An Overview of the Greater Cincinnati Beacon Collaboration

Current State of Healthcare • Healthcare costs are enormous

• Providers are reimbursed based on volume not on quality care

• Quality of care is inconsistent • Patient data is often incomplete and not

available at the point of care to drive best decision making

• National standards of care for some of the sickest and most costly patients are not often known or followed

National Quality Strategy & Beacon Alignment

Principles for the National Quality Strategy 1. Person-centeredness and family engagement

2. Specific health considerations 3. Eliminating disparities in care 4. Aligning the efforts of public and private sectors 5. Quality improvement 6. Consistent national standards 7. Primary care will become a bigger focus 8. Coordination will be enhanced 9. Integration of care delivery 10. Providing Clear Information

What Did the Work in Cincinnati Look Like Before Beacon?

• Quality Improvement and Clinical Transformation efforts were very separate from Health Information Technology (HIT) improvement efforts that were emerging

• These coalitions were very successful in

their own right, showing promising results in small pockets of transformation

What Did the Work in Cincinnati Look Like Before Beacon?

Multiple talented coalitions working on healthcare transformation: • HIE-HealthBridge 1997 as the Health Information

Exchange • Lab & Radiology results • Admission, Discharge &Transfer messages

• The Health Collaborative • AF4Q & Patient Centered Medical Home (PCMH) • CVE applicant for Cincinnati

• Greater Cincinnati Health Council-Local entity working with hospitals on many improvement efforts

Greater Cincinnati AF4Q -CVE

Aligning Forces 4 Quality Grant-RWJF, 2007 Led by The Health Collaborative

Convened consumer groups, health plans, physicians, employers and HealthBridge to improve care for patients with diabetes and other chronic illnesses in the outpatient setting

Goals: Help providers improve their abilities to deliver quality care Help providers measure and publicly report their

performance Help patients and consumers understand their role in the

care delivery process Charted Value Exchange-2008 designation for Cincinnati

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Greater Cincinnati Beacon Collaboration

Our Journey

The Greater Cincinnati Beacon Collaboration Team

The Concept of Our Beacon Community

Better care for individuals, better health for populations, and lower per-capita costs. IHI-Triple Aim Initiative

Beacon Health Information Technology &

Health Information Exchange Enhancements Led by HealthBridge

HIT/HIE Improvement Description Aim

Electronic Health Record Adoption and Meaningful Use

Support for all participating practices with adopting an EHR and meeting meaningful use, provided in coordination with the Tri-State Regional Extension Center

60% Meaningful Use achievement across community

Core IT Infrastructure Purchased-Enhancements with Beacon Funds

A powerful, new set of technologies including a master patient index, data warehouse, mapping, business intelligence and analytics tools that will provide the community with unprecedented data reporting, quality improvement and analytics capabilities needed for meaningful use and payment reform

Community level data for improving rates of optimal care, aggregate community reporting capabilities, community quality dashboards, payer data

ED-Admit Alerts Electronic notices delivered to primary care teams in real-time when patients with chronic conditions are admitted for emergency room, urgent or and inpatient care

Reduce unnecessary ED visits and hospital readmissions

Beacon Health Information Technology & Health Information Exchange Enhancements

Led by HealthBridge Integrated Disease Registry

Technology application that is integrated with existing EHRs and practice managements systems to provide practices with customized quality reporting, patient self-management and decision support tools for improving care for a population of patients with diabetes or asthma

Improve care using best practice and preventive care using clinical alerts and decision support tools within the registry

Direct Email Specialized secure email communications among hospital and post-acute providers using national “Direct” protocols aimed improving the flow of information during transitions of care

Transmit ED/Admit alerts and Transition of Care Documents

Txt4Health Mobile technology initiative to help people at risk for diabetes to be healthier through evidence-based text messages (CDC & ADA)

Texting program aimed at people to engage in self

Race, Ethnicity And Language (REL) Data Collection

Standardization of data collection and special training for hospital and practice staff on collecting REL data

Reduce documented health disparities

Beacon Clinical Demonstrations Quality Improvement Activity

Lead Organization

Description

Adult Diabetes Demonstration

The Health Collaborative

44 physician practices with 189 physicians and clinical team involved in patient centered medical home transformation or diabetes quality improvement collaborative

Pediatric Asthma Demonstration

Cincinnati Children’s 42 practices involved in Asthma improvement – 39 community practices, 4 CCHMC Primary Care practices; improving care coordination for high risk patients; using root cause analysis to address utilization; improving care using the asthma decision support tool and other IT tools

Hospital Community Collaborative

Greater Cincinnati Health Council

19 hospitals working jointly to reduce hospital readmissions through sharing goals, data and best practices; improving transitions in care and handoffs between hospitals and other providers; and reducing health disparities

Practice Transformation What Does It Look Like From the

Provider’s Perspective? “Our work with asthma is just the beginning of managing

all of our patients with complex medical problems. As each patient sees a specialist or has contact with another health care provider, regardless of the location or institution, that information is being sent to the medical home and …captured for surveillance, management, pay for performance, and quality improvement efforts. This is being done with minimal staff requirements and a high level of sustainability in an electronic environment.”

Scott Callahan, M.D., Pediatrician Children’s Health Care, Batesville IN Beacon Community Physician

GREATER CINCINNATI BEACON COMMUNITY SUSTAINABILITY

Cincinnati Community Commitment to Sustainability

• Forged Relationships through Beacon-breaking new ground • Fundamental culture change emerging across the entire

healthcare community • Public & Private Sector coordinating efforts toward a healthier

community-GE as a sponsor AND a large employer • Data Sharing across a community to allow the data to be

patient-centric rather than provider centric • Payers at the table to: incentivize PCMH for better primary

care • Support for a Shared Community Data Infrastructure

Cincinnati Community Commitment to Sustainability

• Beacon Governance Group & Beacon Leadership Group • Convene a working group to create a strategy to address:

• Pause to Understand Our Successes and Failures • Spread and Scale of Beacon IT/QI work rooted in Beacon • Shared Community IT Infrastructure Use • Alignment with other Community Stakeholder Groups • Priorities of Focus for the Next Three Years • Participate in Current Organizational and Merger

Discussions

New Shared Community Infrastructure Made possible by the Beacon Community Grant

Enhance Transitions in Care Using

NwHIN Direct Email

HealthBridge HISP

Hospital Discharge

Continuity of Care Document

CCD

Skilled Nursing Facilities

Home Health Agencies

HealthBridge ED Alert Architecture

Hospital

Admission

ADT

1 Patient Hospital Visit

The patient goes to the hospital and is admitted to the ED.

HealthBridge

Alert Aggregator

2

Clinical Messaging

A

D

C

B

Practice

HealthBridge Integration

HealthBridge receives the ADT and matches on the patient. If the patient is part of a subject group, an alert will be created from one of the four options (A, B, C, D).

ALERT

3 Practice Follow-up

Practice receives preferred alert from HealthBridge and calls patient for a follow-up visit.

ED/Admit Alert Report New Clinical Decision Support Tools

Disease Registry-A Very Important Decision Support Tool

We Don’t Have All The Answers Yet On Sustainability

Don Berwick, MD-”To save healthcare from the cliff, we must reduce costs, by reducing waste, at scale, everywhere, and do it now….”

Put the patient first. Every single deed – every single change – should protect, preserve, and enhance the well-being of the people who need us. That way – and only that way – we will know waste when we see it.

Among patients, put the poor and disadvantaged first – those in the beginning, the end, and the shadows of life. Let us meet the moral test.

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We Don’t Have All The Answers Yet On Sustainability

Start at scale. There is no more time left for timidity. Pilots will

not suffice. The time has come, to use Göran Henrik’s scary phase, to do everything. In basketball, they call it “flooding the zone.” It’s time to flood the Triple Aim zone.

Return the money. Success will not be in our hands unless and until the parties burdened by health care costs feel that burden to be lighter. It is crucial that the employers and wage-earners and unions and states and taxpayers – those who actually pay the health care bill – see that bill fall.

Act locally. The moment has arrived for every state, community, organization, and profession to act.

We need mobilization – nothing less.

Pattie Bondurant DNPc, MN RN Email: pbondurant@healthbridge.org Phone: 513-247-6870