Hawai‘i Island Beacon Community

East Hawai`i IPA SymposiumAugust 19, 2012

Components of HITECH Act

Taken from: Blumenthal, D. “Launching HITECH,” posted by the NEJM on 12-30-2009.

BEACON

Build and strengthen health IT infrastructure and exchange capabilities - positioning each community to pursue a new level of sustainable health care quality and efficiency over the coming years.

Improve cost, quality, and population health - translating investments in health IT into measureable improvements.

Test innovative approaches to performance measurement, technology integration, and care delivery - accelerating evidence generation for new approaches.

Beacon Community National Program Aims

17 grantees each funded ~$12-16M April 2010 – March 2013:

17 Beacon Communities

4

Hawaii Island Beacon Community

Hilo, HI

Southeast Michigan Beacon Community

Detroit, MI

Crescent City Beacon CommunityNew Orleans, LA

Delta BLUES Beacon Community

Stoneville, MS

Keystone Beacon Community Danville, PAUtah Beacon

CommunitySalt Lake City, UT

Beacon Community of Inland Northwest

Spokane, WA

Great Tulsa Health Access Network Beacon

CommunityTulsa, OK

Southeastern Minnesota Beacon Community

Rochester, MN

Rhode Island Beacon Community

Providence, RI

Greater Cincinnati Beacon Community

Cincinnati, OHSouthern Piedmont Beacon Community

Concord, NCSan Diego Beacon Community

San Diego, CA

Western New York Beacon Community

Buffalo, NY

Colorado Beacon Community

Grand Junction, CO

Bangor Beacon CommunityBrewer, ME

Central Indiana Beacon Community

Indianapolis, IN

Trajectory to Value Based Purchasing

It is a Journey – not a fixed model of care

Supports base for ACOs, PCMH Networks and Bundled Payments

Health Information Technology and Meaningful Use

Improving patients’ access to and experience of care within the Institute of Medicine’s 6 domains of quality: Safety, Effectiveness, Patient-Centeredness, Timeliness, Efficiency, and Equity.

Better care

Increasing the overall health of populations: address behavioral risk factors; focus on preventive care.

Better health

Lowering the total cost of care while improving quality, resulting in reduced monthly expenditures for Medicare, Medicaid, and CHIP beneficiaries.

Lower costs

$

HIT and MU Are the Foundation for Obtaining Measurable Results

6

• Screening• HgA1c control• BP control• Lipid control

• Health Eating• Active Living• No Smoking

• Potentially Avoidable re-admissions and ER visits by condition

Hawaii Island Beacon CommunityTransformation Strategy

VISION: Transforming health and health care delivery through collaboration, technology and community engagement resulting in better care, better health and lower cost.

OBJECTIVES:• Improve access to primary care, specialty care & behavioral health care

•Avert the onset and advancement of diabetes, hypertension and hyperlipidemia

•Reduce health disparities for Native Hawaiians andother populations at risk

•Achieve EHR adoption and meaningful use >60% of primary care providers

Clinical Transformation

Patient, Provider and Community

Engagement

Health Information

Exchange

Primary Drivers:

Leadership

Reliable Processes

Provide care in appropriate setting

Delivery System Design

Community, Patient and

Family Voice

Communication

Decision Support

Secondary Drivers: Interventions

Practice Redesign - PCMH Coaching - EMR/MU Stage I - Care Coordination

Care Transitions - Hospital Discharge

Enabling Services Healthy Lifestyles HEAL Projects

Alere/Wellogic - Clinical Decision Support

Caradigm/Amalga - Population Health Monitoring

Hawaii Island Beacon CommunityTransformation Strategy

VISION: Transforming health and health care delivery through collaboration, technology and community engagement resulting in better care, better health and lower cost.

OBJECTIVES:• Improve access to primary care, specialty care & behavioral health care

•Avert the onset and advancement of diabetes, hypertension and hyperlipidemia

•Reduce health disparities for Native Hawaiians andother populations at risk

•Achieve EHR adoption and meaningful use >60% of primary care providers

Clinical Transformation

Patient, Provider and Community

Engagement

Health Information

Exchange

Primary Drivers:

Leadership

Reliable Processes

Provide care in appropriate setting

Delivery System Design

Community, Patient and

Family Voice

Communication

Decision Support

Secondary Drivers: Interventions

Practice Redesign - PCMH Coaching - EMR/MU Stage I - Care Coordination

PCMH Coaching

• Partners:

• Beacon Leadership:– Melinda Nugent, MS, Clinical Program Manager– Kahealani Wakinekona, Practice Coach

• Activities:– Support to Practices/Practice Coaches – National Kidney Foundation– Outcome Data Reporting – HMSA– Practice Assessments - TransforMED– Learning Collaborative/Interactive Instruction – TransforMED– Delta Exchange On-line Information Sharing - TransforMED

PCMH Coaching

Participating Providers:

NEXT LEARNING COLLABORATIVE:SEPTEMBER 15 AND 16, 2012

West Hawai‘i

Minolu Cheng MDDominador Genio MDDavid Arthurs DOElizabeth Catanzaro MDLambert Lee Loy MDSukchai Satta MDRobert Laird MD

North Hawai‘i

John Dawson MDMaria Perlas MDWilliam Lawrence MDMalcolm MacDonald MDMichele Shimizu MD

East Hawai‘i

Doug Olsen MDKara Okahara MDDavid Jung MDJoseph D’Angelo MDRoy Koga MDJulie Chee MDKristine McCoy MD

PCMH Reporting Requirements

• HMSA PCMH Pay for Quality Measures

– Data Not Yet Available for the second PCMH cohort.

Primary Care Access Measure

Source of ER data: Hawaii Health Information Corporation Emergency Department Database.Sources: Denominator(Population) U.S. Census, 2009 Intercensal Estimates of the Resident Population for Counties of Hawaii (CO-EST00INT-01-15), 2010 to 2011 Estimates of the Resident Population for Counties of Hawaii (CO-EST2011-01-15)Notes: Census population is annualized over 4 quarters. Where population estimates have not been updated, the most current previous year estimate is used. The National Uniform Billing Committee (NUBC) dropped ""Admitted via ER"" as a valid code for ""Admission Source"" effective July 1, 2010 to better capture patient origin prior to presenting to the ER. HHIC has updated data through December 31, 2010 to account for admissions via ER. To allow continued tracking of patients admitted via ER, HHIC will capture data from revenue codes submitted by the hospitals.

Primary Care Access Measure

Source of ER data: Hawaii Health Information Corporation Emergency Department DatabaseNumerator = total number of avoidable ER visits. Denominator = total number of ER visitsSource of Avoidable ER Visit definitions: 2008 Statewide Collaborative QIP, Reducing Avoidable Emergency Room Visits, Re-Measurement Report. California Department of Health Care Services Health Services Advisory Group, Inc. November 2010. (Appendix A). www.dhcs.ca.gov/dataandstats/reports/Documents/MMCD_Qual_Rpts/EQRO_QIPs/CA2009-10_QIP_Coll_ER_Remeasure_Report_F2.pdfminator = total number of ER visits

UTI, Headache, Sore Throat and Lower Back Pain

Meaningful Use Stage 1

• Partners:

• Beacon Leadership:– Melinda Nugent, MS, Clinical Program Manager– Technical Support: Saturnino Doctor, Kevin Ikeda, Linda Ranney

• Activities:– Network, Hardware and Connectivity Support– Monitoring of Progress Toward Stage 1 MU– Basic MU Technical Preparation for Handoff to REC

Meaningful Use Stage 1 Progress: June 2012

Care Coordination

• Partners:

• Beacon Leadership:– Della Lin, M.D., Performance Improvement Consultant– Cynthia Ross, MPA, Clinical Program Coordinator

• Activities:– Public/Private Partnership in Care Coordination Infrastructure Development– Clinical Transformation/Process Change– Target Population of Focus– Process/Outcome Measurement

Hawai‘i Island Beacon Community Clinical Transformation:Target Population of Focus: Patient Enrollment

Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-120

100

200

300

400

500

600

1752

108 106 105 1058

8

2626

34 42

59

75

229225

240245

23

2929

3844

33 53 60

Hawaii Island Beacon Community Clinical Transformation Patient Enrollment

West Hawaii CHCHui Malama-WestHui Malama-NorthHamakua HCBay Clinic

Month

Num

ber o

f Pati

ents

N = 496

Selection Criteria: Diagnosis, Co-morbidities, Age, Utilization

Blood Pressure Screening PerformedJune 2012 = 94%

• Clinical Transformation Population of Focus diabetic patients who had an HbA1c screen in the last 12 months.

BP < 140/90June 2012 = 69%

• Diabetic patients whose most recent BP was less than 140/90 in the last 12 months. The patient is counted if the most recent BP for the last 12 months is less than 140/90. The patient is not counted if the result for the most recent BP test during the measurement period is ≥ 140/90, or is missing, or if an HbA1c test was not performed.

• The goal is for 70% of diabetic patients to achieve HbA1c<9.0%.

HbA1c Screening PerformedJune = 73%

• Clinical Transformation Population of Focus diabetic patients who had an HbA1c screen in the last 12 months.

• Diabetic patients whose most recent HbA1c was less than 9.0% in the last 12 months. The patient is counted if the most recent HbA1c for the last 12 months is less than 9.0%. The patient is not counted if the result for the most recent HbA1c test during the measurement period is ≥ 9.0%, or is missing, or if an HbA1c test was not performed.

• The goal is for 70% of diabetic patients to achieve HbA1c<9.0%.

HbA1c < 9.0June 2012 = 55%

LDL-C Screening PerformedJune 2012 = 63%

• Clinical Transformation panel patients who had a LDL-C screen performed in the last 12 months.

LDL-C < 100 mg/dLJune = 33%

• Patients whose most recent LDL-C was less than 100 mg/dl in the last 12 months. The patient is counted if the most recent LDL-C for the last 12 months is less than 100 mg/dl. The patient is not counted if the result for the most recent LDL-C test during the measurement period is ≥ 100 mg/dl, or is missing, of if an LDL-C test was not performed.

• The goal is for 70% of patients to achieve LDL-C<100 mg/dl.

Summary

Measure Percentage Screened Percentage Controlled

Blood Pressure control < 140/90 94% 69%

HbA1C control < 9.073% 55%

LDL-C control < 100 mg/dL63% 33%

Hawaii Island Beacon CommunityTransformation Strategy

VISION: Transforming health and health care delivery through collaboration, technology and community engagement resulting in better care, better health and lower cost.

OBJECTIVES:• Improve access to primary care, specialty care & behavioral health care

•Avert the onset and advancement of diabetes, hypertension and hyperlipidemia

•Reduce health disparities for Native Hawaiians andother populations at risk

•Achieve EHR adoption and meaningful use >60% of primary care providers

Clinical Transformation

Patient, Provider and Community

Engagement

Health Information

Exchange

Primary Drivers:

Leadership

Reliable Processes

Provide care in appropriate setting

Delivery System Design

Community, Patient and

Family Voice

Communication

Decision Support

Secondary Drivers: Interventions

Practice Redesign - PCMH Coaching - EMR/MU Stage I - Care Coordination

Care Transitions - Hospital Discharge

Care Transitions

• Partners:

• Beacon Leadership:– Alistair Bairos, M.D., Care Transitions Re-Design Manager

• Activities:– Discharge Planning Process Improvements

• Readmit Risk Factor Screen • Medication Reconciliation• Patient and Caregiver Education and Teachback• Post-Discharge Instructions and Handoffs

– Alignment with Community Based Care Coordinators– Alignment with PREMIER QUEST PATIENT SAFETY AND QUALITY IMPROVEMENT

Utilization Measure: Chronic ConditionComposite PQI for Q1 2009 through Q1 2012

• Numerator - Hospital inpatient data) Hawaii Health Information Corporation, Inpatient Database [for more information, go to http://hhic.org/inpatient-data.asp];• Denominator – Population data) U.S. Census Bureau, Population Division, Inter-censal Estimates of the Resident Population for Counties of Hawaii: April 1, 2000 to July 1, 2010 (CO-

EST00INT-01-15) and Annual Estimates of the Resident Population for Counties of Hawaii: April 1, 2010 to July 1, 2011 (CO-EST2011-01-15). Notes: Census population is annualized over four quarters. Where population estimates have not been updated, the most current previous year estimate is used.

• Risk-adjusted rate = (observed rate/expected rate)*reference population rate.• Chronic conditions include: short- and long-term and uncontrolled diabetes, lower extremity amputation among diabetics, COPD or asthma in older adults, hypertension, CHF, angina

and asthma in younger adults.• Source of Potentially Avoidable Hospitalizations definition: The Prevention Quality Indicators (PQIs) were developed by the Agency for Healthcare Research and Quality (AHRQ) and can

be used with hospital inpatient data to measure quality of care for conditions sensitive to ambulatory care.

Utilization Measure:30-Day Potentially Preventable Hospital Readmissions All Causes Q1 2009 through Q4 2011

• Source: Hawaii Health Information Corporation • Potentially Preventable Readmission: A Potentially Preventable Readmission is a readmission (return hospitalization within the

specified readmission time interval) that is clinically-related to the initial hospital admission.• Readmission: Readmission is a return hospitalization to an acute care hospital that follows a prior admission from an acute care

hospital. Intervening admissions to non acute care facilities (e.g., a skilled nursing facility) are not considered readmissions and do not impact the designation of an admission as a readmission.

• Source: 3M™ Health Information Systems: Potentially Preventable Readmissions Classification System

Premier QUEST Readmission FindingsJuly 1, 2010 – June 30, 2011

Hilo Medical Center:

• Top 3 MS-DRGs opportunities psychosis, heart failure, cellulitis

• Principle diagnosis heart failure, chronic bronchitis, diabetes

• 53% of admissions within 30 days occur by day 10

• Readmission rate is 8.1%

Kona Community Hospital:

• Top 3 MS-DRG opportunities normal newborn, pneumonia and heart failure

• Principle diagnosis perinatal jaundice, pneumonia and heart failure

• 63% of admissions within 30 days occur by day 10

• Readmission rate is 4.9%

Utilization Measure:30-Day Potentially Preventable Hospital Readmissions: Cardiovascular Conditions Q1 2009 through Q4 2011

• Potentially Preventable Readmission: A Potentially Preventable Readmission is a readmission (return hospitalization within the specified readmission time interval) that is clinically-related to the initial hospital admission.

• Readmission: Readmission is a return hospitalization to an acute care hospital that follows a prior admission from an acute care hospital. Intervening admissions to non acute care facilities (e.g., a skilled nursing facility) are not considered readmissions and do not impact the designation of an admission as a readmission.

• Source: 3M™ Health Information Systems: Potentially Preventable Readmissions Classification System

Hawaii Island Beacon CommunityTransformation Strategy

VISION: Transforming health and health care delivery through collaboration, technology and community engagement resulting in better care, better health and lower cost.

OBJECTIVES:• Improve access to primary care, specialty care & behavioral health care

•Avert the onset and advancement of diabetes, hypertension and hyperlipidemia

•Reduce health disparities for Native Hawaiians andother populations at risk

•Achieve EHR adoption and meaningful use >60% of primary care providers

Clinical Transformation

Patient, Provider and Community

Engagement

Health Information

Exchange

Primary Drivers:

Leadership

Reliable Processes

Provide care in appropriate setting

Delivery System Design

Community, Patient and

Family Voice

Communication

Decision Support

Secondary Drivers: Interventions

Practice Redesign - PCMH Coaching - EMR/MU Stage I - Care Coordination

Care Transitions - Hospital Discharge

Enabling Services Healthy Lifestyles HEAL Projects

Community Engagement

• Partners:

• Beacon Leadership:– HEAL – Jessica Yamamoto, MBA, Community Engagement and Communications Manager– HEAL – Mari Horike, Community Outreach Facilitator– Della Lin, M.D., Performance Improvement Consultant– Cynthia Ross, MPA, Clinical Program Coordinator

• Activities:– Enabling Services

• Healthy Eating and Active Living – Community Based Programs• Health Education• Outreach• Transportation• Social Services

H.E.A.L. PROJECTS

Hawaii Island Beacon CommunityTransformation Strategy

VISION: Transforming health and health care delivery through collaboration, technology and community engagement resulting in better care, better health and lower cost.

OBJECTIVES:• Improve access to primary care, specialty care & behavioral health care

•Avert the onset and advancement of diabetes, hypertension and hyperlipidemia

•Reduce health disparities for Native Hawaiians andother populations at risk

•Achieve EHR adoption and meaningful use >60% of primary care providers

Clinical Transformation

Patient, Provider and Community

Engagement

Health Information

Exchange

Primary Drivers:

Leadership

Reliable Processes

Provide care in appropriate setting

Delivery System Design

Community, Patient and

Family Voice

Communication

Decision Support

Secondary Drivers: Interventions

Practice Redesign - PCMH Coaching - EMR/MU Stage I - Care Coordination

Care Transitions - Hospital Discharge

Enabling Services Healthy Lifestyles HEAL Projects

Alere/Wellogic - Clinical Decision Support

Caradigm/Amalga - Population Health Monitoring

Health Information Exchange

• Partners:

• Beacon Leadership:– Jeff Jendrysik, Senior Project Manager– Laurie Bass, HIT Manager– Andy Levin, Patient Ombudsman– Brad Peska, Strategic Technology & Innovation Consultant

• Activities:– Governance– Contracting– Data Security/HIPAA Compliance– Project Implementation Management Oversight

Alere-Wellogic Implementation

Caradigm/Amalga Implementation

• Project has been re-scoped• Final deliverable – successful data input• Caradigm currrently evaluating data feeds

from Hilo Medical Center – ADT– Medications– Discharge Summaries

A Familiar Patient Story

Kimo is a 280 pound, 44 year old male with a BMI of 46 suffering from coronary artery disease (triple bypass), diabetes and renal insufficiency. His sibling is a diabetic amputee. Kimo is a Native Hawaiian QUEST patient. He farms livestock and lives off the grid in a remote rural location in North Hawaii. He was identified for the BEACON Care Coordination program at Hamakua Health Center is now with a Private Practice. He was recently admitted to NHCH through the Emergency Department with a diagnosis of cellulitis and an infected abscess. His hospital length of stay was 10 days.

Improvement Cycle: PDSA

1. Discharge Note/Med List (NHCH)2. Patient Contact List (NHCH & Hamakua)3. Informed of Discharge (Hui Malama)

Testing in Progess…Ownership through small tests

• “This puts everything together so it makes sense!”

• “The fact that we could come together is the most rewarding thing that I have done!”

• “We understand better now why we do things.. the little every day tasks… we know the impact of those little everyday tasks that we do.. there is a feedback loop”

• “No task is too great if we do it together!!”

Reflections

Next Steps

• First steps in transforming care – Relationships– Communication channels– Trust– Follow-through– Problem solving strategy

• Next steps– Health Information Exchange to streamline communication channels

and facilitate problem solving strategies– Measure effectiveness of interventions

• Process• Outcome• Cost

Future Direction

• HIE and Clinical efforts implemented in North Hawaii to spread island wide• Sustainability business model for 501c3 Service Lines include support for

physician practices:– HIT Network and Connectivity – Performance Improvement/Care Redesign– Management/Leadership– Administrative Functions– Data Analysis for Performance Incentives

• Central Authority for Health Information Exchange on Hawaii Island• Current and future activities lay foundation for Accountable Care• Value Proposition with an Affordable Price• Alignment with State Transformation Vision• Actively pursuing program investment funding for continued

transformative change

Commitment to a Hawaii Island Shared Vision

Transforming Health and Health Care

Delivery through

Collaboration, Technology

and Community Engagement