Provider Portal and IC Reports Update for LME-MCO Users May 19, 2014

Outline Provider Portal IC Reports What is current and still useful Medication updates Care Triage How Portal is used on the ground IC Reports Current Hospital Visits (ADT) Report Patient List New Reports How Reports are used on the ground

Useful Information The website is https://portal.n3cn.org The website to get to Provider Portal is portal.n3cn.org Once you log on you see the 6 tabs including Home, Patient List, Patient Profile, Report Site, Meducation, and Patient Education At the top right you see three ways you can search for a patient: by MID; by last name and exact birthday; or by partial first name, partial last name, and birth year

Care Team Tab The care team tab contains some useful information. At the top you can see demographic information including recent enrollment information. Next you can see the primary care practice that the patient is enrolled in if they are part of CCNC. Under this there is a dashboard of different elements about the patient. Each category such as recent hospital use or office visits has a number beside it. Clicking on this number will bring you to the Visit History tab to show you the details of the events. This dashboard also patient documents that have been uploaded onto Portal such as pain agreements and advanced directives. Note that these are based on 15 months of data. The dashboard contains updated data for care alerts that are still active (those based on medications), recent hospital use, other utilization data from MCOs where we have it (Cardinal and ECBH), lab values, All medication fills, and immunizations.

Care Team Tab Continued Further down on the Care Team Tab there is information on care management status from CCNC and the last time the person was contacted by CCNC. This information includes the current case status of a person and who their care manager and pharmacist are. It also allows a note to be sent to the care manager. This section includes the LME-MCO and Health Check Coordinator associated with the area the person lives also. To the right of the care coordination label you can see print care team and print patient profile. These are easy ways to print information from Portal. Below that there are spots for the most recent service providers and most recent office visit providers. This comes from the most recent claims we have.

Visit History Tab The visit history tab gives the detailed information from the dashboard on the care team tab. Hovering over each element in the dashboard gives additional information like how often the data is updated and sources of the data. The date range can be changed at the top of this tab. The default date range is 15 months ending June 2013. Current Hospital Visits are based on Admission, discharge, and transfer information. We do not get this from every hospital, but do get 65-70% of hospitals visits in NC. The diagnses here are free text, not based on ICD-9 codes as claims are.

Visit History Tab Continued Office visits and Behavioral Health Services are two other areas that are updated in areas where we have encounter claims. We hope to have all encounter claims in the system soon. Since these are from claims the diagnoses are standardized. Also for the behavioral health services this includes therapy and enhanced services.

Medication Tab The Medications Tab contains multiple tabs within it. At the top is demographic information and also information about allergies and adverse reactions a person has had. The first tab is then the consolidated med list. On this tab you can either look at the current regimen (chronic meds in the last 365 days, acute meds in the last 100 days) or complete history where you can change the date range. From this tab you can also see drug therapy problems that have been identified for the patient. There is also an adherence index that shows if the person is filling medications at regular intervals.. This tab also shows the pharmacy and prescriber information for each medication.

Meducation Meducation is a tool to help patients understand how to take their medications. This has been updated so when you click the meducation tab the med list again populates, but this time it is with a links column where you can link to either written instructions or a video demonstration for things like an inhaler. These instructions can be communicated in multiple languages and written materials can we printed in larger font.

Adherence TimeView™ is a software program that visually represents a patient’s medication fill history to enable rapid assessment of non-adherence. This view only includes filled medications from the electronic pharmacy claims processing. The patient’s medications are sorted into 3 categories: 1) Chronic, 2) PRN (Any medication with “prn” or “as needed” in its SIG), and 3) Acute . Chronic and Acute are determined by the Medispan drug database. Medications filled with comparable NDC codes will be grouped together into a single row. A green bar represents each fill transaction. The black arrow indicates when the medication was processed by a pharmacy. The number immediately to the right of the arrow indicates the number of days supply provided if that information is available in the data source. The length of the green bar indicates the duration of the medication based on the days supply filled. If a medication is refilled before it runs out, a hashed green bar indicates a carry over supply from the previous fill. White spaces between green bars indicate times when the patient would have run out of their medications if they were using it as indicated. REORGANIZING If any medication was not initially assigned to the correct group, you can click-and-drag any row into a different group. Similarly, using the same click-and-drag, you can reorganize the medications within each group, as you wish. 6-MONTH VIEW The default time span is 6 months. If you wish to view any prior months or the following months’ fill history, click on the arrows to the left and right of the months shown at the top of the display. The asterisk after a medication name indicates no prior fill data before the current 6-month display window. Medications without asterisks therefore indicate existence of medication fill data to the left of the current window. VIEWING DETAIL DATA To view the data details for any medication row, right-click on a medicine name and then select “Detail”. This option will open a pop-up window with information for all transactions in the selected row. To view the SIG instructions for any transaction (a single green bar), roll your mouse over any green bar. To view all details for any transaction, left-click on any green bar. COMBINING MED ROWS If you wish to combine two or more rows, hold the CTRL button and left-click on the names of the rows you wish to combine. A selected name will highlight. After all the rows names are selected, right-click and then select “Group”. To ungroup, right-click on a group and then select “Ungroup”. PRINTING Select magnifying glass icon in the upper left hand corner to bring up a window to save or print.

Care Triage Care Triage Risk Tab- When selecting Care Triage, the user is taken into the Risk Tab. This tab will assess the patient’s risk of hospital admissions and drug therapy problems Composite Score- The Composite Score reflects the patient’s overall risk. This is calculated using analytics that predict both hospital admission and drug therapy problems Patient Risks- Care Triage is designed to predict (1) risk of a hospital admission and (2) risk of finding a drug therapy problem. The two are calculated separately using two distinct predictive models. The color boxes show the individual risk percentile that this activity may occur Patient Ranking Comparison- Gives the user a visual assessment of how the patient’s composite score compares to that of all the patients in the general population and again to those in the transitional care population. General population references the CCNC population and transitional care population is a subset of the overall population. Risk Options- Allows the user to customize which risks, probabilities and graphs will display on the risk tab Question Mark (?) – Additional content available within Patient Risks and Patient Ranking Comparison.

Provider Portal How it is being used in the field

IC Reports You can get to the reports site from Provider Portal with the Report Site tab or can go directly there through icreports.n3cn.org. Once in the pathway to your reports is LME Standard Reports->Your LME-MCO->then you see the list of reports available to you. Though many of the reports are stale the Current Hospital Visit and LME-MCO Patient list do have updated information and so we will focus on them.

Current Hospital Visits Report The Current Hosptial Visit Report (ADT) allows parameterization. You can choose to look only at certain hospitals, certain visit types, time periods, ages, and how quickly they should be seen for outpatient follow up after an inpatient stay. This report shows all patients in the LME-MCO catchment area.

Current Hospital Visits: Report Details Once the report is run there are report details that explain different fields, show date ranges used within the report, and contain links to give more details like the most current lists of hospitals contributing data. You can also see the parameters you chose above in the parameters section. These will also be included on the report when exported to Excel.

Priority Indicators Priority Indicators now include information from the Care Triage Scores we saw earlier in Portal. CCNC Priority is the top 1% of the Medicaid population with the highest Care Triage Scores. Transitional care priority, people who who benefit most from transitional care after they are in the hospital are a combined group oof people with certain clinical risk groups based on older claims and non Duals with a Care Triage Score more than 10.

Columns to Note Link to Provider Portal Multiple MIDs Diagnoses Outpatient Follow-up Recommended Within CCNC and Provider Enrollment Inpatient/ED Visit History Priority Indicators Some columns to note in the report The first column is a link that will bring you directly to provider portal There is a base and current Medicaid Identification Number- either of these IDs will work in Portal Diagnoses in the ADT report are free texted in by the hospital, they are not systematic Evaluation at CCNC has shown that there are subsets on patients who it is most important that they be seen in 7 days 8-15 days, 16-21 days, and 22-30 days after a hospitalization to decrease the likelihood that they will be readmitted. The number of days recommended is now shown on this report. CCNC network and PCP information can be found on the report The inpatient and ED historical information from claims is from the year ending June 2013 and so is very old at this point. It will be updated quarterly when we have new data Priority indicators as discussed on the last slide can be found at the end of the report.

Patient List The Patient List is a list of all patient in the LME-MCO catchment area, it contains both older data and new data, with the current data in greem (care management, enrollment) and older data in blue. This also contains priority information for the entre catchment area.

Patient List Report Details

Columns to Note Green Columns are current data Blue Columns are based on older data with the year ending June 2013 Risk admission for inpatient within the next 12 months For your whole patient population you can see the risk of admission (this is related to the CareTriage tab in Provider Portal)

Reports How reports are being used in the field

Questions