data oct5
TRANSCRIPT
Camden Coalition of
Healthcare Providers
Data Collection
Basics of Capturing Care
Management Process and Outcomes Data
Camden Coalition of
Healthcare Providers
www.camdenhealth.org
Evolution of Program Data Thinking
1. Data is an asset to your programs
2. Start thinking about data early
3. Information Technology plays an important role in data collection
4. Check data quality
5. Activate you data
6. Think about, talk about, debate the “activated” data
7. Do something with findings (share your successes, fine tune the program, gather new data)
8. An iterative process
CCHP CMMI Program Goals (aka Outcomes)
• Stabilize
• Coordinate
• Improve Health
• Reduce cost
CCHP measures these goals (Outcomes)and steps in to process
towards achieving these goals (Process Measures)
Tenets of Good Care (and the role of data)
• It takes a team
• Enroll based on specific triage data r/t preventable readmissions
• Engage patient at hospital
• Build/maintain rapport with patients/families
• Assess medical/social complexity
• Provide immediate post d/c(<72hours) in-person intake
assessment
• Accompany to PCP < 7 days post d/c
• Build the relationship between patient/family and PCP/specialists
• Individualized care plan with specific graduation timeline
• Collect information at each step to evaluate/improve program
• Helping patients help themselves to find long-term sustainable
resources
CCHP CMMI Data collection touch points • Real Time Data to Identify Currently Hospitalized “High Utilizer”
– Camden HIE data
• Triage– CCHP Triage tool
• Pre-enrollment– CCHP Risk Stratification tool
• Intake – CCHP Intake Form
– Client Perceptions of Coordination Questionnaire (CPCQ) (Coordinate)
– Healthy Days Survey
• Care Provided– CCHP Client Track Form (Staff time activities for each patient)
• Home visit measures– Care Plan Progress
– Healthy Days Survey (Improve Health)
– 30 day readmissions (Stabilize)
• Status– Graduated/lost to follow-up/moved/deceased
• Graduation– Client Perceptions of Coordination Questionnaire (CPCQ) (Coordinate)
• Post-graduation follow-up– Healthy Days Survey (Improve Health)
• Six month and one year post enrollment– Compare pre and post cost per month (Reduce Costs)
Process Measure
Outcome
Care Management Intervention – Data Collection Timeline
Past Utilization Data for Risk
Tool Collected
TRIAGE
Risk Stratification Tool
Bedside Intake
PRE-
ENROLLMENT
HOSPITAL DISCHARGE
(DAY ZERO)
Enrollment Intake CPCQ
Healthy Days
Ongoing
Staff time/activities for each patient
CLIENT
TRACKING ENROLLMENT
30 DAY DECISION
POINT
60 DAY DECISION
POINT
Re-administer Risk Tool & Healthy
Days
HOME VISIT
Graduate? Re-administer
CPCQ Ongoing
Staff time/activities
for each patient
CLIENT
TRACKING
Re-administer Risk Tool & Healthy
Days
HOME VISIT
Graduate? Re-administer
CPCQ
Re-administer Risk Tool and Health Days During Follow-up Phone Call
6 MONTH POST-DISCHARGE (DAY 0)
Camden Coalition’s CMMI Data Collection Plan
Data to Information
Example: CCHP Client Track Form
Since February 2012:
Example: Client Track Summary Report
Data to Information
Data to Information
Data to Information
Site Specific Decisions:
• How to collect data
– Paper
– EMR System
– Customized Solution
• How to review/discuss data
– When
– Who
– What
Q & A
THANK YOU!