using healthix to support dsrip: opportunities and...
TRANSCRIPT
Using Healthix to
Support DSRIP:
Opportunities and
Challenges
February 25, 2016
1
Contents
1. Community Care of Brooklyn Overview (2 – 5)
2. Healthix Enablement of CCB IT Strategy (6- 13)
3. Challenges (slide 14)
4. Discussion
Community Care of Brooklyn
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• Maimonides Medical Center = PPS Lead and fiduciary
• Maimonides Performing Provider System (Maimonides PPS) = a broad
network of health and social services providers, Brooklyn-based
community groups and others
• Community Care of Brooklyn (CCB) = the name of the Maimonides PPS
• CCB is not a separate entity; it is established via Master Services
Agreements (MSAs) between CCB Participants and MMC
• Includes 3,000 providers (including 1,100 primary care physicians) and
more than 300 partner organizations including 6 hospitals, 8 FQHCs, a
number of community-based organizations, other entities
• Governance through committee structure, with consensus-based
approach to decision-making
• Maimonides Central Services Organization (CSO) = team providing
management services to support CCB
CCB Governance Structure
October 2015
Finance Committee
CMS
Information Technology Committee
Care Delivery & Quality
Committee
CCB Executive Committee Nominating Committee
NYSDOH
Maimonides (Fiduciary) Maimonides CSO
Workforce Committee
Compliance Committee
Community Engagement Committee
3
CCB Initiatives / DSRIP Projects
Initiatives Descriptions / Participant Types Status
Create IDS (2.a.i) Overarching, cross-cutting work that will support multiple DSRIP projects, achievement of overall DSRIP goals
Ongoing
Reduce 30-day readmissions (2.b.iv)
Hospital-based program focusing on identifying patients at risk for readmission, effecting linkages to primary, specialty care and social services as appropriate
Launched with key Participants, ongoing rollout
ED Triage (2.b.iii) Reducing the number of low-intensity ED visits; requires availability of accessible PCP services, urgent care, care management and social services support
Launch underway, ongoing rollout
4
CCB Initiatives (continued)
Initiatives Descriptions / Participant Types Target Launch
PCMH + (2.a.iii – HH at risk, 3.a.i – integration of behavioral health and primary care, 3.d.ii – home-based asthma care, 3.b.i – management of cardiovascular disease, 3.g.i –palliative care)
Ensure that PCPs achieve required level of Patient Centered Medical Home (PCMH) designation; early focus on Federally Qualified Health Centers (FQHCs), free-standing Diagnostic & Treatment Centers (DTCs) and larger physician practices
Launched with key Participants, rollout ongoing
Population Health: HIV Access to Care (4.a.iii)
Citywide effort; NYCDOHMH serving as
lead; work focused on ten (10)
interventions to improve screening and
early access to care
Planning underway
Population Health: MHSA (4.c.ii)
Citywide effort; target population is
youth and young adults (ages 12-25);
focusing on school-based health services
to improve MHSA identification and
linkages to care
Planning underway
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6
CCB IT Strategy
Leverage and build upon previous local, NYS, and
Federal investments in Health IT:
Scale and adapt to the MMC PPS the proven and compliant Care
Coordination platform, available via the internet and interoperable
with Healthix/SHIN-NY, that was established and enhanced by MMC
as part of the HEAL, Health Home, and CMMI HCIA Programs.
Expand and enhance the use of MU certified EHRs for core clinical
data capture and exchange, and promote connectivity to the
Healthix/SHIN-NY infrastructure and participation in state-wide Health
Information Exchange (as a verb) for all Participants in the PPS.
Promote and leverage current and future NYS Health Information
Exchange infrastructure, data, and services including Healthix, the
SHIN-NY, MAPP, Salient analytics, etc.
0
500
1,000
1,500
2005 2006 2010 2011 2012 2014 2015
Jan. 2010: HEAL 10 MMC received funding to develop MHH model and HIT infrastructure; seven stakeholders and South Beach Psychiatric enter into HEAL contracts to
improve care for schizophrenics
2006: Co-location of primary care & behavioral health services at
South Beach
Oct. 2010: Development of
Mental Health Home Standards completed
Jan. 2011: HEAL 17 MMC received additional funding; five stakeholders
added and diagnoses expanded to include
schizoaffective disorder, bi-polar disease and serious
depression
Dec 2011: Health Home MMC designated as
Medicaid Health Home (Brooklyn Health Home), receiving PMPM fee for
IT-enabled, comprehensive care
management
July 2012: HCIA MMC received CMS Health Care Innovation Award to enhance HIT functionality, develop care management
training program and migrate from fee for
service to total cost of care payment model
Care Coordination Platform – GSI Health
Care Coordination Platform
Car
e C
oo
rdin
atio
n
Pla
tfo
rm
Care
Co
ord
inatio
n
Platfo
rm
Speciality Physcians
SHIN-NY/BHIX
SHIN-NY/BHIX
SHIN
-NY
/BH
IXSHIN-NY/BHIX
SHIN
-NY
/BH
IX
SHIN-NY/BHIX
Payer
Homeless Shelters
Correctional Services
Supporting Housing
Organizations
Peer Advocacy
FamilyIntensive Care Management
Providers
SPOA
Public Health Authorites
OASAS/Addiction Services
Social Service Provider
Case Management
Home Care
Patient
Care Manager
Care N
avigator
Psychiatrist
Pri
mar
y C
are
Ph
ysic
ian
Therapist
Soci
al S
erv
ice
s
Specialists
Social Se
rvices
Specialists
2005: BHIX Consortium of
hospitals, nursing homes, home
health providers & insurers
establish BHIX with HEAL NY
funds.
Jan. 2014: HARP Pilot MMC, Brooklyn Health
Home, FEGS and Healthfirst initiate HARP Pilot, integrating a payer into the care model in a
meaningful way
April 2014: DSRIP planning begins. MMC
and Steering Committee of partners organize Community Care of
Brooklyn.
April 2015: DSRIP Q1 begins.
Community Care of Brooklyn initiates
first DSRIP projects
MMC Technology for Population Health
7
8
Adapt PPS Model from BHH Model
Key Feature of the BHH
model: Virtual co-location of providers
and services enabled by
health IT and coordination
of services
9
Care Coordination, Communication, and
Reporting
User Interface/ Dashboard
Platform
Enrollment
Care Teams
Apps
EHR EHR
EHR EHR
Alerts
Messages
Coordinated Care Plan
Patient Engagement
Population Manager
SHIN-NY
Patient Summary/ CareBook
© 2015 GSI Health LLC. All rights reserved. GSI Health LLC and the GSI Health logo are registered trademarks of GSI Health, LLC. All other trademarks are the property of their respective owners.
GSIHealthCoordinator Clinician Engagement
Healthix CCD data
combined with Care
Coordination data
One page summary view
depicting patients history and
current
medical/behavioral/social
issues
Access to platform from MMC
ED EHR system (July)
Continuous care
documentation
© 2015 GSI Health LLC. All rights reserved. GSI Health LLC and the GSI Health logo are registered trademarks of GSI Health, LLC. All other trademarks are the property of their respective owners.
10
GSIHealthCoordinator Operational Reports
Assessment Report
Encounters Report
Care Teams Report
Care Plan Issues Report
Healthix Alerts Report
Gaps in Care Report
11
© 2015 GSI Health LLC. All rights reserved. GSI Health LLC and the GSI Health logo are registered trademarks of GSI Health, LLC. All other trademarks are the property of their respective owners.
GSIHealthCoordinator Mobile App
Ability to View and Send Messages
Notification for new alerts and messages
Same view and functionality as GSIHealthCoordinator
App available in App Store and Google Play
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© 2015 GSI Health LLC. All rights reserved. GSI Health LLC and the GSI Health logo are registered trademarks of GSI Health, LLC. All other trademarks are the property of their respective owners.
Healthix CENs
(Alerts)
Healthix HISP-HISP
Direct Messaging
Healthix CENs Brooklyn Health Home received Alerts from 25 Healthix connected facilities. Please see the list below for count of Alerts of all types since 9/27/2015, a weekly average of 364.
Facility Total Alerts
Beth Israel Kings Highway 74
Beth Israel Petrie Division 38
Brookdale University Hospital and Medical Center 1179
Forest Hills Hospital 13
Franklin Regional Hospital 16
Good Samaritan Hospital Medical Center 3
HHC Correctional Health Services (Rikers Island) 34
Jamaica Hospital Medical Center 5
Jewish Home Lifecare 1
Kingsbrook Jewish Medical Center 142
Lutheran Medical Center 1028
Maimonides Medical Center 919
Mount Sinai 63
Mount Sinai Sant Luke's Hospital 18
Nassau University Medical Center 1
New York Hospital Medical Center 5
New York University Medical Center 68
NYP/Columbia 30
NYP/Cornell 43
Richmond University Medical Center 30
Roosevelt Hospital 23
Staten Island University Hospital 17
SUNY Downstate 162
The Brooklyn Hospital Center 523
Wyckoff Heights Medical Center 1761
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Challenges • Funding – CRFP Funds for EHRs and Healthix Connectivity
• Confusion - swirl of vendors, solutions, and mandates • Care Coordination, Predictive and other Analytics, Patient Engagement/Activation,
SMS Text Based Messaging, etc.
• Example - Options and/or Mandates re Care Coordination / Care Plan • My local EHR or Care Plan
• PPS(s) Care Plan(s)
• Planned Healthix Care Plan
• NYS DOH Care Plan (MAPP - Curam)
• Where do I invest my time and money?
• What is the data of record?
• What will really be required and/or provided and when?
• NYS (and national) Consent Policy • Opt-Out vs Point of Access vs Community Wide vs Program Consent
• SAMHSA Requirements and Possible Changes
• Availability and Utility of NYS Claims (MCD/PHI) Data • Channels – Direct vs. MAPP Salient vs. Curam vs. Healthix
• Technical Security and Process Requirements
• Practicality – I can have it, but how can I use it?
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Discussion
Questions
and
Comments
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