• Integrated Health Associates (IHA) and Mercy PHO

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Improving TOC with Better Information

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IHA Complex Care ManagementSources of Patients (MiPCT only)

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PRISM

Predictor of mortality, re-admission developed by Dr. Cowen and Quality Institute at St. Joe’s

5 PRISM levels (1-highest risk, 5-lowest risk)Calculated on admission in the ED, in pre-op for

elective surgery at SJM Ann Arbor

4

% of Patients, 30 day re-admissions by PRISM score

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PRISM 2 & 3 patients account for 63% of all re-admits

5

Days to Re-AdmissionPRISM 1/2/3, Nov 2012 – June 2013

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Of all re-admissions, ~40% occur within the first 7 days

TOC Information Goals1. Provide care managers real-time

information on when patients are admitted and discharged

2. Provide risk scores to help care managers prioritize interventions

3. Integrate information into NextGen EMR to avoid multiple logins, screens, etc.

4. Store data to provide reports back to care managers and leadership

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Care Management Data Flow

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Database

ADT Feed

Risk Score (PRISM)

Care Manager

Panel

Reporting

Care Manager

Templates

Process Metrics

Outcomes Activity Panel Size

Data warehouse

Notification

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DischargeAdmit

NextGen Task

NextGen CM Panel

NextGen Task

NextGen Task

Next Morning

W/in 2 hours

NextGen CM Panel

W/in 2 hours

Next Morning

Next Morning

NextGen PAQ

24-48 hours

Admit Notification

Admit Notification D/C Notification

D/C Notification

D/C Notification

Discharge Summary

PCPPCP

Care ManagerCare Manager

Practice RNPractice RN

Next Morning

Next Morning

Call Center RN

Non-MiPCT referred to practice RN

NextGen Tasking

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Due date set based on protocol:•Follow up call within 24 hours•PCP appointment within 7 days

Flow of Patients in NextGen Care Manager Panel

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Patients move from Admit panel to Discharge panel when dischargedPatients move from Discharge panel to Active panel when enrolled

Care Manager Panel

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ReportingCare Management Dashboard

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Discharges % Enrolled% Seen by PCP w/in

7 daysDischarges % Enrolled

% Seen by PCP w/in 7 days

High Risk SJMHS MiPCT Discharges All SJMHS MiPCT Discharges

Metrics calculated bi-weekly by care manager

ReportingCare Management Dashboard

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Panel Size Panel Size/FTE Encounters/FTE # Phone Calls # Face To Face Care Coord # Comp. Assm

Metrics calculated bi-weekly by care manager

Tiffany Francis, MPHLori Vollstaedt, BSN, RN

Mercy Physician Community PHO• 145 Primary Care and Specialty Care

Physicians• 38 PCPs, 20 utilizing Crimson Care Registry• 6 MIPCT Practices• 3 Hospitals in St. Clair County, MI– St. Joseph Mercy-Port Huron, our affiliate– Port Huron Hospital, independent– St. John-River District

Discharge Process• St. Joseph Mercy Port Huron

– Daily feed through secure Trinity email system of all inpatient and emergency room discharges

• Port Huron Hospital– Daily feed through a secure web portal of all

inpatient and emergency room discharges

• St. John River District/Outlying Facilities– No current PHO process, though physicians

occasionally get their information through portals that they have access to individually.

Challenges We OvercameWorking with a “competing” hospital to

get data to promote better health in our community

Administrative burden of handling data in a timely manner

Training of offices on what to do with the data

Decreasing ED utilization for PCS diagnosis…a work in constant progress!

Internal PHO Process• Team Member accesses both files

and saves to our local drives in excel• Team Member separates each

physician onto its own formatted excel page by group• Physician group excel pages are

faxed or emailed securing to each office with DC for that day

Registry Component• Discharges for physicians on our

registry are added a service entry with a note by our Team• Physician office will then see the

service (ER or IP stay) and admitting diagnosis as well as dates of service

Care Manager Process• If office is a MIPCT office:–Complex Care Manager accesses the

excel file through the shared Trinity drives

–CCM makes the calls to patients who are DC from the hospital or ED

–Calls are logged on the log the Care Management Team uses

–Calls are logged in Crimson when there is a goal set or follow up needed.

Office Process• We train our offices to utilize these

lists and contact the patients to get them into the office.• Since many health plans incentivize

offices for seeing patients post IP stay, our offices really appreciate the daily lists

Findings/Quality

• We routinely track and share information with our Quality Committee and physicians related to time of day and insurance type.• Find that most are M-F 9AM-5PM• Most are Medicare • Diagnosis are Primary Care Sensitive

Top 10 Diagnosis for ED

Time and Insurance September 2013

• 1435 ED Visits between SJMPH and PHH• 654 between hours of 9AM-5PM• 373 between hours of 5PM-9PM• 408 between hours of 9PM-9AM• 115 Uninsured• 246 Medicaid• 644 Medicare• 430 Commercial Insurances

MIPCT Success Story 162 year old female3 IP and 7 ED visits in preceding 12

monthsUCIDDM, CHF, COPD, O2

DependentInattentive Family

MIPCT Patient 1 Plan/SuccessMonthly PCP and Care Manager

MeetingsEducation re: signs and symptoms,

impending troublesLearned to anticipate illness and

contact PCP1 IP stay and 2 ED visits in last 12

months

MIPCT Success Story 228 year old female>25 ED visits preceding 12 monthsMany ED visits via ambulanceMinor medical historyAll ED visits were primary care

sensitive

MIPCT Patient 2 Plan/SuccessAccess to Complex Care ManagerMeetings every two weeksCalls from Care Manager each ED

visitClose working between PCP and

Care Mgr.3 ED visits in last 12 months

Questions?