Optimizing Care Transitions with RIQI Tools

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Presentation transcript:

Optimizing Care Transitions with RIQI Tools Using Care Management Tools Alerts Dashboard New Dashboard features (identifying high risk) Using CurrentCare: fill gaps and find the data you need CurrentCare Hospital Alerts for PCPs Optimize CurrentCare Enrollment CurrentCare for Me Designee Alerts Resources for you practice

Care Management Services Based on your patient panel Near real time data for hospital (ED and Inpatient) admissions and discharges Encounter data and risk scores (*new) Care Management Services Rhode Island’s Health Information Exchange Opt-in: patients need to enroll Data repository: medications, lab results, discharge documents and more

Care Management Tools: Alerts Dashboards

Care Management Services Patient visits ED, Hospital, SNF Real-time CM Alerts Received by Care Team Alerts ADT Practices, ACOs RIQI Care Management Services Real-time CM Dashboards Available to Care Team Dashboards

Care Management Alerts Lifespan Discharges include CoC Document All of this data is fabricated. There is no PHI displayed. Near real time updates from RI acute care hospitals Screenshots contained in this document and on any training files do not contain Protected Health Information (PHI). All data presented for training purposes has been randomly generated from databases of fictitious data.

Care Management Dashboard Admitted Discharged All of this data is fabricated. There is no PHI displayed. ….. Data is updated every 10 minutes Trending

Navigating - View Details Each encounter is displayed as a row in the patient lists All of this data is fabricated. There is no PHI displayed.

Navigating - View Details Use the Care Management Dashboard to find key data for Care Transitions: Reason for Admission Discharge Location (when available) Discharge Disposition (code with reference source) ---------- All of this data is fabricated. There is no PHI displayed.

Navigating – View all encounters View list of all this patient’s encounters (Inpatient, ED, Outpatient) *New Dashboard feature ---------- All of this data is fabricated. There is no PHI displayed.

NEW: Risk Scores Charlson Comorbidity Index – Predictor of mortality risk based on a weighted score of chronic conditions. LACE index – Indicator of readmission risk based on: Length of stay / Acuity of admission / Charlson Comorbidity Index / ED – 6 mos ED visit count. --- All of this data is fabricated. There is no PHI displayed.

Care Management Tools: Improving Care Transitions and Care Coordination CareLink Community Health Team: Case Managers in the Emergency Departments are often overwhelmed because they have so many activities they need to set-up for patients. It makes it easier for them when we are able to coordinate care and they know they can rely on us to get the services a patient needs beyond the hospital setting. Rhode Island Primary Care Physicians Corp. (RIPCPC) Nurse Care Managers: By having timely and reliable admission and discharge information for all our patients, we can be sure to effectively target the needs of each individual in our care. We can ensure they have follow-up appointments scheduled with the right doctors. We can also make sure that they have other specific support and care, depending on the situation.

CurrentCare: Viewer/ CurrentCare in EHRs Hospital Alerts for PCPs

Health Information Exchange CurrentCare: Rhode Island’s HIE Medical Professionals can see patient data via the CurrentCare Viewer Health Information Exchange Consumers can view and download their record via CurrentCare for Me

Need More Information? Care Management Dashboard ---------- All of this data is fabricated. There is no PHI displayed. In CurrentCare: Lifespan CoC Discharge Summaries (Fatima & Roger Williams) Medical Record Summaries Medications, Lab Results, Imaging and More

CurrentCare: Building a Resource Medication data, lab results, imaging reports, allergies, problems/diagnoses Discharge documents: Lifespan Continuity of Care Document Fatima and Roger Williams discharge summaries Clinical summaries (CCDs) also helpful for care transitions *Coming Soon: Landmark discharge CoC, SCH discharge summary, information from Yale New Haven Health and more SNF data

CurrentCare Enrollment RI is an “Opt-In” state More than 500,000 Rhode Islanders have enrolled

CurrentCare and VLER: for RI Veterans

CurrentCare Hospital Alerts Must be enrolled in CurrentCare CurrentCare enrollee visits hospital Hospital Alert received by care team Health information of enrolled patients Must Identify PCP PCP must subscribe to Alerts

About Hospital Alerts Lifespan Discharges include CoC Document

Support Enrollment: CurrentCare Informational Video https://enroll.currentcareri.org/

Thank you! Questions?