1. Integrated Health Associates (IHA) and Mercy PHO 9/19/2015

2. Improving TOC with Better Information 9/19/2015

3. IHA Complex Care Management Sources of Patients (MiPCT only) 9/19/2015 MD discretion, reviewed by care manager Physician Referral High ER Utilizers from St. Joseph Mercy Health System (SJMHS) predictive scores High Risk Patients PRISM risk scores Transitions of Care

4. PRISM Predictor of mortality, re-admission developed by Dr. Cowen and Quality Institute at St. Joe’s 5 PRISM levels (1-highest risk, 5-lowest risk) Calculated on admission in the ED, in pre-op for elective surgery at SJM Ann Arbor 4

5. % of Patients, 30 day re-admissions by PRISM score 9/19/2015 PRISM 2 & 3 patients account for 63% of all re-admits 5

6. Days to Re-Admission PRISM 1/2/3, Nov 2012 – June 2013 9/19/20156 Of all re-admissions, ~40% occur within the first 7 days

7. TOC Information Goals 1. Provide care managers real-time information on when patients are admitted and discharged 2. Provide risk scores to help care managers prioritize interventions 3. Integrate information into NextGen EMR to avoid multiple logins, screens, etc. 4. Store data to provide reports back to care managers and leadership 9/19/2015

8. Care Management Data Flow 9/19/2015 Database ADT Feed Risk Score (PRISM) Care Manager Panel Reporting Care Manager Templates Process Metrics Outcomes Activity Panel Size Data warehouse

9. Notification 9/19/20159 Next Morning Call Center RN Non-MiPCT referred to practice RN

10. NextGen Tasking 9/19/201510 Due date set based on protocol: Follow up call within 24 hours PCP appointment within 7 days

11. Flow of Patients in NextGen Care Manager Panel Admit Panel Discharge Panel Active Panel 9/19/2015 Patients move from Admit panel to Discharge panel when discharged Patients move from Discharge panel to Active panel when enrolled Patients move from Admit panel to Discharge panel when discharged Patients move from Discharge panel to Active panel when enrolled

12. Care Manager Panel 9/19/201512

13. Reporting Care Management Dashboard 9/19/2015 Metrics calculated bi-weekly by care manager

14. Reporting Care Management Dashboard 9/19/2015 Metrics calculated bi-weekly by care manager

15. Tiffany Francis, MPH Lori Vollstaedt, BSN, RN

17. Mercy Physician Community PHO 145 Primary Care and Specialty Care Physicians 38 PCPs, 20 utilizing Crimson Care Registry 6 MIPCT Practices 3 Hospitals in St. Clair County, MI – St. Joseph Mercy-Port Huron, our affiliate – Port Huron Hospital, independent – St. John-River District

18. Discharge Process St. Joseph Mercy Port Huron – Daily feed through secure Trinity email system of all inpatient and emergency room discharges Port Huron Hospital – Daily feed through a secure web portal of all inpatient and emergency room discharges St. John River District/Outlying Facilities – No current PHO process, though physicians occasionally get their information through portals that they have access to individually.

19. Challenges We Overcame Working with a “competing” hospital to get data to promote better health in our community Administrative burden of handling data in a timely manner Training of offices on what to do with the data Decreasing ED utilization for PCS diagnosis…a work in constant progress!

20. Internal PHO Process Team Member accesses both files and saves to our local drives in excel Team Member separates each physician onto its own formatted excel page by group Physician group excel pages are faxed or emailed securing to each office with DC for that day

21. Registry Component Discharges for physicians on our registry are added a service entry with a note by our Team Physician office will then see the service (ER or IP stay) and admitting diagnosis as well as dates of service

22. Care Manager Process If office is a MIPCT office: – Complex Care Manager accesses the excel file through the shared Trinity drives – CCM makes the calls to patients who are DC from the hospital or ED – Calls are logged on the log the Care Management Team uses – Calls are logged in Crimson when there is a goal set or follow up needed.

23. Office Process We train our offices to utilize these lists and contact the patients to get them into the office. Since many health plans incentivize offices for seeing patients post IP stay, our offices really appreciate the daily lists

24. Findings/Quality We routinely track and share information with our Quality Committee and physicians related to time of day and insurance type. Find that most are M-F 9AM-5PM Most are Medicare Diagnosis are Primary Care Sensitive

25. Top 10 Diagnosis for ED

26. Time and Insurance September 2013 1435 ED Visits between SJMPH and PHH 654 between hours of 9AM-5PM 373 between hours of 5PM-9PM 408 between hours of 9PM-9AM 115 Uninsured 246 Medicaid 644 Medicare 430 Commercial Insurances

27. MIPCT Success Story 1 62 year old female 3 IP and 7 ED visits in preceding 12 months UCIDDM, CHF, COPD, O2 Dependent Inattentive Family

28. MIPCT Patient 1 Plan/Success Monthly PCP and Care Manager Meetings Education re: signs and symptoms, impending troubles Learned to anticipate illness and contact PCP 1 IP stay and 2 ED visits in last 12 months

29. MIPCT Success Story 2 28 year old female >25 ED visits preceding 12 months Many ED visits via ambulance Minor medical history All ED visits were primary care sensitive

30. MIPCT Patient 2 Plan/Success Access to Complex Care Manager Meetings every two weeks Calls from Care Manager each ED visit Close working between PCP and Care Mgr. 3 ED visits in last 12 months

32. Questions?