1. Health Information Technology for Care Coordination in a Federally Qualified Health Center Community Health Center, Inc. Weitzman Institute Middletown, CT 00/00/001

2. Presenter Disclosures (1)The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months: Deb Ward RN “ No relationships to disclose”

3. Our Vision: Since 1972, Community Health Center, Inc. has been building a world-class primary health care system committed to caring for underserved and uninsured populations and focused on improving health outcomes, as well as building healthy communities. Three Foundational Pillars Clinical Excellence Research & Development Training the Next Generation Innovations Integrated primary care disciplines Fully integrated EHR Patient portal and HIE Extensive school-based care system “Wherever You Are” Health Care Centering Pregnancy model Residency training for nurse practitioners New residency training for psychologists CHC Inc. Profile: Founding Year - 1972 Primary Care Hubs – 13 No. of Service Locations - 216 Licensed /Total SBHC locations – 28 comprehensive/39 behavioral health only/190 mobile dental Organization Staff - 658

4. Patient Care Model PCMH (NCQA Level 3) TJC Accredited and Recognized PCMH Advanced access scheduling “Planned Care” and the Chronic Care Model Integrated behavioral health services Comprehensive dentistry/oral health Expanded hours and 24/7 coverage Comprehensive HIV /AIDS & Hep C care Formal research program Residency training for nurse practitioners Neighborhood outreach, screening, enrollment Top Chronic Diseases Cardiovascular DiseaseObesity/Overweight DiabetesChronic Pain AsthmaDepression Patients who consider CHC their health care home: 130,000 Health care visits: more than 429,000 Care Delivery: Medical, Dental, Behavioral Health, Prenatal and Ancillary Services CHC Patient Profile

5. 00/00/005 Foundations for Building Clinical Excellence: Quality Improvement and Research & Development Engaging Frontline Clinical Teams

6. 00/00/006 Data Driven: the Right Data at the Right Time EHR ETL Process Data Warehouse Structured Data Pulls Dashboards Scorecards

7. “the deliberate organization of patient care activities between two or more participants involved in a patient’s care to facilitate the appropriate delivery of health care services” (1). Patients who benefit include those with:  multiple chronic illnesses  poorly controlled chronic diseases, such as DM and HTN  complex medical needs involving multiple providers and agencies  patients in transition 00/00/007 About Care Coordination

8. Project Overview: Develop and Implement Nurse- driven model of the Care Coordination across 12 CHCI sites over 18 months

9. New London County Training Implementation Fairfield County Training Implementation New Haven County Training Implementation Middlesex County Training Implementation Hartford County Training Implementation Fairfield: Danbury, Stamford, Norwalk Hartford: New Britain, Enfield, Bristol Middlesex: Middletown, Clinton New Haven: Meriden, Waterbury New London: Groton, New London Project Timeline

10.  Comprehensive didactics for Complex Care Management Transition Care, Medication Reconciliation, CHF, DM, Pediatric Asthma, COPD, Psych, Motivational Interviewing, Self Management Goal Setting Supervision Case Reviews via videoconference Care Plan/Zone Sheet development & Self-Management  EHR Templates Structured Intakes/Follow up Outcome Measures Dashboards  Community Engagement Open House Data Sharing RN Complex Care Management

11. Deb Ward, RN Quality Improvement Manager wardd@chc1.com 00/00/0011 Development of an operable population-based clinical dashboard to provide decision support for care coordination in primary care

12. 00/00/0012 Session Objective: Describe how an operable population-based electronic dashboard was developed to provide decision support for nurse care coordinators in primary care.

13.  Why a dashboard  Development of dashboard:  work with BI and nurses  Defining chronic diseases: algorithms based on UDS  Importing CHN data re: admissions/discharges  How it works/screen shots  Data on its use  Revisions/lessons learned 00/00/0013 Challenge: Nurses needed a “go-to” source to identify patients who would benefit from care coordination Solution: Nursing Care Coordination Dashboard

14. 00/00/0014 Care Coordination Dashboard Select Provider Select “Active” for Panel Review Select “Eligible” for Proactive Enrollment

15. Reason for Care Coordination

16. Consider Possible Data Sources

17. Customizing the Sort

18. Additional Actionable Data

19. Additional Steps to Support Dashboard Use Implementation/Roll Out Additional Support Post Go-Live Training New Staff Usability Ongoing Feedback from Frontline Users Responsive Tool Adjustments Based on Feedback