Record of April 30th Medical Neighborhood Project Implementation Meeting Improve referral infrastructure across the medical neighborhood in Greater Columbus WHY: Improved care coordination among the medical neighborhood is essential for moving towards a higher performing healthcare system in the United States. Potential benefits of improved care coordination in the medical neighborhood include:
Improved clinical outcomes for patients.
Improved patient satisfaction with the care they receive.
Improved patient safety.
Lower costs from reduction in duplicative services, increase in delivery of preventive services, and delivery of more evidence-based patient care.
HOW: Implement referral infrastructure across the medical neighborhood in Greater Columbus. The Medical Neighborhood Project will focus on implementing the CliniSync Referral Tool among healthcare providers and social service agencies in Greater Columbus. 2015 Objectives: At least ten social service agencies and five local healthcare providers participating in project Collect project measures, document lessons learned, and share learning with public-private partners
Click here to view presentation slides Click here to view the project webpage Click here to visit the CliniSync website
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PROJECT SCOPE AND APPROACH Project Overview Similar to the Healthcare Collaborative of Greater Columbus’ work on the PatientCentered Medical Home, the intent is to spread this project in waves. In Q3 2015, 15 – 25 healthcare providers and social service agencies will begin using the CliniSync Referral tool to exchange referrals amongst themselves. Additional organizations will be identified by project participants and invited into future waves. This cycle will continue as needed. Organizations will also be invited to participate in a Medical Neighborhood Learning Group in late 2015. This group will spend time sharing lessons learned and best practices related to the medical neighborhood. Proposed Project Measures Participate Measures - Collected Monthly o Number of organizations in CliniSync referral network o Number of services available in CliniSync referral network o Number of patients in CliniSync referral network System Use Measures - Collected Monthly o Number of referrals sent within CliniSync Referral Tool o Total number of referrals made by an organization inside and outside of CliniSync Referral Tool (Self-reported by participating organizations) Value Measures - Collected Quarterly (All measures self-reported by participating organizations) o Value of CliniSync Referral Tool to the organization o Estimated time saved by CliniSync Referral Tool o Estimated number of new organization relationships from participating in the Medical Neighborhood Project.
AWARENESS ON FUNCTIONALITY OF CLINISYNC REFERRAL TOOL A demonstration of the CliniSync Referral Tool was provided by Dan Paoletti and Karen Bishop from the Ohio Health Information Partnership. The Ohio Health Information Partnership is responsible for implementing CliniSync throughout the state of Ohio. Slides used during the demonstration can be viewed by clicking here.
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Participant comments and questions of clarity regarding the Medical Neighborhood Project and the CliniSync Referral Tool Participant Comments/Questions of Clarity Response Can a social service agency refer to another Each organization will have the ability to refer to any social service agency, not only to healthcare other organization using the referral tool. The providers? referral process will be the same for healthcare providers and social service agencies. Can an organization use the referral tool as No, the referral tool will not replace an organization’s their EMR, or client database? EMR or client database. The tool should only be used to enhance the exchange of referrals. Can organizations host documents that need Organizations will be able to maintenance documents to be included in the referral process? (list of on their profile pages. When creating referral services, address, website, phone #, agreements each organization will have ability to necessary paperwork, etc.) indicate what steps need to be followed to make referrals. Can you submit multiple referrals for a Each referral needs to be sent individually. Following patient at the same time or do you need to each referral the system will ask if you would like to send individually? send another referral for the same patient. System will retain Reason details from the previous referral so that the user does not have to re-enter. Clients self-referring? The project design team decided to select a tool that would not allow patients to self-refer, or access the system. This approach will help ensure that information in the system is accurate and easier to monitor. How can/does this interface with other Healthcare providers will have the ability to upload a technologies; seems like there is a lot of Care Summary or Encounter Summary directly from uploading info with this while other systems the Community Health Record. Currently social may eliminate all the lab uploading, etc., service agencies will not be able to bridge the system creating a more coordinated patient record to any other client databases unless Direct messaging rather than duplicate medical records capabilities are available to both parties. This (upload/download all the time) functionality is a request that will be submitted to the vendor for consideration in a future release. How will data on demographics, race and Organizations will have the ability to include a ethnicity be collected and used? patient/clients demographic information in the referral. How this information is used will be determined by the participating organization. Is the referral process done/completed while Each organization will have their own unique patient is still at appointment, or after workflow. Best practices suggest that the patient patient has left office? should be included in the referral process. Is there an ability to use zip code or geocode This functionality does not currently exist in the to sort distance to referred services from the referral tool, but will be submitted for consideration patient/member/client? in a future release. Is there any quality measure to determine if The project will simply be focused on implementing one entity is better than another when infrastructure to streamline the referral process. referring? Organizations can determine the quality of care provided by another organization by using available
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Many PCP’s use ipads for patient charting. Any thoughts on app development? Questions and comments related to referral agreements o Scatter referrals?—favorites…limit scatter of multiple referrals for the same services simultaneously o Send to multiple organizations at the same time? o Standardized or customized response to referrals? o Will have to create a threshold for response to a referral o What’s the expectation from primary care organization of social service agency and follow up to patient --letter, phone, contact to patient? Questions and comments related to reporting o Can an agency run reports for their clients and related information? How many inbound referrals, outside referrals, appointments held? o Can the referrals be tracked—as aggregated data—for meaningful use to qualify as P2P referrals? o Customized reports o What reports will we be able to access around demographic data? When will decisions on this be made? Time stamps and reminders for follow up for appointments?
What are the licensing requirements?
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quality tools, or developing a relationship with the organization. Users can access the system from their tablets internet browser. System does not require an app to be developed as it is web-based. Organizations that commit to participate in the project will be brought together to develop referral agreements. These agreements will provide guidelines for using the CliniSync referral tool. Referral agreements typically include what information needs to be included in a referral, appropriate amount of time to respond to a referral, and what follow up needs to be performed. Organizations can also customize a referral agreement for each unique relationship they develop in the medical neighborhood.
Currently the CliniSync Referral Tool is able to generate reports that show total number of referrals sent within the community, from an organization, and from a provider/service. The national vendor of the tool has agreed to listen to feedback and potentially add additional measures to the reports based on need. A process will be put into place to gather this feedback as the project moves forward.
The current system does not send reminders to users for appointment follow up. The system will send users an email notification when they receive a new referral. Number of users will be determined by each organization. Organizations will need to self-police their internal system and follow all CliniSync guidelines for use. CliniSync and HCGC staff will train one or two staff members to use the system and they will be responsible for training additional users.
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What about uncovered patients (undocumented) referred to agency/organization who accepts covered patients? What consent is necessary for…
Where in Southern Ohio is CliniSync being used? What types of organizations are allowed to participate?
Individual organizations will determine what patients they will accept and deny. Organizations will have the ability to include information around the type of clients/patients they are currently accepting in their profile. Same for all… HIE – Community Health Record To query for information within the Community Health Record on a patient who has not previously Opted In When adding a New Patient to the Community Health Record in order to send a new referral When selecting an existing patient from the Community Health Record who has not previously Opted In when creating a new referral Chronic Care Management Beneficiary consent for electronic transfer of care plans within the Medical Neighborhood community of participants CliniSync is currently being used in the Portsmouth, Ohio Area. The project will start with primary care providers and healthcare related social service agencies that are considered covered entities. Over time the goal will be to spread the project to include healthcare specialists, and additional social services. Covered Entity Source: http://www.hhs.gov/ocr/privacy/hipaa/understanding/coveredentities/
For Covered Entities and Business Associates The HIPAA Rules apply to covered entities and business associates. Individuals, organizations, and agencies that meet the definition of a covered entity under HIPAA must comply with the Rules' requirements to protect the privacy and security of health information and must provide individuals with certain rights with respect to their health information. If a covered entity engages a business associate to help it carry out its health care activities and functions, the covered entity must have a written business associate contract or other arrangement with the business associate that establishes specifically what the business associate has been engaged to do and requires the business associate to comply with the Rules’ requirements to protect the privacy and security of protected health
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information. In addition to these contractual obligations, business associates are directly liable for compliance with certain provisions of the HIPAA Rules. If an entity does not meet the definition of a covered entity or business associate, it does not have to comply with the HIPAA Rules. See definitions of “business associate” and “covered entity” at 45 CFR 160.103. A Covered Entity is one of the following: A Health Care Provider This includes providers such as: Doctors Clinics Psychologists Dentists Chiropractors Nursing Homes Pharmacies ...but only if they transmit any information in an electronic form in connection with a transaction for which HHS has adopted a standard. A Health Plan This includes: Health insurance companies HMOs Company health plans Government programs that pay for health care, such as Medicare, Medicaid, and the military and veterans health care programs A Health Care Clearing House This includes entities that process nonstandard health information they receive from another entity into a standard (i.e., standard electronic format or data content), or vice versa.
Who would a PCP refer to (for example)… a patient diagnosed w/ diabetes-- would PCP refer to Central Ohio Diabetes Association, or a diabetes self-management education program (ie: YMCA)? Are we linking to the organization or the specific program/class/offering? www.hcgc.org
The individual making the referral should engage the patient to determine where their needs will be best met. Organizations will have the option to create one profile, or list their services as separate profiles. If an organization chooses to use separate profiles, each one will need to be monitored for activity. However, this is best managed by customized questions. 6
Will you be able to search for an organization based on the services they offer?
Would an organization need to create multiple profiles for the different services they offer?
Yes, organizations will be able to connect their organization to the services that they offer. Organizations will have the option to create one profile, or list their services as separate profiles. If an organization chooses to use separate profiles, each one will need to be monitored for activity. When making a referral you will be able to search for organizations based on the service you are attempting to refer to. Organizations will have the option to create one profile, or list their services as separate profiles. If an organization chooses to use separate profiles, each one will need to be monitored for activity.
ACTIONABLE NEXT STEPS
May 2015: Healthcare provider organizations invited to participate in project. Committed providers identify social service agencies that they exchange the most referrals with and invite them to participate in wave 1. If you are a healthcare provider interested in participating, please contact Krista Stock (krista@hcgc.org).
May 2015: At least five healthcare provider organizations and ten social service agencies committed to participate in wave 1 of project.
June 2015: Convene leadership from committed organizations to develop referral agreements and explore how project will be implemented within their organization.
June 2015: Team leaders from committed organizations participate in kick-off webinar exploring the technical aspects of implementation with CliniSync.
Q3 2015: Training and implementation of CliniSync Referral Tool within wave 1 organizations.
Q3 2015: Organizations exchanging referrals using the CliniSync Referral Tool.
The Healthcare Collaborative of Greater Columbus thanks the following public-private partners for participating at the session and sharing their diverse prospectives. Jane Seleshi Stephanie Ashley Nancie Elizabeth Lisa Karen Larry
Acri Asfaw Baker Ballard Bechtel Beck Benton Bishop Blosser
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Central Ohio Area Agency on Aging Ethiopian Tewahedo Social Services Clintonville-Beechwold Community Resource Center Ohio Association of Community Health Centers Columbus Public Health The Ohio State University Wexner Medical Center Aetna Ohio Health Information Partnership Central Ohio Primary Care
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Roy LeRoy. Ladonya Nita Joy Steve Teresa Cathy William Erica James Connie Linda Barbara John Mohamed Amy Dottie Isi Liz Stephanie Awes Patricia Richele Jo David Alex Sarah Lori Judy Mark Mary DeAndree Colleen Kiley Tanesha Dan April Brian Julie Marci
Bobbitt Boikai Brady Carter Chivers Collins Collins Costello Cotton Drewry Dye Emerson Gillespie Goedde Gregory Hassan Headings Howe Ikharebha Kitchen Koscher Kosha Lattimer MacDowell Marcucci Maywhoor Meyer Miller Miller Minaudo Mollenkepf Mutegi Norris O'Brien Orchard Owens Paoletti Pegis Pierson Rinaldi Ryan
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Central Ohio Diabetes Association Ethiopian Tewahedo Social Services Mount Carmel Medical Group UHCAN Ohio Gladden Community House Aetna Helping Hands Health and Wellness Center Ohio Health Information Partnership Nationwide Children's Hospital National Church Residences American Cancer Society Concord Counseling Services Central Ohio Area Agency on Aging The Ohio State University Wexner Medical Center LifeCare Alliance Horn of Africa Voluntary Youth Committee Mid-Ohio Foodbank Ohio Health Information Partnership Physicans CareConnection Ohio Department of Health Prevent Blindness Ohio Horn of Africa Voluntary Youth Committee Mount Carmel Health System OhioHealth Group Central Ohio Primary Care UHCAN Ohio CompDrug, Inc. Community Refugee and Immigrant Services Mount Carmel Medical Group Central Ohio Primary Care Mid-Ohio Foodbank Physicans CareConnection United Way of Central Ohio The Ohio State University Wexner Medical Center HandsOn Central Ohio Mount Carmel Medical Group Ohio Health Information Partnership Mount Carmel Health System Mount Carmel Health System Syntero Godman Guild Association
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Manju Tara Hunter Jenny Sandy Steve Dana Matthew
Sankarappa Schiller Schouweiler Shrodes Stephenson Thompson Vallangeon Yannie
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Ohio Asian American Health Coalition Charitable Pharmacy of Central Ohio Mount Carmel Health System Central Ohio Diabetes Association Southeast, Inc. Helping Hands Health and Wellness Center Lower Lights Christian Health Center United Way of Central Ohio
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