PreManage Pilot One way to address ED utilization: Real time ED Visit Notification Christine Stalie

Partnering with Qualis HUB: Community Psychiatric Clinic Inquired which clinics are participating in each initiative Identified shared clinics Joint meetings Shared resources Ongoing communication Through this partnership we identified a need to better understand and respond to patient ED utilization Partnering with Qualis HUB: Community Psychiatric Clinic

PF Developing Connections Joint Assessment P-TCPI Practice Facilitator P-TCPI BH Champion Qualis HUB Coach CPC Director of Quality and Analytics PF Developing Connections Connected clinic with: New tool Necessary funding Technical assistance Working in Tandem PF facilitating development of new work flow, PDSA, and roll out of new tool Qualis coach connected clinic that has done similar work Coordinating Efforts P-TCPI PF and Qualis Coach attend joint meetings when possible PF focused on ED utilization Qualis coach focused on development and use of registries Greater Than the Sum of Parts

Emergency Department Usage Clinics have often noted that ED usage remains: Unknown Self-reported by patient & family Frequent, repeated, unnecessary Something they feel is out of their control Emergency Department Usage

Information needed Where Why Understand baseline Who Timely individual When Where Frequent Concerns Population Health Management High Utilizers Information needed Timely individual case management

PreManage Closing communication gaps to close gaps in care.

EDIE (Emergency Department Information Exchange) “Every ED Instantly at Your Fingertips” Purpose: to give ED clinicians the information they need to make a fully informed decision so that they can provide the base care possible for their patients. EDIE also empowers ED Case Managers to help coordinate with other providers who have a treatment relationship with the patient so that the patient’s sometimes complex needs can be addressed in the most appropriate care venue. Tool for Emergency Departments that distills the longitudinal patient record down to actionable insights, and delivers those insights immediately upon patient registration via whatever method an ED prefers. But I’ve heard of EDIE? Supported by: Washington State Hospital Association, Washington State Medical Association, & American College of Emergency Physicians (Washington Chapter)

Complementary Tools PreManage EDIE (Emergency Department Information Exchange) Complementary Tools View information in real time (1 minute within data enter) Upload care plans Track usage & trends: patient registries, graphs, and customizable reports 18 months of retrospective data Patient ED visit or inpatient admission Who: patient contact information Why: diagnosis code When: visit/admission/discharge date & time Where: provider & location

Why? Improved Patient Experience Population Health Management Right time, right care, right treatment Reduce utilization & readmission ED utilization HEDIS measures Improved Communication More patient information Less resources spent on searching for information Identify and stratify risk Identify high utilizers & common diagnoses Improved health outcomes Improved patient experience Improved Patient Experience Population Health Management Lower Cost Improved Clinician Experience Why?

PreManage in a clinic How do we get started? A pilot project to

Determine clinic interest & readiness Preparation Determine clinic interest & readiness Create a list of clinics by priority Introductions Schedule initial meeting with clinic & Collective Medical Tech Practice Facilitator/ Coach facilitates meeting between clinic & Collective Medical Tech Set up Determine contract &/or sponsoring MCO Clinic send flat file of patient panel to Collective Medical Tech Roll out PreManage web demonstration with clinic data Clinic develops notification response work flow Clinic trains supervisors and begins PDSA Scale up Test PreManage with one team Adapt notification response workflow as necessary Train all involved staff and expand PreManage access & usage

Notification Response Workflow Behavioral Health provider example from Community Psychiatric Clinic, Seattle, WA

NOTIFICATION Clinician ED or Inpatient; and Diagnosis ED Psych Called to ED to assess Follow CPC existing protocols for ED assessment visits Any necessary changes to crisis plan and treatment plan? NOT called to ED to assess Call client to follow up within 2 business days; document in Avatar as progress note Any necessary changes to crisis plan and treatment plan? + manual notification to medical team, peer, and anyone on care team record ED Physical Health Consult with nurse ( print information and meet with nurse) to decide if the notification needs to go to the medical team Need get ED records and lab results? IF CPC medical team directs, coordinate with PCP Inpatient Psych Follow CPC existing protocols for Inpatient Psych admission Inpatient Physical Health Consult with medical team if necessary Call patient to follow up within based on medical team's advice for cases of chronic disease (e.g. cancer) or trauma (e.g. accident) CPC Care Coordinators to follow up if necessary Patient Contact Information Verify contact information is correct, and update if necessary in Avatar - immediately; add extra numbers if necessary PCP/Doctor's Contact Information Verify PCP and PCP contact information in Avatar - both in coordination of care and outside provider (check PCP) immediately Supervisor Back-up Coverage Programmatic Reports Track general trends - receive and review reports monthly (summary broken down by program, clinician; number of ED visits - broken down by psych/medical; number of admissions by psych/medical) Bring up significant concerns and/or changes to CPC leadership `CPC QI will use this in quarterly reports Review reports of high utilizers Develop changes to care plan, program-wide proactive measures, etc. if necessary High Utilizers - create a registry from individual notifications Care Coordinators TBD - following Health Homes requirements NOTIFICATION

Next Steps: Trained for all PFs and coaches Identifying interested clinics and respective readiness to begin learning and using this new tool Personalizing introductions to clinics Facilitating set up, funding and roll out of new tool Sharing lessons learned from the pilot project, which may be of particular interest to other BH providers Providing ongoing technical assistance Next Steps:

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