Hawai‘i Island Beacon Community East Hawai`i IPA Symposium August 19, 2012 Hawai‘i Island Beacon Community

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

Beacon Community National Program Aims 17 grantees each funded ~$12-16M April 2010 – March 2013: 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.

17 Beacon Communities Bangor Beacon Community Brewer, ME Western New York Beacon Community Buffalo, NY Beacon Community of Inland Northwest Spokane, WA Southeastern Minnesota Beacon Community Rochester, MN Rhode Island Beacon Community Providence, RI Southeast Michigan Beacon Community Detroit, MI Central Indiana Beacon Community Indianapolis, IN Keystone Beacon Community Danville, PA Utah Beacon Community Salt Lake City, UT Colorado Beacon Community Grand Junction, CO Greater Cincinnati Beacon Community Cincinnati, OH Represent communities from Hawaii to Maine, with more advanced E.H.R adoption and HIT infrastructure investments. Diverse communities with very different starting points (very sophisticated delivery systems e.g., Geisinger, Intermountain Mayo, and HIEs e.g., HealthBridge, IHIE, to rural communities in the Mississippi Delta and other very competitive provider markets like San Diego and New Orleans). Award was given to a lead organization (listed here), but was very much awarded to all the other partners (payers, providers, employers, public health departments etc). Southern Piedmont Beacon Community Concord, NC Great Tulsa Health Access Network Beacon Community Tulsa, OK San Diego Beacon Community San Diego, CA Delta BLUES Beacon Community Stoneville, MS Hawaii Island Beacon Community Hilo, HI Crescent City Beacon Community New Orleans, LA

Trajectory to Value Based Purchasing HIT Infrastructure: EHRs and Connectivity Primary Care Capacity: PCMH Care Coordination and Transitions: FQHC/Hospital/Private Sector Model Value/Outcome Measurement: Reporting of Quality, Utilization and Patient Satisfaction Measures Value Based Purchasing: Reimbursement tied to Performance on Value (shared savings) 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 HIT and MU Are the Foundation for Obtaining Measurable Results 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 Screening HgA1c control BP control Lipid control Increasing the overall health of populations: address behavioral risk factors; focus on preventive care. Better health Health Eating Active Living No Smoking Lowering the total cost of care while improving quality, resulting in reduced monthly expenditures for Medicare, Medicaid, and CHIP beneficiaries. Lower costs $ Potentially Avoidable re-admissions and ER visits by condition Health Information Technology and Meaningful Use

Hawaii Island Beacon Community Transformation 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 and other populations at risk Achieve EHR adoption and meaningful use >60% of primary care providers Primary Drivers: Secondary Drivers: Interventions Leadership Reliable Processes Provide care in appropriate setting Delivery System Design Community, Patient and Family Voice Communication Decision Support Clinical Transformation Patient, Provider and Community Engagement Health Information Exchange 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 Community Transformation 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 and other populations at risk Achieve EHR adoption and meaningful use >60% of primary care providers Primary Drivers: Secondary Drivers: Interventions Leadership Reliable Processes Provide care in appropriate setting Delivery System Design Community, Patient and Family Voice Communication Decision Support Clinical Transformation Patient, Provider and Community Engagement Health Information Exchange Practice Redesign - PCMH Coaching - EMR/MU Stage I - Care Coordination

PCMH Coaching Partners: Beacon Leadership: Activities: 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: West Hawai‘i North Hawai‘i NEXT LEARNING COLLABORATIVE: SEPTEMBER 15 AND 16, 2012 West Hawai‘i Minolu Cheng MD Dominador Genio MD David Arthurs DO Elizabeth Catanzaro MD Lambert Lee Loy MD Sukchai Satta MD Robert Laird MD North Hawai‘i John Dawson MD Maria Perlas MD William Lawrence MD Malcolm MacDonald MD Michele Shimizu MD East Hawai‘i Doug Olsen MD Kara Okahara MD David Jung MD Joseph D’Angelo MD Roy Koga MD Julie Chee MD Kristine 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 UTI, Headache, Sore Throat and Lower Back Pain The percent of potentially avoidable ER visits has trended upward over the eight quarters. After an initial decrease from 10.4% avoidable visits in Q1 2010 to 8.4% avoidable visits in Q3 2010, the rate has increased to 11.6% in Q4 2011, a 38% increase of avoidable ER visits over the five quarter period. Annualizing the data shows an increase in Avoidable ER visits from 9.4% in 2010 to 11% in 2011. Source of ER data: Hawaii Health Information Corporation Emergency Department Database Numerator = total number of avoidable ER visits. Denominator = total number of ER visits Source 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

Meaningful Use Stage 1 Partners: Beacon Leadership: Activities: 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: Activities: 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 Selection Criteria: Diagnosis, Co-morbidities, Age, Utilization

Blood Pressure Screening Performed June 2012 = 94% Clinical Transformation Population of Focus diabetic patients who had an HbA1c screen in the last 12 months.

BP < 140/90 June 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 Performed June = 73% Clinical Transformation Population of Focus diabetic patients who had an HbA1c screen in the last 12 months.

HbA1c < 9.0 June 2012 = 55% 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%.

LDL-C Screening Performed June 2012 = 63% Clinical Transformation panel patients who had a LDL-C screen performed in the last 12 months.

LDL-C < 100 mg/dL June = 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 < 9.0 73% 55% LDL-C control < 100 mg/dL 63% 33%

Hawaii Island Beacon Community Transformation 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 and other populations at risk Achieve EHR adoption and meaningful use >60% of primary care providers Primary Drivers: Secondary Drivers: Interventions Leadership Reliable Processes Provide care in appropriate setting Delivery System Design Community, Patient and Family Voice Communication Decision Support Clinical Transformation Patient, Provider and Community Engagement Health Information Exchange Practice Redesign - PCMH Coaching - EMR/MU Stage I - Care Coordination Care Transitions - Hospital Discharge

Care Transitions Partners: Beacon Leadership: Activities: 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 Condition Composite PQI for Q1 2009 through Q1 2012 The Potentially Avoidable Hospitalization measure is one of several measures used to assess the HIBC program’s impact on averting disease onset and advancement. A chronic disease composite and risk-adjusted rate is calculated by an HIBC data contractor; the rate involves conditions for which effective outpatient care or early intervention potentially prevents the need for hospitalization. By definition, chronic diseases entail conditions such as short- and long-term and uncontrolled diabetes, lower extremity amputation among diabetics, CHF, angina, hypertension, COPD, and asthma. 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 Findings July 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 Community Transformation 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 and other populations at risk Achieve EHR adoption and meaningful use >60% of primary care providers Primary Drivers: Secondary Drivers: Interventions Leadership Reliable Processes Provide care in appropriate setting Delivery System Design Community, Patient and Family Voice Communication Decision Support Clinical Transformation Patient, Provider and Community Engagement Health Information Exchange Practice Redesign - PCMH Coaching - EMR/MU Stage I - Care Coordination Care Transitions - Hospital Discharge Enabling Services Healthy Lifestyles HEAL Projects

Community Engagement Activities: 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 Community Transformation 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 and other populations at risk Achieve EHR adoption and meaningful use >60% of primary care providers Primary Drivers: Secondary Drivers: Interventions Leadership Reliable Processes Provide care in appropriate setting Delivery System Design Community, Patient and Family Voice Communication Decision Support Clinical Transformation Patient, Provider and Community Engagement Health Information Exchange 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

Reflections “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!!”

Next Steps First steps in transforming care Next steps 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 Hawaii Island Shared Vision Transforming Health and Health Care Delivery through Collaboration, Technology and Community Engagement