NYC Health Home Program (Care Management Agency)

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CCN General Medicine offers a comprehensive range of medical specializations for both chronic and acute conditions. It participates in the Health Home Program management by NYC CMA (Care Management Agency). Health Home program run by CMS is one of the most complicated outreach programs designed to address mental health patients with 1 or more chronic conditions. The program is delivered by a lead community agency, namely ‘Lead Health Home’ and CMAs.

Program Accountability

To be part of the program, patient needs to be enrolled in Medicaid. CCN General is responsible for maintaining the eligibility. Patient assignment is dynamic and managed by CMS and Lead Health Home. Roster management is a big deal for CCN General as patients can be added and/or dropped without their knowledge. Also, physical acknowledgement of the patient is required on a quarterly basis. In order to get reimbursed for the services provided, CCN General needed a system that can record and report monthly assessments and outreach activities.

In order to manage this population and provide timely care coordination, CCN General, chose Equipo’s Care Coordination system. The goals of the system were many:

• Maintain eligibility
• Manage patient roster
• Conduct patient outreach
• Keep up with the changes in assessment
• Show patient progress
• Keep patients out of ER and Hospital
• Keep high morale of the Care Team
• Produce reports for Lead Health Home
• Provide timely care

Equipo’s care management platform solved the needs by providing an integrated care delivery system. Now, CCN has replaced numerous spreadsheets with active roster management and monitoring of all care activities. The system’s key components include:

• Customizable assessments and care plans allow for staying in sync with CMS mandates and regulations
• Easy activity and task management with alerts enables care teams to plan their daily activities
• Role based reporting and activity tracking allows management to plan for resource workloads and to monitor operational efficiency
• Intake of social statistics of patients and integration with their clinical data allows to identify care gaps and take action immediately

Outcome

Increase in patient enrolment by 500% in 2 years

Achieved 90% reporting compliance for billing

Drop in ER and hospital visit by 40%

Increase in patient satisfaction by 18%

Increase in program manager’s efficiency by 24

Large Community Hospital: Connectivity Through Electronic Referral

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Large Community Hospital is the largest voluntary, not-for-profit health and teaching hospital system serving the South and Central Bronx. It is also among the largest providers of outpatient services in New York City, with more than one million visits annually and an ER that is responding to 139,000 visits, one of the busiest in New York. Large Community Hospital is now completing the third year as a Performing Provider System (PPS) lead in New York State’s Delivery System Reform Incentive Payment (DSRIP) Program. The DSRIP program (entitled Bronx Health Access) is providing Large Community Hospital and its community partners with the opportunity to adapt to a value-based payment system, with an emphasis on keeping patients and the community healthy. Large Community Hospital’s DSRIP Performance is also in the top six of all Performing Provider Systems in New York State.

Accountability and Connectivity

Until recently, the system was plagued with a severe backlog for medical sub-specialty appointments. For example, the wait time for a gastroenterology appointment was 2 months. Referrals were paper-based and faxed or hand-delivered; sometimes the referral was never received, and the patient never scheduled. If a patient needed an expedited appointment, the primary care provider (both internal and external) had to spend time trying to contact a specialist to advocate on the patient’s behalf.

In order to address the backlog, Large Community Hospital, chose Equipo’s electronic referral management and consultation system (e-Referral). The two primary goals of the system was to:

• Track referrals so that there was accountability for referrals.
• Reduce wait times.

The technology platform was custom made to fit to the hospital’s needs by the Equipo Team. Together with the provider relations staff from Large Community Hospital, Equipo successfully spread the eReferral system to more than 150 primary care providers/medical specialty clinics and services, including radiology services, home care, and diabetes support groups. The system’s key components include:

• All referring clinics must use the eReferral system to refer to participating specialty services.
• A centralized, electronic queue for each participating specialty service.
• Each participating specialty service has a designated specialist clinician reviewer (associate) with dedicated time to review and respond to referral requests. The reviewer can use the system to schedule appointments, triage patients, request clarification of the consultative question, and provide guidance for pre-visit evaluation.
• The referring provider and associate can communicate in an iterative fashion using the eReferral system until the patient’s clinical issue has been addressed, with or without an appointment.
• The eReferral system is tightly integrated with the hospital EHR so that all information exchange is documented in the patient’s chart in real time.

The following flow diagram depicts how the eReferral system works.

Large Community Hospital believes that one of the primary values of the eReferral system is facilitation of communication between primary care and specialist providers (both internal and external). Such communication shortly led to workflow efficiencies at both ends. Primary care providers now receive guidance on evaluation and management in a timely fashion, while specialists who see patients in clinic receive clear consultative questions. This information connectivity not only reduces unnecessary specialist appointments but gives PCPs more opportunity to learn and treat their own patients’ clinical issues. Community PCPs are satisfied with the eReferral system. Equipo’s eReferral system recently received accolades and is promoted as a successful system. The following results demonstrate that the system’s goal of reducing wait times has been achieved.

Outcome

• Increase of referrals by 10% in 6 months
• Reduced wait time by 30%
• 8% reduction in hospitalization and ER
• Increased employee retention and job satisfaction (visibly less friction due to efficient workflow)
• Record implementation time, 50% partner added in the system in 3 months (best in history)

New York City IPA: Moving to Value Based Care

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Value based care is complex process. A true care model requires collaboration from every participating entity. Equipo integrates the whole care delivery system to help achieve value-based care model. New York City IPA practice leaders realized payment reform was a reality; they needed transformation into a new model of care.

Challenges

• Several providers with disparate EMRs. Missing unified repository for a unified view.
• Organization lacked real time access to patient data through participating providers.
• Providers had no easy way to find out their performance and to act on gaps in care.
• Data unavailable from external entities like Hospitals, MCOs, Community Labs and pharmacies. Providers unaware of hospitalizations or ED visits.
• MCOs needed visibility on real-time progress and manage outliers for improved care.

Solution: A comprehensive integrated solution that compiles all data in real time, analyzes the data and provides actionable insights for continuous improvement.

Equipo Story

• Integrates data from individual providers in near real-time.
• Integrates data from MCOs (Roster, Medication Adherence, Care Gap, High Flyer list).
• Integrates Transition care data in real-time.
• Integrates Medication data in real-time.
• Integrates Eligibility data in real-time.

Once all the data elements are compiled, Equipo runs its quality analysis for finding out gaps in care, risk gaps, gaps in medication adherence, gaps in transition care. Data is presented as a task list for the care team to act on.

• Filter to identify most critical patients
• Identify and act on most impactful cases
• Generate real-time monitoring alerts
• Task management for care managers
• Automate reminders and follow ups

Outcome

• 22% increase in reduction of Care Gaps
• 28% increase in Roster Enrollment
• 16% decrease in Inactive patients
• 12% increase in Medication Adherence
• 90% adherence in Transition Care
• 24% overall cost savings

Remote Patient Monitoring

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Traditional care requires in-person visits. In contrast, remote monitoring programs passively and continuously collect and transmit patient-generated health data (PGHD) from in-home medical devices to providers and care teams. PGHD, when compared to health data collected exclusively during in-person doctor’s visits, more accurately and holistically reflects lifestyle choices, health history, symptoms, medication, treatment information, and biometric data such as heart rate, blood glucose, blood pressure, temperature, oxygen levels, and weight. As a result, provider organizations are adopting remote patient monitoring (RPM) services – inclusive of data from home health devices – as a new standard of care.

St Anthony Home Health – a leading healthcare provider in South Texas manages a patient population that have chronic conditions like Diabetes and Hypertension. Its providers can now have actionable information gleaned from the data presented via the Equipo Platform. Equipo identifies data trends, elevate critical data points, and help aggregate, summarize, and visualize PGHD in meaningful ways. It allows both patients and providers to easily share, view, and act upon the insights. This makes PGHD useful at the point of care, while encouraging health professionals of St Anthony’s to embrace the available data and further benefit its patients.

For many of St Anthony’s patients, healthcare is episodic. They are treated for the issues that are discussed in in-person doctor’s visits and their providers base treatments around the data collected at that time. It implies that once they leave after receiving treatment for an acute health event, they are largely disconnected from their provider and the continuing care they may need. In contrast, RPM improves outcomes in post-acute care by helping patients and providers manage short-term care after in-person treatment with remotely collected data. Programs educate patients on their condition and recovery needs while providing regular reminders, early interventions, post-discharge information, or medication adherence tracking. With the information garnered from PGHD, St Anthony’s providers are able to evaluate the effectiveness of treatments and customize care plans between patient visits.

Routine monitoring allows for intervention and education as early and as often as needed to keep the patient engaged, healthy, and adherent to their treatment programs. By continuously tracking the routine and biometric measurements of people with chronic conditions, providers are empowered to intervene earlier in disease progression, which helps prevent complications that can result in unnecessary in-person or hospital visits. Equipo simplifies these interventions so that they can be executed by a physician assistant; by a nurse or care manager. It empowers a care team with technology to more effectively intervene and manage treatments.

How Equipo Impacts Health Systems

People with chronic conditions are rising at a staggering rate which pressurizes healthcare stakeholders to improve access to care with reduced number of resources, at the same time providing efficiency and effectiveness. Integrating such programs of care allows providers to improve health outcomes, lower costs, and take advantage of reimbursement opportunities. These programs also create space for operational efficiencies that:

• Relieve stress on overburdened providers
• Ensure doctors spend more time with high-risk patients
• Improve operational efficiency by reducing manual or redundant tasks
• Reduce costs associated with readmission penalties, emergency department visits, and administration
• Improve quality metrics and patient satisfaction scores
• Engage patients in planning, goal-setting, and self-management of care
• Identify trends and outliers which creates opportunities for more effective data analysis and monitoring. This offers the potential for earlier data-driven diagnosis, interventions, and treatments.