Community Coordination of Care-Beyond Meaningful Use

Kim R. PembleExecutive Director WHIE

Alison Lopez, RN, ED Case Manager

Meaningful Use

Blumenthal: 2013 meaningful use to ramp up HIE, decision support

“… an exchange that consciously ignores economic relationships, geographic relationships and political jurisdictions.” “We want information to follow patients,” Blumenthal said.

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 >=2010

100

1000

10000

100000

1000000

178,

067

47,6

30

18,9

20

8,99

2

4,75

3

2,60

5

1,66

1

1,03

4

706

476

339

253

178

125

118

106

54 61

42

356

95,2

60

56,7

60

35,9

68

23,7

65

15,6

30

11,6

27

8,27

2

6,35

4

4,76

0

3,72

9

3,03

6

2,31

4

1,75

0

1,77

0

1,69

6

918 1,09

8

798

11,3

83

# Patients, Total # ED Encounters by # ED EncountersJanuary 1, 2009 - December 31, 2009

8.2% Patients and 29% Encounters Patients with 4 or more Encounters

#Patients #TotalEDVisits

21,859 Patients and 134,868 Encounters

Impact to Public Health, Policy, Care Delivery based on near real time data.

‘4 to 10’ = 20,227 Patients and 106,376 Encounters

1 2 3 4 5 6 7 8 9 >= 101

10

100

1000

10000

100000

1000000

229,

769

29,9

32

5,17

0

1,13

7

286

118

35

20

6

3

315,

309

99,2

03

30,3

32

10,7

25

4,32

2

2,61

8

1,27

5

694

277

200

# Patients Total # Encounters by # Facilities VisitedJanuary 1, 2009 - December 31, 2009

3% Patients and 11% Encounters visited 3 or more Facilities# Patients # Total ED Visits

Wisconsin Health Information ExchangeWHIE is non profit organization 501(c)(3)Key stakeholders

Milwaukee Health Care PartnershipDepartment of Health ServicesHumana and Business Health Care GroupPatientsAdvisory Board – 22 seats

Technical Service Provider for WISHIN

Active Use CasesED Linking Clinical Summary View

Fourteen EDs and One Community Health CenterPublic Health Disease Surveillance – 24 WI

Counties, 44 hospitals, numerous clinicsCare/Case Management (Clinical Settings)Auto Print History SummaryProvider and Care/Case Manager MessagingPatient Consent

WISCONSIN HEALTH INFORMATION EXCHANGE AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION V2011 02 09 PATIENT INFORMATION Patient Name _________________________________ Patient Birth Date (mo/day/year) ___________________ Patient Address ________________________________ City _________________________ State ____ Zip ____________ TO WHOM THE INFORMATION MAY BE DISCLOSED This Authorization is for disclosures to The National Institute for Medical Informatics (NIMI). NIMI is a not-for-profit company managing the Wisconsin Health Information Exchange (WHIE). WHIE is a local effort in Milwaukee, which electronically shares personal health information for improving patient safety. This sharing also is intended to aid in improving the quality and efficiency of care. A list of participating organizations (WHIE Participants) is attached as part of this Authorization. NIMI is acting on behalf of the WHIE Participants to obtain this Authorization. This form authorizes NIMI and the WHIE Participants to receive, disclose, and re-disclose as permitted by law, your personal health information via electronic transfer or other reasonably secure means of transfer. WHAT INFORMATION IS AUTHORIZED FOR DISCLOSURE By signing this Authorization, I authorize for disclosure any of my existing and future medical records. Medical records include: 1. demographic, insurance, and financial information; 2. medication and allergy information; 3. complaints and diagnoses, procedures, care plans and advance directives; 4. laboratory, radiology and other tests performed and their results; and 5. discharge summaries, progress notes, and consultation notes

DISCLOSURE AND RE-DISCLOSURE SUBJECT TO APPLICABLE LAW, BY SIGNING THIS AUTHORIZATION, I PERMIT THE DISCLOSURE AND RE-DISCLOSURE OF PERSONAL HEALTH INFORMATION DESCRIBED ABOVE, AS WELL AS PERSONAL HEALTH INFORMATION AND HEALTH CARE RECORDS RELATED TO MY HIV TEST RESULTS OR DIAGNOSIS, TREATMENT OR DIAGNOSIS OF MENTAL HEALTH, DEVELOPMENTAL DISABILITIES, SICKLE CELL ANEMIA, AND/OR ALCOHOL AND DRUG ABUSE FOR THE PURPOSES DESCRIBED IN THE SECTION BELOW. PURPOSE OR NEED FOR DISCLOSURE I authorize the disclosure of this information for direct health care treatment purposes. The information may also be disclosed as permitted by law for purposes related to public health, quality improvement, medical care case management, insurance eligibility, and/or research approved by an Institutional Review Board. Medicaid claims data will be specifically excluded from disclosures of health information used for research purposes. PATIENT RIGHTS WITH RESPECT TO THIS AUTHORIZATION 1. Right to Inspect or Copy Information to be Disclosed. I understand that I have a right to inspect and copy the records or information I have authorized for disclosure. I understand that there may be a reasonable fee for this request. This request will be made by contacting the clinic or hospital making the disclosure. 2. Right to Receive Copy of This Authorization. I understand that if I sign this permission form, I will be provided with a copy of this form. 3. Right to Refuse to Sign Authorization. I understand that I am under no obligation to sign this form. I understand that health care facilities may not condition providing care to me on signing this permission form. 4. Right to Revoke this Authorization. I understand that I have the right to revoke this permission. I understand that my revocation will be effective on and after the date it is received. I understand that revocation does not apply to any disclosures of personal health information made before the date and time of revocation. I may revoke this permission by contacting in writing the clinic or hospital that asked me to sign this Authorization. I may also revoke this permission by contacting in writing any other of my healthcare providers that participate in the WHIE. 5. HIV Test Results. I understand that my HIV test results may be disclosed without authorization to individuals or organizations that have the right to access these results under State and/or federal law. A list of those organizations is available by contacting the clinic or hospital that asked you to sign this permission form. 6. Re-Disclosure Notice. I understand that the information I authorize to be disclosed may be re-disclosed by the recipient of the records if permitted by law. The recipient of re-disclosed information may be controlled by different laws. EXPIRATION DATE This Authorization is valid until revoked by me or expires three years following the date I sign this Authorization. Signature: ______________________________________ Date: ____________________Print Name: ___________________________________ If signed by someone other than the patient, indicate relationship and authority for signature: _____________________________________ ___________________________________________ Relationship (e.g. parent, spouse) Authority (e.g. guardian, health care agent, parent)

DATA COLLECTED IN SEGREGATED DATA STRUCTURES

44 hospitals (9 delivery networks), 1 community health center, Medicaid and 1 MCO populating the WHIE

Patient Registers For Care -- Triggers WHIE

Establish “care relationship” through admission record

Hospital AHealth

System BClinic C

Medicaid Claims

Clinic C MedicaidHealth System B

Hospital A

Wisconsin Health Information Exchange

Pt. A

DT

Pt. A

DT

Claim

s

Pt. A

DT

.

Pt. A

DT

Pt. A

DT

Cla im

s

Pt. A

DT

Managed Care Org.

Care

Pla

ns

MCO

Ca re

Pla

ns

Information About Today… Today

07/04/2009

Reapplying data to a different question

ER Utilization Management

PPACA on ED Management

12

“HOSPITAL REFERRALS.—A State shall include in the State plan amendment a requirement for hospitals that are participating providers under the State plan or a waiver of such plan to establish procedures for referring any eligible individuals with chronic conditions who seek or need treatment in a hospital emergency department to designated providers” (i.e., designated Health Homes). Sec. 2703 (d)

iCare ER Utilization Experience

iCare Member ER Utilization Profile Y10

Range: Visits to ER per Year

Total Members Visiting

Members Total Visits to ER

Members Total Hospital Admits

after ER

61-70 1 63 4

51-60 4 215 3

41-50 3 129 16

31-40 10 353 8

21-30 37 905 107

11-20 189 2,594 307

10 46 460 54

9 62 558 64

8 105 840 67

7 151 1,057 127

6 203 1,218 167

5 293 1,465 169

4 519 2,076 224

1,623 11,933 1,3171-3 5,991 9,313 938

7,614 21,246 2,2550 12,744 0 0

Sum 20,358 21,246 2,255

iCare ER Utilization Profile Y10Visits to ER

Per YearAve Visits to ER per Mem

Ave Cost per ER Visit

Ave ER Cost/Mem

per Year

Inpatient Admits/ER

Visit

Inpatient Admits/

Mem

Ave Cost/Inpat

Stay

Ave Inpat Cost/Mem

per Year

All Members Visiting 2.79 $232 $646 0.106 0.296 $8,370 $2,479

Members Visiting 1-3Xs/Yr 1.55 $236 $367 0.101 0.157 $9,470 $1,483

Members Visiting 4-60 Xs/Yr 7.35 $228 $1,675 0.110 0.811 $7,586 $6,156

iCare ER Cost Experience

14

Effect on iCare CORE Members

– iCare identifies members who have a need to obtain a physical exam and specific health indicator metrics at their ER visit

– iCare alerts ER providers of the need for PE and HI actions to protect ongoing eligibility and insurance benefit coverage

– iCare ensures that current PE and HI information is posted to avoid duplication of services

CORE Notice: “This patient is a BadgerCare Plus CORE member who requires a physical examination to maintain BadgerCare Plus CORE eligibility. As part of your examination, please record height, weight, and blood pressure. This is a Medicaid requirement for this patient to maintain their eligibility.”

Effect on iCare SSI Members

– iCare identifies members who have a history of high ER utilization

– iCare configures for ER providers an avenue for them to address clinically inappropriate utilization

– iCare Care Coordinators educate members regarding PCP/MedHM use.

– iCare encourages members to make appropriate care access decisions OVER TIME

SSI Notice: “This patient has used the ER 4 or more times in the last 12 months. If the reason for this visit is not an emergency, refer to an urgent care center or PCP. Call iCare for transportation at 414-223-4847. See case management module for Care Coordinator contact information.”

iCare Change MetricsiCare-ER Evaluation Metrics (using Y10)

Measure Before After GainsMember Satisfaction with iCare >97% >97%

Member Satisfaction with ER 85% >90%

Member Satisfaction with PCP 85% >90%

ER Cost/>3x Member Visiting @ <80% $1,675 $1,340 ($335)

Inpatient Cost/>3x Member Visiting @ <80% $6,156 $4,925 ($1,231)

PCP Cost/>3x Member Visiting @ >20% $1,146 >$1,432 $286

Total ER Cost/>3x Member Visiting $2,719,275 <$2,175,420 ($543,855)

Total Inpatient Cost/>3x Member Visiting $9,991,266 <$7,993,013 ($1,998,253)

Total PCP Cost/>3x Member Visiting $1,859,181 >$2,323,977 $464,795

Re-admission Prevention

PPACA on Post-Discharge Services

“Beginning on January 1, 2015, a qualified health plan may contract with— (A) a hospital with greater than 50 beds only if such Hospital — … (ii) implements a mechanism to ensure that each patient receives a comprehensive program for hospital discharge that includes patient-centered education and counseling, comprehensive discharge planning, and post discharge reinforcement by an appropriate health care professional …” PPACA, Sec. 1311(h)(1)

Access to Post-Discharge Plans

iCare Post-Discharge Experience RateDischarge Plan presented by Hospital to iCare 0%

Written Discharge Plan given by Hospital to Member 65%

Written Discharge Plan presented by Member to iCare 67%

Written Discharge Plan as presented by Member is Complete 63%

Written Discharge Plan as presented by Member is Legible 88%

iCare Visiting Nurse Contacts the PCP Post-Discharge 92%

iCare Post-Discharge Patterns

Case PatternPlan written by

hospital and shared with

iCare

Plan written by hospital and given to the

member

Written plan held by

member and shared with iCare nurse

Written plan is shared and

complete in all parts

Written plan is shared and legible in all

parts

iCare visiting nurse required to contact PCP

Distribution

Member X 0 0 0 0 0 1 35%

Member Y 0 1 1 1 1 1 22%

Member Z 0 1 0 0 0 1 22%

Member P 0 1 1 0 1 1 11%

Member Q 0 1 1 1 1 0 5%

Member R 0 1 1 0 0 1 3%

Member T 0 1 0 0 0 0 3%

Post-Discharge Measures

12 Months Prior < Intervention < Current (12/2010)

Medical Measure Pre-Intervention

Post-Intervention

Decrease (Increase)

Admissions/1000 2,454 1,702 30.6%

Inpatient Days/1000 10,153 8,770 13.6%

Cost PMPM $1,800 $1,394 22.9%

Use Cases In DevelopmentEngaging other Community Health Centers (CHC)

Sixteenth Street CHCMilwaukee Health Services CHCWestside Healthcare Association CHC

Ongoing Care RelationshipsCare Managers and Primary Provider

eCommunity Care Plans

Yes44%

No47%

N.R.10%

N=420

“Preliminary questionnaire results indicate that the information provided by the ED Linking Project has an impact on clinical care. Additional data collection is planned to further delineate the effects of specific types of information.” Dr. Jonathan Rubin

Work up or treatment of the patient altered?

Study Results: Evaluation Impact on MD Ordering

Med Orders

Imaging Orders

52%decreased

8%increased

25 %no change

61%decreased

9%increased

16%no change

59%decreased

8%increased

19%no change

Lab Orders

15%no response

14%no response 14%

no response

Time Spent Seeking Information

Time to Disposition Decision

40%decreased

3%increased

53%no change

41%decreased

0%increased

Study Results Impact on Efficiency

4%no response

4%no response N=420

55%no change

More importantly, partnerships such as ours help improve the health of the community as a whole addressing key problems facing our health care system: fragmentation of medical history, waste accrued through repetitive testing and an inability to provide a community-wide solution to care coordination. Not only do providers and patients benefit, but payers realize a positive ROI. Dr. Albert Tzeel, MD, MHSA, National Medical Director Humana One

Payer Feedback

Clinical Labs

ImagingHospitals, IDNs

Payers/MCOs

Pharmacies, PBM

Public Health Specialist

People

PHR

Data Registries

Regional and State HIE

PCP

EMS/First Responders

Portal

Health Care Community “Integration Engine”

NHIN and otherNetworks