Downstate New York Care Coordination Project September 16, 2013

Context NYS Medicaid Health Homes have implemented (or are implementing) care coordination solutions to meet their near term requirements Each Health Home currently uses a separate care management system or EHR In the Downstate NY region, there are many providers who are in multiple Health Homes and multiple RHIOs and their patients will cross borders If various care management tools do not support interoperability, providers may have to use 2 or 3 different systems and this is not sustainable Current state leaves untenable situation of no care plan interoperability 2

Goals and Objectives Develop consensus around functionality that would enable enhanced care coordination, care plan management and interoperability across Health Homes and RHIOs through the SHIN-NY Align activity with developments at the national level Develop Requirements to support the interoperability and joint management of Care Coordination Plans across organizations Phase I implementation - Demonstrate the ability for two sites with two different care management tools to exchange Care Coordination Plans 3

Requirements Enrollment of Health Home patients Linking of patients and providers: care teams Exchange of interoperable care plans Clinical Event Notifications Secure Messaging Access to medical records for clinicians Access to care plans for non-clinicians 4 The DCC Workgroup agreed upon the following seven functions:

NY Downstate Pilot Participants 5 Org. NameTypeVendor/TypeLCC Standards Addiction Institute of NY- Methodone Mgmt Program Behavioral HealthNetsmartCare MgmtCare Plan Addiction Institute of NY- Outpatient Treatment Program Behavioral HealthNetsmartCare MgmtCare Plan St. Lukes Roosevelt Hospital Acute CareCaradigmHIE/ Care MgmtCare Plan Continuum Health Home Network (CHHN) IDNCaradigmHIE/ Care MgmtCare Plan CHHN AIDS Service CenterCBOCaradigm/ HealthIXHIE Care Plan CHHN AmericareHome CareCaradigm/ HealthIXHIE Care Plan CHHN Argus CommunityCBOCaradigm/ HealthIXHIE Care Plan CHHN Association for Rehab CM & HousingCBOCaradigm/ HealthIXHIE Care Plan CHHN Beth Israel Medical CenterAcute CareCaradigm/ HealthIXHIE Care Plan CHHN Callen Lorde Community Health CenterPCPCaradigm/ HealthIXHIE Care Plan CHHN DennelisseCBOCaradigm/ HealthIXHIE Care Plan CHHN NADAPCBOCaradigm/ HealthIXHIE Care Plan CHHN Project RenewalCBOCaradigm/ HealthIXHIE Care Plan CHHN Puerto Rican Family InstituteCBOCaradigm/ HealthIXHIE Care Plan CHHN Ryan Health CenterPCPCaradigm/ HealthIXHIE Care Plan CHHN Services for the Under ServedCBOCaradigm/ HealthIXHIE Care Plan CHHN Westside Federation for Senior & Supportive HousingCBOCaradigm/ HealthIXHIE Care Plan CHHN Institute for Family HealthPCPCaradigm/ HealthIXHIE Care Plan CHHN Isabella Nursing HomeNHCaradigm/ HealthIXHIE Care Plan

Care Coordination Plan (CCP) refers to a shared document that is used to track problems, goals, interventions and outcomes related to both clinical and social issues CCPs are a focus of collaboration for diverse care teams across organizations 6 Care Coordination Plan (CCP) Collaboration What is a CCP?

7 Care Coordination Plan (CCP) Collaboration Use Case 1. Author will create and edit the CCP in a care management tool that uses a national agreed upon structure for interoperable CCPs 2. Editor will view the CCP in their local care management tool, and suggest edits to the Author for review and approval. The Author retains editorial control of the CCP 3. Reader can view the most recent CCP in the RHIO, and provide comments to the Author through secure messaging Iterative process based on interoperability standards

Healthix HEAL 17 – Project Highlights Identified two sites with two different vendors to participate in Phase 1 implementation, both part of Continuum Health Partners Addiction Institute of New York Methodone Treatment Program (Netsmart) Outpatient Treatment Program (Caradigm) Held kick off meeting with stakeholders in early June Agreed on Requirements and Phase 1/2 development June – July: Design phase; engaged Lantana to align the data model with proposed standard as closely as possible July - August: Development, finalize draft data model for the standard Care Coordination Plan with the LCC Standards Workgroup September: Testing, Acceptance October: Phase 1 Implementation, Evaluation 8