MiPCT/CCM Spotlight ADT Alert and workflow Training for Care Managers and PO/CCM Leads

January, 2014

AGENDA

1. Brief Spotlight Overview of “Phase One” Member List Functionality

2. “Phase Two” ADT Alert Briefing

3. Care Management Workflows▫ Prompt action on Transitions of Care▫ How ADT alerts can be used to prioritize

and manage your caseload

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Spotlight Overview

What is the MiPCT Spotlight Offering?

A way for Care Managers to receive

web-based access to MiPCT member

lists with near real-time alerts when

patients are hospitalized or discharged

where available.

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Spotlight Data Security• External security audit review performed in 2012 with

CynergisTek and subsequent review planned for 2013 upon CCM Version 2 rollout completion

• Annually CTC undertakes:▫ Risk analysis of the company, our processes, assets,

applications, data (under a NIST 800-30 based risk management program)

▫ Review of all our policies and BAAs internally and with lawyers▫ Disaster recovery test▫ External network/application security tests

• Worked with Healthcare Law Consultancy (CCM) to address new HIPAA omnibus regulations (September 2013)▫ Policies in place and updated as HIPAA regulations change to

address things such as security breaches including notification to affected parties.

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Phase 1: MiPCT Member Lists via CTC Spotlight

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Phase 1: New Member Alerts via CTC Spotlight

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ADT Availability

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•Through partnership with MiHIN, MSMS, and others

•Leverages MiHIN/CareBridge ADT work

•Expands ADT availability with additional feeds with prioritization of ADT feeds of greatest value to MiPCT practices

Spotlight Leverages ADT Access

ADTs Available Q1 2014

Facilities included in the first set of ADT feeds for MiPCT patients with hospitalizations or ED visits:

• Beaumont▫ Working on identifying individual facilities

• Henry Ford Health System▫ Macomb to start▫ Wyandotte and Main campus to follow

• Trinity

Admission, Discharge, Transfer MiPCT Data Flow and Progress

Over half of our POs participate in the Crimson Care Management (CCM)/MiPCT partnership• Care managers now receive member lists electronically via a web interface• ADT notifications being added

Phase 2: Admission/Discharge AlertingPatient Admitted Email Alert

Phase 2: Admission/Discharge AlertingPatient Discharged Email Alert

Phase 2: Admission/Discharge AlertingPatient ER Visit Email Alert

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Phase 2: Admission/Discharge Alerting

Alerting – Acknowledge via emailLogin to Spotlight

Alerting – Acknowledge via emailClose Alert

Admission/ER Visit Information

Discharge Dispositions:

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Care Management Workflows

St. John Providence, Partners in CareMiPCT-P.O.- Soft launch Partner

CTC/ADT alert only process flow

developed by:

Transitions of Care Best Practice Workflows

Care Manager (CM) ADT alert workflows:

•Associated with corresponding faxed patient information.

•Associated with CM electronic access to patient record.

CM Workflow for Inpatient Alert

CM Workflow for Discharge Alert

Best Practice Transitions of Care Process: Practices with Care Team Connect(CTC) and Admission, Discharge and Transfer(ADT) Feeds

Care Manager receives Alert in CTC: Responds within 24-48 hours of receiving the alert

Patient Transfer to Long Term Acute Care, Rehabilitation, or Skilled Nursing Facility

Patient Discharge

CM enters assigned patient list. Locates patients name. Receives hospital name and

pertinent information.

CM enters assigned patient list. Locates patients name. Receives hospital name and

pertinent information.

CM reviews patient EMR/discharge summary to determine the name of the facility patient was

transferred to. CM reviews patient EMR/discharge

summary.

CM contacts facility Case Manager or Social Worker for TOC call.

CM records receipt of CTC Discharge alert and communication with facility Case Manager or

Social Worker. Record plan for anticipated discharge as well as anticipated timeline for CM

follow up in CTC and patient medical record (EMR or paper chart).

CM records receipt of CTC Discharge alert and communication with patient or

caregiver. Record initial care management plan and anticipated timeline for CM follow up in CTC and patient medical record (EMR

or paper chart).

CM contacts patient for TOC call.

CM places patient name on CM schedule

for follow up.

When the CM does not have access to the hospital record: · Arrange to receive daily faxes of pertinent patient information (admission history and physicals for

admissions and discharge summaries for discharges).· Contact the inpatient case manager to arrange receipt of the needed patient medical information

(admission history and physical, discharge summary, medication list and any other information needed to arrange and provide appropriate follow up care).

· Contact the patient or care giver if unable to determine the patient’s disposition.

Patient discharged to home

Fax from hospital

Access the hospital EMR

Fax from hospital

Access the hospital EMR

CM Workflow for ED Alert

ADT Alerts Best Practice Process

• The following steps are completed by the CM 24-48 hrs. after alert notice.

• Acknowledge receipt of admission, discharge or ER alert from CCM.

• Investigate patient change in status and determine care management intervention.

• Document receipt of alert, intervention(review of EMR and follow up with facility contact, patient and physician) and planned follow up with patient in EMR.

Transitions of Care Integrated Workflow

(displays inpatient, discharge and ED flows in one screen)

Best Practice Transitions of Care Process: Practices with Care Team Connect(CTC) and Admission, Discharge and Transfer(ADT) Feeds

Care Manager receives Alert in CTC: Responds within 24-48 hours of

receiving the alert

Patient Inpatient

Admission

Patient Transfer to Long Term Acute Care,

Rehabilitation, or Skilled Nursing Facility

Patient Discharge

CM enters assigned patient list. Locates

patients name. Receives hospital name and

pertinent information.

CM reviews patient inpatient information

CM contacts hospital

Inpatient Case Manager

CM records receipt of CTC Admission alert and communication with IP Case Manager. Record

plan for anticipated discharge and timeline for CM follow up in CTC

and patient medical record (EMR or paper

chart).

CM places patient name on CM schedule for

follow up.

CM enters assigned patient list. Locates patients name. Receives hospital name and

pertinent information.

CM enters assigned patient list. Locates patients name. Receives hospital name and

pertinent information.

CM reviews patient EMR/discharge summary to determine the name of the

facility patient was transferred to.

CM reviews patient EMR/discharge summary.

CM contacts facility Case Manager or Social

Worker for TOC call.

CM records receipt of CTC Discharge alert and

communication with facility Case Manager or Social Worker. Record

plan for anticipated discharge as well as

anticipated timeline for CM follow up in CTC and patient medical record (EMR or paper chart).

CM records receipt of CTC Discharge alert and

communication with patient or caregiver.

Record initial care management plan and anticipated timeline for CM follow up in CTC and patient medical record (EMR or paper chart).

CM contacts patient for TOC

call.

CM places patient name on CM schedule for

follow up.

CM places patient name on CM schedule for

follow up.

When the CM does not have access to the hospital record: · Arrange to receive daily faxes of pertinent patient information (admission history and physicals for

admissions and discharge summaries for discharges).· Contact the inpatient case manager to arrange receipt of the needed patient medical information

(admission history and physical, discharge summary, medication list and any other information needed to arrange and provide appropriate follow up care).

· Contact the patient or care giver if unable to determine the patient’s disposition.

Patient discharged to home

Fax from hospital

Access the hospital EMR

Fax from hospital

Access the hospital EMR

Fax from hospital

Access the hospital EMR

ADT/CTC Summary of Key Points• Alerts need to be acknowledged on a timely basis

throughout the day to minimize multiple alerts on the same patient. (i.e. admission alert that is not acknowledged by the time of discharge will generate another alert -> discharge alert)

• When acknowledging an alert by email, click on “view care plan” button once logged in CTC. Clicking “close” will remove alert from your home page and require you to look up patient by name. ( Patient hospitalization report is being developed via CTC website to see patient TOC activity.)

• It is recommended that review of the discharge disposition code be incorporated into your process.