Care Coordination and Transitions in Care: Improving the Information Flow HealthBridge 2011 Meaningful Use and Health Care Transformation Conference May 20, 2011 Julie Schilz BSN MBA Colorado Beacon Consortium Teams Are Reaching Goals Every Time Exploring One Beacon Communities Experience

 Brief Description of the Beacon Community  Overview of Colorado Beacon Consortium  Linkages to Care Coordination & Care Transitions Today’s Discussion

3 Look through Patient & Family Eyes for Value National Quality Strategy 2011 Two Priorities Safer Care Eliminate preventable health care-acquired conditions Care Coordination Create a delivery system that is less fragmented and more coordinated, where handoffs are clear, and patients and clinicians have the information they need to optimize the patient-clinician partnership

4 Sorting Through the Acronyms ( and methodologies) REC? PCMH ? ACOs? MU? Transitions of Care? PPACA? Or ACA? Project RED Boost Starr? ONC? ARRA?

5 The Beacon Community Program Goal: Share best practices that help communities achieve cost savings and health improvement  17 demonstration communities that will: – Build and strengthen their HIT infrastructure and exchange capabilities and showcase the Meaningful Use of EHRs – Provide valuable lessons to guide other communities to achieve measurable improvement in the quality and efficiency of health services or public health outcomes

Bangor Rhode Island Keystone Greater Cincinnati Southern Piedmont Inland Northwest Utah Colorado San Diego Hawaii Southeastern Central Southeast Western Minnesota Indiana Michigan New York Greater Tulsa Delta Blues Crescent City The Beacons

Activities across the CoPs will align to enable high quality, cost efficiencies, patient-focused health care, and population health through clinical transformation ONC Beacon Community Integrated Learning Networks

8 Colorado Beacon Consortium The CBC is a collaboration of health providers and community agencies in Western Colorado. The project is led by the following Community members:

9 Colorado Beacon Consortium Region

Overall Aim CBC Offerings Technology Enhancements  HIE Connectivity  EMR Interface  Provider Portal (simplified sign on)  Improved Analytics & Reporting  Community Registry  Inter-HIE Connections Practice Transformation  Clinical Process Efficiency Consultation  Performance Improvement Skills  Practice Transformation  Collaboration with REC Partner for Meaningful Use  Financial incentives to reduce barriers to participation.

Practice Transformation Program Guiding Principles  IHI Triple Aim  IOM Six Aims Program Methodology  Care Model  Model for Improvement  Performance Improvement  QIAs and Learning Collaboratives Timeframe and Goals  One Year with Advisors and Learning Collaboratives  Close the Gap by 50% from Baseline Measures  Improve Value–Team, Evidence Based Guidelines, Patient-Centered, HIE/HIT

13 Our Philosophy, Tools & Program CBC Change Package  Performance Improvement Steps for Performance Improvement Choose a measure. Determine a baseline. Evaluate your performance. If performance is not what you would like, develop a performance aim. Make changes to improve performance. Monitor performance over time.  Practice Transformation  Based on the Expanded Care Model  Curriculum  Pre-Work Curriculum  Year long transformation with Learning Collaboratives  Monthly Narrative & Measure Reporting

14 Adapted from IHI Breakthrough Series Collaboratives

Pediatric & Adult Measures Pediatric Phase I  Asthma – Appropriate Medications for Persistent Asthma  Immunizations – Up to date by age 2 Phase II  Child Weight Assessment & Counseling Adult Phase I  Diabetes (BP & HbA1c)  IVD (Lipid screen and control)  Depression Screening (Diabetes & IVD) Phase II  Adult Weight Assessment & Counseling  Breast Cancer Screening  Tobacco Ask & Counseling

CBC Practice Transformation Program Highlights with emphasis on HITs supporting role  Team Based Care  Care Compacts  Care Coordination/Transitions Multi-Disciplinary and HIT/HIE Focus

Specialty Practices Request the Following Information: Patient name Patient demographics Patient Insurance (if known) Diagnosis or symptoms Relevant notes, lab and radiology results Current medications list ICD-9 code, if possible Send in QHN Primary Care Practices Request the Following from Specialty Practices: Date and time of the appointment Notification if the patient was a “no show” Copy of transcription from the specialist, use QHN to cc the PCP!! Outline of the plan of care Communication about who will manage the medications When there are critical issues, pick up the phone and call! All Parties Request and Agree: A standardized process for creating and responding to referrals is best Each office should have a referral contact person Provide adequate information so both parties can treat the patient!! Use QHN when possible Use fax as second choice Use phone calls when in doubt Community Referrals using QHN All Parties Request and Agree: A standardized process for creating and responding to referrals is best Each office should have a referral contact person Provide adequate information so both parties can treat the patient!! Use QHN when possible Use fax as second choice Use phone calls when in doubt Primary Care Practices Request the Following from Specialty Practices: Date and time of the appointment Notification if the patient was a “no show” Copy of transcription from the specialist, use QHN to cc the PCP!! Outline of the plan of care Communication about who will manage the medications When there are critical issues, pick up the phone and call! Specialty Practices Request the Following Information: Patient name Patient demographics Patient Insurance (if known) Diagnosis or symptoms Relevant notes, lab and radiology results Current medications list ICD-9 code, if possible Send in QHN

How HIT Fits!

-Consistency around registry data capture -Work flows around Health Information Technology -Medication reconciliation for Diabetic patients -Establishing focused care visits -Transitioning to Meaningful Use Electronic Medical Record -Creating Electronic Medical Record templates -Redefining office protocols around the Beacon chronic disease measure set -Implementation of team huddles and daily patient preparation -Processes around patient check in/check-out procedures and scheduling -Standardizing office standing orders -Streamlining lab reconciliation processes

24 What Can You Do By Next Tuesday?

Questions ? Teams Are Reaching Goals Every Time