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Panel: Transitions of Care and ADT (without Rachel Sherman)
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
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.
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
13
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.
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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?
Notas do Editor
This count only includes instances where there is a discharge date and visit type equals ER Visit or In-Patient Visit. All facilities experienced notification highs for ER and IP visits in January. There was only one instance where a facility experienced more IP notifications than ER notifications (Eastside, Mar).
Numerator: All instances where data is in the Post Admission Days To Contact Denominator: The totals calculated in the total number of notifications graphs In Apr, Cherry experienced fewer IP notifications than in the previous two months (9 IP admissions in Apr vs. 16 in Mar), which probably explains the decreasing trend.
This count only includes instances where there is a discharge date and visit type equals ER Visit or In-Patient Visit.
Numerator: All instances where data is in the Post Admission Days To Contact Denominator: The totals calculated in the total number of notifications graphs Compared to the other facilities, EFM has very low notifications, which likely makes it more feasible for them to achieve such high outreach percentages
This count only includes instances where there is a discharge date and visit type equals ER Visit or In-Patient Visit.
Numerator: All instances where data is in the Post Admission Days To Contact Denominator: The totals calculated in the total number of notifications graphs In Mar, Pine nearly doubled their outreach to IP from the previous month (26 contacts vs. 14 contacts in Feb) and they experienced fewer IP notifications, which explains why we see the spike.