Freya Spielberg MD MPH

Director Community

Oriented Primary Care

GWU

A case study of

Prevention at Home

PAH Program Aims

• Improve Health - To decrease HIV (151 cases)

and STI transmission (353 cases) in Washington

DC through improving access to education, early

detection, linkage to care, retention in care, and

adherence to medication

• Lower Health Care Costs – To decrease

Medicaid costs ($40M) by preventing new cases

of HIV and STI, and by decreasing ER visits and

Hospitalizations among patients with HIV and

STIs by improving access and adherence to

care

Prevention at Home Design

Mobile Health and Care Management

POC

Test

Early Early Cx

Dx Tx to Care

Txt Message, Care Plan Management - Need

Testing, Counseling, Medical Care, Behavioral

Care, Social Support, Linkage Support

CHW Reconnect to Care (high viral load, missed

visit, missed refill, ER visits, Hospitalization) Impact Viral

Load

HIV

Cases

Cost

ER

Hospital

Pt Exp

Easy

Conven.

Cult. Ap.

CHW

Home

Community

Privacy Barriers to Implementation

Health System Barriers

Legal Barriers

HIPAA

Proposed Solutions

Health System Barriers

Some clinical entities will not even use

their own EHR to reach out to patients

who need HIV testing or HIV care

management support

Over interpretation of HIPAA

Legal Barriers

“Patients have to give affirmative consent to sharing their

medical information outside their own patient-physician

relationship, and the HIE does not allow parties who do not

have a direct relationship with patients to have access to their

identifiable medical information without that affirmative

consent.”

“You can't identify the patients from whom you want that

consent without first obtaining their private medical

information. Your subs who do have that relationship can

engage with the patients and obtain their consent, but you

can't do that directly because you don't have the patients'

permission.“

The Privacy Rule expressly permits a covered entity to disclose

PHI to a business associate, or allow a business associate to

create or receive PHI on its behalf, so long as the covered entity

obtains satisfactory assurances in the form of a contract or other

agreement that the business associate will appropriately

safeguard the information. See 45 C.F.R. §§ 164.502(e), 164.504(e).

Business associate includes: A person that offers a personal

health record to one or more individuals on behalf of a covered

entity. See § 160.103 Definitions.

HIPAA

Proposed Solutions Educate Clinical Entities and their legal teams

on the legality of using HIE for preventive and

chronic disease management

Edit HIPAA consents to expressly approve the

use of health information exchanges for

preventive and chronic disease management.

Create State Guidance that promotes use of

HIEs for preventive and chronic disease

management.

Thanks to our PAH Partners • Milken Inst. Dept of Prevention and Community Health,

• Dept of Health Policy,

• Dept of Epidemiology & Biostatistics,

• GW School of Medicine & Health Sciences

• GW School of Nursing

• The GW Medical Faculty Associates

• AmeriHealth

• DC DOH HAHSTA

• DC Dept of HealthCare Finance (DHCF)

• DC Primary Care Association (DCPCA)

•Family & Medical Counseling Services (FMCS)

• Institute for Public Health Innovations (IPHI)

• Johns Hopkins University

•United Medical Center

• Mary Center/Capital Clinical Integrated Network (CCIN)

• MetroHealth

• N-Tonic

• New York University

• Oliver Wyman Actuarial Consulting Inc.

• Prince George’s County

• Providence Hospital

• Resources Online

• Tiani Spirit

• University of Massachusetts

•Us Helping Us

• Women’s Collective

• Whitman-Walker Health

Discussion

Presentation

Improving community health through

mobile health tools and HIEs

Prevention at Home – A case study

Privacy barriers

Our Challenge – The Quadruple Aim

Improve health outcomes

Improve patient experience

Lower Health Care Costs

Diminish Health Disparities

Community Health Improvement

HIE - Identify Prevention and Chronic

Disease Self Management needs

Mobile Health - Implement evidence

based interventions to individuals in

need

Integrate community based support -

through a linked in CHW network to

address health disparities.

Prevention at Home Goals and Innovations

0%

20%

40%

60%

80%

100%

Diagnosis Linkage Retained inCare

PrescribedART

VirallySuppressed

Ideal

Goal

Current

Home Testing GIS Outreach Mobile Health

Same Day Apt. Escort Portal Link

Provider Match Incentives Portal Services

Med Check Provider QA Pharmacy Rx

Adherence IT Outreach Home VL

Care Innovations

Comparison of fee for service and capitated outcomes and costs Determination of financing model to promote cost effective innovations

Payment Reform Innovations

System Innovations

HIE IT Integration – between CHW, primary care, specialty care, hospitals Billing Integration – CHW point of care billing for diverse payers 3yr

Savings $40 Million