Using ADT Feeds to Promote Practice Transformation

June 5, 2013

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Who / What is CareBridge?

Currently support 6 Michigan Physician Organizations and 69 Primary Care Practices in the MiPCT program.

•Red = CIPA•Green = SPHN•Purple = WMPN•Blue = PMC•Yellow = OPNS•Light Blue = McLaren PHO

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Our Technology

• Standardize documentation.

• Scale best practices ADT Pilot.

• Enterprise level reporting use information to improve workflow and make comparisons.

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But Workflow is the KEY

• Technology supports efficiencies with communication, but the key is understanding how to most efficiently USE that information in a meaningful way.

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ADT Pilot

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The result: immediate notification of Inpatient, ER, Observation, SNF admissions from Spectrum Health.

Meet the Practice Teams:

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Group 1

•3 practices, consisting of 13,000 MiPCT members (5.25 FTE need in Care Managers)•1 full time care manager hired end of January, 2013. •1 half time care manager hired mid-February 2013.•1 full time care manager hired end of May, 2013

Main Challenges:•3 different locations, with not enough FTE support.•New processes, new technology.

Group 2

•2 practices, consisting of 1,250 MiPCT members (1 FTE need in Care Managers)•1 full time care manager hired Q3 2012.

Main Challenges:•2 very different practices, with different technology and processes.•Need for info beyond what comes in the ADT feed.

Group 3

•2 practices, consisting of 8,000 MiPCT members (3.25 FTE need in Care Managers)•4 RNs fulfilling this need, with other duties in the practice.

Main Challenges:•RNs have responsibilities beyond MiPCT work.•Care Manager on maternity leave; just added another Hybrid Care Manager to support the process.•New processes and technology.

Total Number of Notifications: Group 1

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Percent of Post-Admission Outreach: Group 1

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Total Number of Notifications: Group 2

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Percent of Post-Admission Outreach: Group 2

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Total Number of Notifications: Group 3

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Percent of Post-Admission Outreach: Group 3

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Post-Admission CN #1 - TopicCare Manager Office

Admission Month

Care Assessment

Note

Care Management

Refusal

Case Closure

Follow Up Note

Hospital Note

Initial/Yearly Assessment

Medical Neighborhood

Communication

Patient Education

Record Review

Telephonic Note

Transition Note

Group 1 Jan 1 35

Feb 3 1 112

Mar 1 1 3 86 2

Apr 1 3 1 96 3

Group 2 Jan 1 9

Feb 2 7 7

Mar 1 3 2 1 10

Apr 8 10 12

Group 3 Jan 8 2 10 13 14 4 25 5

Feb 8 7 13 6 1 1 1 14 12

Mar 3 8 2 6 4 8 39

Apr 11 1 1 1 19 14 19

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Record Review / Triage is the major activity for Groups 1 & 2, but Group 3 has a much larger variety of outreach types.

Post-Discharge CN #2 - Topic

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Care Manager Office

Discharged Month

Care Assessment

NoteCase Closure Follow Up Note Hospital Note

Medical Neighborhood

Communication

Patient Education Record Review Telephonic

Note Transition Note

Group 1 Jan 4 4 9 8

Feb 5 1 22 7

Mar 2 1 5 3 14 11

Apr 3 1 4 3 13 30

Group 2 Jan 1 4 2 2

Feb 1 2 3 2 3

Mar 8 5 3 1

Apr 1 1 1 10 10 2 1

Group 3 Jan 3 6 7 2 1 12 2

Feb 4 3 5 17 6

Mar 2 5 2 2 12 13 4

Apr 3 8 14 6

After triage upon admission notification, the telephonic notes increase dramatically, and the variety of outreach is larger.

Initial Lessons Learned

• Without the direct flow of information, we wouldn’t have been able to develop these processes.

• BUT, just having the information isn’t enough.

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Still Learning

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The technology allowed us to identify the opportunities in workflow.

Continuing to tackle complexity of integrating processes and patient information amongst care managers, offices, and hospitals • Expectations for follow up• Continuous improvement of workflow• Patient triage: knowing we can’t work with everybody, how

is this completed and documented?• Population management: Case load / frequency of follow-up • Collaborative ‘Lessons Learned’• ‘Value’ metrics in 2Q13: too much information is a bad thing.

Next Steps• Refine current processes:– Triage & documentation of triage process;– Census and high ED utilization reports – i.e.

identifying which info is most useful for targeting appropriate patients.

• Begin to view transitions of care within the greater processes of the practice – instead of developing the process in isolation.– True population management focus.

• Prepare for expansion of the pilot to other hospital systems and other practices.

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April 12, 2013

Main focus was to alert primary care physicians and care coordinators to relevant hospital admissions and to improve care coordination through the United Physicians Network

Project Components:◦ Establish Facility Census report for UP Primary Care

Physicians and Care Coordinators from: Beaumont, Crittenton and St. Joseph Oakland Hospitals Augment information with Discharge note

◦ Determine Primary Care Physician if no PCP is identified in ADT message by checking patient information against Patient-Physician attribution lists

◦ Pediatric program – use message to alter pediatricians so they can send CCD (via fax) to Beaumont Peds Unit

◦ Pass message on to MiHIN for St. Joseph Oakland

Facility Census developed and live on UP portal

ADT feeds from Beaumont and St. Joseph Oakland live◦ Crittenton to go live June 4

ADT messages are being compared to patient – physician attribution and posted in Facility Census for PCP’s

Notification being sent to physicians in box

# ADT messages◦ 175,000/mo – Beaumont (3 hospitals)◦ 6,250/mo - St. Joseph Oakland

Status of Initial roll-out◦ 213 physicians live◦ 15 United Physicians care coordinators

Roll-out plan for remaining physicians ◦ Approximately 2,000 physicians by end of

September

ADT message is a standard message, not many issues with establishing feed from hospitals or integrating into structure◦ Other than prioritization

Issues◦ How do you determine which data to pull/filter?◦ Patient – Physician Attribution◦ Integration into practice work flow

500 primary care physicians = 1.1 million patients in UP population

Participating Plans (attribution lists)◦ Plan Lists Used 106,000

<11% of population◦ Unused Plan Lists 183,000

Still only 26% of population

Needed to determine attribution from other sources◦ PMS feed◦ Registry Information◦ Other sources

◦ UP now has over 84% of patients attributed to a primary care physician

Physician reaction upon receiving notification…◦ That’s great, what happened?◦ Some patients, it was immediately helpful, but for

many they needed more information

Establishing feed for discharge note to be sent at time of discharge◦ Working with Beaumont, St. Joseph Oakland and

Crittenton on Discharge summary feed

Some offices have embraced immediately Most offices struggling with integration into

the office workflow

Establishing training to increase physician adoption◦ LEAN LITE

Focus on working with care coordinators or key person within each office

Original Intent◦ Pediatricians who round on their own patients wanted

their office information better represented on the patient chart

◦ Upon notification of admit, Ped office to pull and send CCD to hospital PROBLEM – who receives the information and what

happens to it? Not consistently applied

New solution◦ Care coordinator in hospital

Key contact for staff Pediatricians Ability to pull/query Ingenium community record Receives CCD from physician office EMR

Continue roll-out to physician community Add Discharge summary to enhance value

of information Emphasis on improving processes for care

coordination Pass messages to MiHIN

Anecdotal now◦ YES◦ Pediatric use case◦ Practices assigning staff to oversee reports

What happened◦ Care coordinators

Work with hospitals and physician organization to track reports over time (re-admits, contacts, etc)◦ Do we have any of this information?