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HIE-Enabled Data Sharing Between Hospital and Home Care Providers to Improve Patient Care Within Bundled Payment Context: a Case Study
This document reviews a case study on the implementation of Health Information Exchange (HIE)-enabled data sharing between hospital and home care providers to enhance patient care in bundled payment contexts, specifically focusing on the collaboration between NYU Langone Medical Center and the Visiting Nurse Service of New York. Key elements include the evolution of data exchange, the results and challenges faced during implementation, and the benefits of integrated care coordination that aims to improve patient outcomes while reducing costs. Overall, the initiative emphasizes the significance of partnerships and technological integration in improving healthcare delivery.
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HIE-Enabled Data Sharing Between Hospital and Home Care Providers to Improve Patient Care Within Bundled Payment Context: a Case Study
- 1. HIE-Enabled Data SharingBetween Hospital and Home Care Providers to Improve Patient Care Within Bundled Payment Context: a Case Study Katie Mullaly MS, RN NYULMC Amy Weiss PT, DPT VNSNY
- 2. Agenda 1. AboutVisiting Nurse Service of New York 2. About NYU Langone Medical Center 3. Bundled Payment for Care Improvement Initiative 4. Evolution of Data Exchange 5. Results 6. Challenges to Date 7. Closing Thoughts Presentation Title Goes Here 2
- 3. VNSNY: Transforming HomeHealthcare for Today’’s Needs • VNSNY is the largest not-for-profit home healthcare organization in the United States • About 65,000 patients under direct or managed care on any given day – Care for more than 35,000 patients daily in all five New York City boroughs plus Nassau, Suffolk and Westchester Counties – Manage the care of more than 30,000 VNSNY CHOICE Medicare and Medicaid Health Planmembers • 17,000 employees including almost 2,000 Registered Nurses and Licensed Practical Nurses • 2,276,690 total paraprofessional (clinical) visits in 2013 • Clinical staff speak 50+ languages • The operational scale to successfully implement quality care innovations across the care continuum About VNSNY
- 4. Working on YourOwn, You Cannot Achieve the Innovation Demanded in Today’s Healthcare Environment About VNSNY: Partnership as a Solution
- 5. Working in Partnership,We Can Innovate and Succeed! About VNSNY: Partnership as a Solution
- 6. About VNSNY: OurPartners Large Academic Medical Center Integrated Delivery Systems Teaching Hospital Specialty Hospitals National Disease Specific Foundations Sub-acute Care Facilities Local Community Hospital Account Care Organizations Federal + State Institutions National + RegionalInsurance Providers Physicians Rehabilitation Centers
- 7. Proof of Concept Build Coalition Create Unified Programming Create Clear Criteria for Success About VNSNY: Partner Process Needs Assessment COLLABORATE 1 Partnering ALIGN 2 Create Value SOLVE 3 Evaluate MEASURE 4
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- 9. • An integratedacademic medical center. • Comprised of four hospitals • 1,069 licensed beds • 39,000 patient admissions • 670,000 outpatient visits NYU LANGONEMEDICALCENTER NYU FACULTYGROUPPRACTICE& NYUPN, CLINICALLYINTEGRATEDNETWORK • Physician owned and operated NYUPN Clinically- Integrated Network, LLC comprised of: •800 voluntary physicians •1400 Faculty Group Practice (FGP) physicians •130,000 lives in commercial ACO contracts •NYU FGP annual volume of patient visits is 2M 9
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- 11. NYULMC’s Road toPayment Reform & Network Integration 2008 2010 2011 2012 2013 2006 Conceptual Planning of Clinically Integrated Network and Health Information Technology Strategy Selection of Epic as Enterprise-Wide EMR •ACA enacted •Creation of Payment Reform Steering Committee •Medicare released the Bundled Payment Request for Application •Selection of NYULMC’s Health Information Exchange (HIE) •Creation of NYUPN Clinically Integrated Network •NYULMC is selected as a demonstration site •Creation of Bundled Payment Steering Committee •Jan –Go-live with BPCI Phase 1 •Oct –Go-live with BPCI Phase 2 •Oct –Go-live with Cigna Collaborative Accountable Care Shared Savings arrangement BPCI: Bundled Payments for Care Improvement (Medicare demonstration project) 2014 • Apr –Go-live with United ACO Shared Savings arrangement • Evaluate additional episodes •Jul –Go-live with Aetna ACO 11
- 12. Selecting Episodes Whatwe considered •Strong clinical leadership •Defined, discrete clinical episodes •Relatively predictable Clinical opportunity •High volume •Procedure-based •Attractive to Medicare Financial opportunity Total Joint Replacement •469-470 Major joint replacement of the lower extremity •800 Medicare cases annually •31 physicians; 55% employed / 45% voluntary Spinal Surgery • 459-460 Spinal fusion (non-cervical) • 235 Medicare cases annually • 18 physicians; 56% employed / 44% voluntary Cardiovascular surgery • 216-221 Cardiac valve • 260 Medicare cases annually • 8 physicians, 100% employed What we selected
- 13. 1 Overview ofBundle Payment For Care Improvement Initiative
- 14. Medicare Bundled Paymentsfor Care Improvement • Payment for episode of care defined by hospital admission in select DRGs for Medicare FFS patients • Four models 1. Retrospective acute care hospital stay only 2. Retrospective acute care hospital + post acute care (30 or 90 days) 3. Retrospective post-acute care only 4. Prospective acute care only • All providers paid traditional FFS rates • Total Medicare cost for episode compared to historical baseline • Savings go to provider organization after discount; provider repays if exceeds historical baseline • Quality measures CMS Demonstration for Episode Based Payment Models 14
- 15. What is Includedin the Model 2 Target Price? Home Health Agencies Outpatient Therapy Services Skilled Nursing Facilities & LTACH Inpatient Rehab Hospital Surgeon Physician Visits (surgeon and other) Any services during the 90-Day Post-Acute Period such as… Consulting Physicians Readmissions (to NYU or others) DME Part B Drugs Outpatient Services Lab Services Anesthesiologist Any services during the Acute Stay such as… Any services that roll into the Index Admission through the current IPPS 72-hour rule such as… ED Visits Days 91-120 CMS will be monitoring the period immediately following to ensure that services are not being shifted outside the bundle. NYUHC will be financially responsible if such behavior is observed and may be removed from the program. 15
- 16. Post Acute Goal–Improved Outcomes and Patient Experience NYULMC Post-Acute Partners Home Health Facilities 1. Visiting Nurse Service of New York Home Care CHHA 2. Village Center for Care CHHA 3. Revival Home Health Care 4. Jewish Home Lifecare Long Term Home Health Care Skilled Nursing Facilities 1. Village Center for Care, Manhattan 2. Gouverneur Healthcare Services, SNF, Manhattan 3. Jewish Home Lifecare, Manhattan, Bronx, Westchester 4. Mary Manning Walsh, Manhattan 5. Terence Cardinal Cooke, Manhattan 6. Haym Salomon Home for the Aged, Brooklyn 7. Cobble Hill Health Center, Brooklyn 8. Clove Lakes Rehabilitation Center, Staten Island 9. Trump Pavilion for Nurse Rehab at Jamaica Hospital, Queens NYULMC clinicians and staff selected facilities based on a set of rigorous quality and care coordination criteria, taking into account existing clinical relationships, patient geography, and physician discharging preferences. 16
- 17. Episodes of CareInitiative Ways to Improve Quality and Efficiency •Reduce readmissions •Reduce LOS •Reduce implant, supply, or drug costs •Reduce OR time •Alter discharge patterns to more cost-efficient settings •Decrease excess utilization (e.g., consults, ancillary tests) Quality improvements and efficiencies will benefit all patients, regardless of payor. 17
- 18. Staffing Care CoordinationStaffing – Dedicated to Bundled Payment • Clinical Care Coordinators (CCC) are the “General Manager” of the 90-day episode •Help answer questions and facilitate communication with providers •Receive regular updates on patient progress •Help ensure follow-up visits with surgeon and PCPs • 5 RN FTE Clinical Care Coordinators manage 1,200 patients •Preoperatively 1 CCC : 20-25 patients •Inpatient 1 CCC : 4-6 patients •90-days post-discharge 1 CCC : 50-60 patients •Annual staffing ratio 1 CCC : 240 patients Program Staffing –Support all Population Management Initiatives • The Network Integration and Payment Reform team consists of: • MD Executive Sponsor • RN Senior Director of Clinical Operations • RN Director of Clinical Care Coordination • RN Manager of Clinical Care Coordination • Director of Program Implementation • Manager of Payment Reform • Data Analyst(s) • Project Manager(s) •Project Assistant(s) 18
- 19. TJR Pathway DevelopmentGovernance Structure Implementation MCIT Reporting Epic Workflow Bundled Payment Initiative Steering Committee Pre-hospital Team Inpatient Team Post Acute Team Total Joint Care Pathway Committee 19
- 20. Standardization • Systematizationand standardizing are the foundations of good operational routines that can be measured and facilitate improvements, outcomes, and ever-greater efficiency. Advantages of Standardization 1. Increased efficiency 2.Improved ability to monitor and study individual factors 3.Improved communication 4.It allows for identification of outliers or modifiable factors 20
- 21. Clinical Management Throughoutthe Pathway The Importance of Care Coordination • Enforces best practices / standardization of pathways, workflows, and order sets • Improves communication between providers and to the patient •Ensures follow-up after care transitions •Optimizes Patient Expectations and Outcomes Goal Develop a pathway with >80% use of all elements with exclusion determined by pathway criteria, not physician preference. 21
- 22. Inpatient WorkflowGoal –StandardPathway with > 80% agreement
- 23. Confidential. Do notDistribute. 23 EMR care coordination tools and patient registries • Care coordination tools were built into the EMR so that Clinical Care Coordinators could see their daily patient lists, view the 90-day longitudinal plan of care as well as document all notes, including information from patients, post-acute providers, and readmissions back to NYULMC and to other hospitals
- 24. Home Care Post-AcutePathway • Two Home Care Pathways – Standard Pathway – Enhanced Support Pathway • VNSNY/TJR Enhanced Support Pathway Pilot Criteria – Single Joint replacement – Caregiver able to participate in therapy prior to DC – Stairs before discharge / No more that 1 flight in home – If private home bed/bath cant be longer than a flight of stairs – Eligible for SNF / Complex Needs • Established risk profile to assist in determining appropriate disposition. • Focus on bi-directional electronic exchange of information. 24
- 25. 1 Evolution Transitionof Care Communication Tool
- 26. Redesigning CareStrategy toImprove Care Transitions The goal: To improve the communication, quality, safety and patient experience across the care continuum. Transitional Care Communication Tool NYULMC in collaboration with partners developed a new electronic communication tool leveraging our (HIE) provide a seamless transfer of clinical data between providers caring for the patient at the time of discharge and throughout the post-acute period. Critical to our success was an effective care transition intervention that reduces fragmentation of care delivery across an episode of care. 26
- 27. • NYULMC’s HealthInformation Exchange • Allows care team to review clinical results/notes of other facilities and physicians • “EMR Light” allows for enhanced communication with post-acute care providers through the use of an electronic transitional care communication tool. The tool consists of: • Transfer Document: Completed by a NYULMC Clinical Care Coordinator upon hospital discharge and made available to the post-acute provider through EMR Light. Includes information such as demographics, type of surgery, care pathway, most recent clinical status, and Clinical Care Coordinator contact information. • Follow-up Form: Sent from the post-acute provider to NYULMC as a patient progress report. Includes information such as post-acute length of stay, changes in clinical condition, physician / nurse practitioner evaluations, and medication changes. • Continuity of Care Document: The post-acute provider can also access the patient’s Continuity of Care Document that is generated by NYULMC’s electronic health record. The document is an electronic patient summary containing a set of standardized clinical elements that are most relevant during care transitions. These elements include allergies, medications, problem list, procedures, and results. Transitional Care Communication Tool Strategy 27
- 28. Jan-Mar. 1st, 2013 Weekly Meeting with PAC partners to develop pathways understand information critical to transition Testing NYU-VNSNY Mar. -Nov 2012 April. 1st, 2013 Sept, 2014 EMR-EMR transfer with VNSNY Risk-Bearing Phase 2 Period begins Oct. 1st, 2013 Live with manual transitional care communication tool Mar, 2014 Transitional Care Communication tool electronically sent to NYULMC HIE Internal/external review of potential system solutions Meetings with PAC partners to develop workflow Testing solution Dec 2012 Jan, 2013 Began training with VNSNY and NYU teams both individually and together Made updates based on feedback from teams Live with Risk Bearing Phase 2 Bundle Payment for Care Improvement Initiative Transitional Care Communication Tool (TCC) Timeline
- 29. Components of TCCForms-CHHA/SNF Transfer Document (Discharge) • Demographics • Type of surgery, date, • Care Pathway • Readmission Risk • Clinical Status • Functional Status • Patient Preferences/Comments • Social History • Knowledge Deficit • Follow-up Appointments • Hospital Contact Information • VS/Smoking Status • Education • +CCD Follow-up Form (weekly) Clinical Status • Pain • VTE pro • Surgical Wound • Pressure Ulcer • UTI • Fever • Diet • Any new medications added • Change in clinical condition • Evaluated by MD/NP Functional Status • Number of PT/OT visits week • Ambulation • Stairs • Transfers • Falls Discharge Status • Anticipated Discharge Date • Barriers to Discharge • Patient on target for Discharge
- 30. NYULMC EMR Lite •NYU clinical staff readies documentation •NYU clinician logs into system & completes Post Acute Transfer Form NYULMC HIE •Facilitates exchange of information between NYU and VNSNY systems VNSNY System •Information received at VNSNY/Clinician notified •Provider logs into system and accesses Post Acute Transfer Form and CCD Transitional Care Communication Workflow Patient ready for discharge from hospital VNSNY nurse visits patient at home
- 31. Transitional Care CommunicationToolProgression • To date we have sent exchanged over 4,000 forms – Approximately 2000 forms with VNSNY April 1 2013 Manual March 2014 VNSNY EMR to NYULMC HIE September 2014 EMR-EMR 31
- 32. Implementing TCC ToolStepsto Success • Foundational work on pathways assisted in identifying areas of focus • Weekly NYULMC-VNSNY Joint IT Operations meetings • NYULMC-VNSNY Training • Continuous updates to improve the functionality of the tool 32
- 33. NYULMC-VNSNY HIE: RealWorld Application • 80 year old female, s/p cardiac valve repair • Discharged home after 5 day hospital stay • Transfer form sent from NYULMC to VNSNY upon transition • Weekly follow-up form sent from VNSNY to NYULMC • NYULMC RN Clinical Care Coordinator observed improved BP control, prompting discussion of medication titration • Patient weaned off of BP meds with ongoing assessment of VNSNY RN • Overall medication adherence improved, BP meds and diuretics adjusted appropriately for optimal fluid management • Patient remained in community, with no readmission during bundled episode
- 34. Staff Feedback • “It’s my eyes and ears telling me how the patient is doing at home” • “It makes our communication more meaningful- instead of reporting vitals and other measurements, we spend our time talking about what we are going to do about the biometric trends we have both been monitoring.” • “The data exchange helps to make the VNSNY home care RN and the NYULMC Clinical Care Coordinator a unified team, both working with the patient to address the key issues and address the patient’s goals.”
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- 36. Changing care deliverywhile improving quality n= LOS: 507 5.62 680 4.27 673 3.84 120 6.46 211 4.58 167 4.67 187 11.81 253 9.82 178 9.27 819 3.49 178 4.83 253 8.70 Discharge Disposition Patterns Based on NYULMC internal data and Medicare claims data FY 2014: Sept.1, 2013 -Aug. 31, 2014 36
- 37. Changing care deliverywhile improving quality Data based on Medicare claims data for bundled payment admissions 90-day all-cause readmission rates 37
- 38. Challenges & NextSteps • Challenges: – HIE Access and Patient Consent – Mapping discrete data – Patient Matching • Next Steps – Continual Improvement of Provider Communication • Order sets • Texting 38
- 39. Closing Thoughts • Our patients are experiencing improved care through enhanced coordination and communication between providers • Well-coordinated care is better for our patients and results in reduced costs • Providing information and education to providers across the spectrum, combined with the financial mechanisms to align incentives, is a powerful combination • Strategic design and implementation of IT infrastructure is a foundation for success 39
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