Breaking It Down Paul Kaye MD VP for Practice Transformation Hudson River HealthCare October 1 2010 Improve the health of the population Improve the experience of care Reduce the cost The Triple Aim ID: 193584
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Slide1
Care Coordination:Breaking It Down
Paul Kaye, MD
VP for Practice Transformation
Hudson River HealthCare
October 1, 2010Slide2
Improve the health of the populationImprove the experience of care
Reduce the cost
The Triple AimSlide3
Population management Care management of the chronically
ill
Referral management (urgent and routine)
Transitions coordination
Reducing readmissionsCoordinating care for special populations
What is Care Coordination?Slide4
Hudson River HealthCareInstitute for Family HealthOpen Door Family Medical Centers
CHCANYS
Hudson Health Plan
Taconic Health Information Network and Community (THINC)
HUDSON
INFORMATION TECHNOLOGY FOR COMMUNITY HEALTHSlide5
All 3 CHCs collaborated in achieving PCMH Level 3 recognitionParticipants in THINC Medical Home project through Taconic IPA Medical CouncilAll 3 CHCs will participate in Johns Hopkins Guided Care curriculum
Joint commitment to useful information exchange with THINC RHIO
Setting the StageSlide6
Aim: Provide 5000 diabetics with coordinated, continual, evidence-based careIsn’t this the Triple Aim?Measures in 3 domains:
Clinical Status (BP, A1C, LDL, screenings)
Care Coordination (SM goals, hospital follow-up, admission and ER utilization rates)
Patient Experience (CAHPS or similar data)
HITCH HEAL 10 ProjectSlide7
Monthly Clinical Committee meeting drives technology requestsMultidisciplinary team includes MDs, CDEs, nursing, operations directorsSubcommittee of CDEs examining best practices and developing standard curriculum for all 3 CHC organizations
HITCH HEAL 10 Clinical PlanSlide8
Population management Care management of the chronically
ill
Referral management (urgent and routine)
Transitions coordination
Reducing readmissionsCoordinating care for special populations
What is Care Coordination?Slide9
Agreement on diabetes clinical guidelinesEmbedded decision supportTracking of self management goals
Tracking of regular screening (eye, foot, urine)
Monitoring population to find new high risk pts
Systematic assessment of barriers to self management and care
Referral to community-based programs (weight control, exercise, smoking)
Population ManagementSlide10
Use EHRs to identify pts with A1C >9 for intensive managementMonthly visit to PCPIntensive monitoring with onsite testing
Individualized care plans recorded in EHR
Referral to standardized Diabetes Education Program
Individual counseling as necessary
Referral to behavioral health as necessaryMultidisciplinary case conferencing
Care ManagementSlide11
CHW/patient navigators/Care Partners managing referrals from inception to reception of reportsElectronic communication between hospitals, specialists, and PCPReferral to public benefit programs to
cever
costs of specialty care
Reinforce self management goals
Transitions CoordinationSlide12
Focus on follow up of diabetic admissionsNotification of admission and dischargeHospital discharge planners and CHC coordinators communicate
early
Nursing phone call from CHC to discharged pt within 24 hrs; daily phone
followup
as neededOffice visit with 2-5 days depending on status
Reducing Readmissions