Payment Reform• Data Analyst(s)• Project Manager(s)• Project Assistant(s)

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TJR Pathway Development Governance Structure

Implementation

MCIT Reporting

Epic Workflow

Bundled Payment Initiative Steering

Committee

Pre-hospital Team Inpatient Team Post Acute Team

Total Joint Care Pathway Committee

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Standardization

• Systematization and standardizing are the foundations of good operational routines that can be measured and facilitate improvements, outcomes, and ever-greater efficiency.

Advantages of Standardization1. Increased efficiency 2. Improved ability to monitor and study

individual factors3. Improved communication4. It allows for identification of outliers or

modifiable factors

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Clinical Management Throughout the Pathway

The Importance of Care Coordination • Enforces best practices / standardization of pathways, workflows, and order sets• Improves communication between providers and to the patient•Ensures follow-up after care transitions•Optimizes Patient Expectations and Outcomes

GoalDevelop a pathway with >80% use of all elements with exclusion determined by pathway criteria, not physician preference.

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Inpatient WorkflowGoal – Standard Pathway with > 80% agreement

Confidential. Do not Distribute. 23

EMR care coordination tools and patient registries• Care coordination tools were built into the EMR so that Clinical Care Coordinators could see their

daily patient lists, view the 90-day longitudinal plan of care as well as document all notes, including information from patients, post-acute providers, and readmissions back to NYULMC and to other hospitals

Home Care Post-Acute Pathway

• Two Home Care Pathways– Standard Pathway– Enhanced Support Pathway

• VNSNY/TJR Enhanced Support Pathway Pilot Criteria – Single Joint replacement– Caregiver able to participate in therapy prior to DC– Stairs before discharge / No more that 1 flight in home– If private home bed/bath cant be longer than a flight of stairs– Eligible for SNF / Complex Needs

• Established risk profile to assist in determining appropriate disposition.

• Focus on bi-directional electronic exchange of information.24

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EvolutionTransition of Care Communication Tool

Redesigning CareStrategy to Improve Care Transitions

The goal: To improve the communication, quality, safety and patient experience across the care continuum.

Transitional Care Communication ToolNYULMC in collaboration with partners developed a new electronic communication tool leveraging our (HIE) provide a seamless transfer of clinical data between providers caring for the patient at the time of discharge and throughout the post-acute period.

Critical to our success was an effective care transition intervention that reduces fragmentation of care delivery across an episode of care.

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•NYULMC’s Health Information Exchange

•Allows care team to review clinical results/notes of other facilities and physicians

•“EMR Light” allows for enhanced communication with post-acute care providers through the use of an electronic transitional care communication tool. The tool consists of:

• Transfer Document: Completed by a NYULMC Clinical Care Coordinator upon hospital discharge and made available to the post-acute provider through EMR Light. Includes information such as demographics, type of surgery, care pathway, most recent clinical status, and Clinical Care Coordinator contact information.

• Follow-up Form: Sent from the post-acute provider to NYULMC as a patient progress report. Includes information such as post-acute length of stay, changes in clinical condition, physician / nurse practitioner evaluations, and medication changes.

• Continuity of Care Document: The post-acute provider can also access the patient’s Continuity of Care Document that is generated by NYULMC’s electronic health record. The document is an electronic patient summary containing a set of standardized clinical elements that are most relevant during care transitions. These elements include allergies, medications, problem list, procedures, and results.

Transitional Care Communication Tool Strategy

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Jan-Mar. 1st, 2013

Weekly Meeting with PAC partners

to develop pathways

understand information critical

to transitionTesting NYU-VNSNY

Mar. - Nov 2012 April. 1st, 2013 Sept, 2014

EMR-EMR transfer with VNSNY

Risk-Bearing Phase 2

Period begins

Oct. 1st, 2013

Live with manual transitional care

communication tool

Mar, 2014

Transitional Care Communication tool electronically sent to

NYULMC HIE

Internal/external review of

potential system solutions

Meetings with PAC partners to develop

workflow

Testing solution

Dec 2012 Jan, 2013

Began training with VNSNY and NYU teams both individually and

together Made updates based on

feedback from teams

Live with Risk Bearing Phase 2 Bundle Payment for Care Improvement Initiative

Transitional Care Communication Tool (TCC)

Timeline

Components of TCC Forms- CHHA/SNF

Transfer Document (Discharge)

•Demographics•Type of surgery, date, •Care Pathway•Readmission Risk•Clinical Status •Functional Status •Patient Preferences/Comments •Social History •Knowledge Deficit•Follow-up Appointments •Hospital Contact Information•VS/Smoking Status•Education •+CCD

Follow-up Form (weekly)Clinical Status• Pain• VTE pro• Surgical Wound• Pressure Ulcer• UTI• Fever• Diet• Any new medications added • Change in clinical condition • Evaluated by MD/NPFunctional Status• Number of PT/OT visits week• Ambulation• Stairs• Transfers • FallsDischarge Status• Anticipated Discharge Date• Barriers to Discharge• Patient on target for Discharge

NYULMC EMR Lite

• NYU clinical staff readies documentation

• NYU clinician logs into system & completes Post Acute Transfer Form

NYULMC HIE

• Facilitates exchange of information between NYU and VNSNY systems

VNSNY System

• Information received at VNSNY/Clinician notified

• Provider logs into system and accesses Post Acute Transfer Form and CCD

Transitional Care Communication Workflow

Patient readyfor discharge from hospital VNSNY nurse visits

patient at home

Transitional Care Communication Tool

Progression

• To date we have sent exchanged over 4,000 forms – Approximately 2000 forms with VNSNY

April 1 2013 Manual

March 2014VNSNY EMR to NYULMC HIE

September 2014EMR-EMR

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Implementing TCC ToolSteps to Success

• Foundational work on pathways assisted in identifying areas of focus

• Weekly NYULMC-VNSNY Joint IT Operations meetings • NYULMC-VNSNY Training • Continuous updates to improve the functionality of the

tool

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NYULMC-VNSNY HIE:Real World Application

• 80 year old female, s/p cardiac valve repair• Discharged home after 5 day hospital stay• Transfer form sent from NYULMC to VNSNY upon transition• Weekly follow-up form sent from VNSNY to NYULMC• NYULMC RN Clinical Care Coordinator observed improved BP

control, prompting discussion of medication titration• Patient weaned off of BP meds with ongoing assessment of

VNSNY RN• Overall medication adherence improved, BP meds and diuretics

adjusted appropriately for optimal fluid management• Patient remained in community, with no readmission during

bundled episode

Staff Feedback

• “It’s my eyes and ears telling me how the patient is doing at home”

• “It makes our communication more meaningful-instead of reporting vitals and other measurements, we spend our time talking about what we are going to do about the biometric trends we have both been monitoring.”

• “The data exchange helps to make the VNSNY home care RN and the NYULMC Clinical Care Coordinator a unified team, both working with the patient to address the key issues and address the patient’s goals.”

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Results

Changing care delivery while improving quality

n=LOS:

5075.62

6804.27

6733.84

1206.46

2114.58

1674.67

18711.81

2539.82

1789.27

8193.49

1784.83

2538.70

Discharge Disposition Patterns

Based on NYULMC internal data and Medicare claims dataFY 2014: Sept.1, 2013 - Aug. 31, 2014 36

Changing care delivery while improving quality

Data based on Medicare claims data for bundled payment admissions

90-day all-cause readmission rates

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Challenges & Next Steps

• Challenges:– HIE Access and Patient Consent– Mapping discrete data – Patient Matching

• Next Steps – Continual Improvement of Provider Communication

• Order sets• Texting

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Closing Thoughts

• Our patients are experiencing improved care through enhanced coordination and communication between providers

• Well-coordinated care is better for our patients and results in reduced costs

• Providing information and education to providers across the spectrum, combined with the financial mechanisms to align incentives, is a powerful combination

• Strategic design and implementation of IT infrastructure is a foundation for success

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Questions?

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