Connecting Michigan for Health 2013 http://mihin.org/

1. Using ADT Feeds to Promote
Practice Transformation
June 5, 2013
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2. 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
2

3. Our Technology
• Standardize
documentation.
• Scale best practices 
ADT Pilot.
• Enterprise level
reporting  use
information to improve
workflow and make
comparisons.
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4. 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.
4

5. ADT Pilot
5
The result: immediate notification of Inpatient, ER,
Observation, SNF admissions from Spectrum Health.

6. Meet the Practice Teams:
6
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.

7. Total Number of Notifications:
Group 1
7

8. Percent of Post-Admission
Outreach: Group 1
8

9. Total Number of Notifications:
Group 2
9

10. Percent of Post-Admission
Outreach: Group 2
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11. Total Number of Notifications:
Group 3
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12. Percent of Post-Admission
Outreach: Group 3
12

13. Post-Admission CN #1 - Topic
Care Manager
Office
Admission
Month
Care
Assessment
Note
Care
Management
Refusal
Case
Closure
Follow
Up Note
Hospital
Note
Initial/
Yearly
Assess
ment
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.

14. Post-Discharge CN #2 - Topic
14
Care Manager
Office
Discharged
Month
Care
Assessment
Note
Case 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.

15. 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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16. 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.

17. 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.
17

18. April 12, 2013

19.  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

20.  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

21.  # 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

22.  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

23.  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

24.  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

25.  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

26.  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

27.  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

28.  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?