# Presentation: 593111

## Hospitals: 		Barton Memorial & Marshall Medical
Clinics: 		El Dorado County Community Health, Barton Community, Divide Wellness, 
		Tribal Health, Marshall Physician Services, Tahoe Family Physicians
County:  		Department of Public Health & Department of Mental Health

**Hospitals:** 		Barton Memorial & Marshall Medical
**Clinics:** 		El Dorado County Community Health, Barton Community, Divide Wellness,
- 		Tribal Health, Marshall Physician Services, Tahoe Family Physicians
**County**:  		Department of Public Health & Department of Mental Health

**Notes:**
I would like to welcome each of you, and thank AHRQ for this opportunity to report on our work in El Dorado County, California., We are a rural county in California, our total population is approximately 178,000 residents. We are working collaboratively as a coalition on two issues with our AHRQ Funds:  1) to improve our Care Coordination through shared  IT, and 2) on Care Communication through our developing Health Information Exchange.  In El Dorado County, our coalition consists of:  two hospitals, both a little a little less than 100 beds,  all clinics serving the underserved  (FQHC, IHS, RHC’s), our County Public Health and County Mental Health Departments, as well as a couple  of clinics who include private payors in their mix of patients. 

## About El Dorado County

- Situated in East Central California’s Sierra mountains
- Topographically two zones: Lake Tahoe Basin & Western Slope
- Approximately 178,000 people

**Notes:**
This slide shows where our county is in relation to the state of California, but what isn’t shown is that running through the middle of our county is the backbone of the Sierra Nevada mountains.  The El Dorado County Sierras are as high as 10,000 ft. with the passes for autos at 7,400ft.  This creates two zones in El Dorado County, separated from each other by those mountains, and a between an hour and an hour and a half apart.  We call these zones the Lake Tahoe Basin and the Western Slope.   Although the Lake Tahoe Basin and the Western slope are geographically separated, they share the same problems, actually, the same problems we all face in U.S. Healthcare, that of care coordination, and of care communication.  

## ACCEL Care Pathways

-     Securing Newborn Health Care Coverage
-     (Newborns) Utilizing a Medical Home
-      Securing Health Care Coverage
-      Annual Eligibility Review (Insurance)
-     Obtaining a Medical Home
-      Pediatric Mental Health Consult
- Community Health Workers assist each person entering a pathway. The Community Health Worker acts as a personal guide and advocate for their client, assisting them to overcome barriers to health care, providing health information, and working with medical establishments on behalf of the client.  Patient hand offs occur seamlessly between agencies depending upon where a patient is in a given pathway.  Standardized steps with patients are understood and agreed to between partner agencies.

**Notes:**
Although I will mention the HIE, this presentation is focused primarily on the first part of our AHRQ effort, Care Coordination,  what we call Care Pathways. A Care Pathway is a shared process,  a narrowly focused process, addressing a specific problem such as maximizing insurance. Each  Care Pathway coordinates the management of that care between the hospitals, the provider offices and the health departments. Care Pathways are our version of  collaborative workflow improvement, developed by Drs. Sarah and Mark Redding in Ohio.  At it’s most basic level, Care Pathways are a series of sequential discrete step by step workflows.  Some steps are the responsibility of one partner, and other steps are the responsibility of another.  
The six Care Pathways listed here are our first ones.  We developed the steps of our Care Pathways first on paper, and have since migrated these steps to our shared electronic application, called iREACH.  iREACH is a customized web-based application allowing access by each partner from their worksite.  Barton Hospital at Lake Tahoe serves as our technology hub and help desk for this application.  Although different partners are responsible for completing different sequential steps within a Care Pathway, a Community Health Worker is the person who provides the glue and oversight as the case manager, the personal guide and advocate for the patient.  Presently CHW’s all reside at and are employed by the Public Health Dept., but a CHW could also be employed by a Partner organization to address issues unique to that partner.   
By migrating Care Pathways to a web based application, we leverage several advantages:
	1.  We eliminate much of the labor and the potential for error which occurs with duplicate patient data entry at different partner sites, (demographics, financial data, employment data, and the like)
	2.  Our patient handoffs between partners become seamless, and they come attached to the patient’s Care Pathway information
	3.  We are able to collect outcomes data for drill down analysis, as well as an ability to examine data on barriers to care, some of which we can address and correct, (like interpretation or transportation issues), and some of which we can’t (like the patient moved out of the area).  
If you notice, four of the six pathways are what one might call “Administrative” in nature, that is, they address access issues which are barriers to even being eligible to obtain care.  The sixth and the second pathway, Pediatric Mental Health Consult, and (Newborns) Utilizing a Medical Home, were our first semi-clinical pathways.  By “semi-clinical”, I mean that although these Pathways allow monitoring of a clinical issue, they are neither treatment algorithms, nor clinical guidelines. The Pediatric Mental Health pathway was developed at the request of the providers who felt that in dealing with mental issues in the Pediatric population, they were often out of their comfort level, and they also felt that communication with the County MHD was poor and inadequate.  The Newborn Utilizing a Medical Home pathway is a Pathway that monitors well child visits and immunizations for the first 8 months of a newborn’s life, making sure that the infants actually use, and obtain the services of a Medical Home.  Because clinicians typically don’t need a lot of health results data for either Pediatric Mental Health Consult or Newborns Utilizing a Medical Home, (like lab results or imaging results), we felt we could set them up within our current iREACH application.  Other, more complex clinical pathways which we hope to develop, (such as pain management, or more complex clinical issues)  will require a more robust ability to exchange  clinical information, and these more Complex Care Pathways will have to await the our implementation of the HIE.  But actually, both the Administrative Pathways, and the “Semi-Clinical” Pathways address transitions in care between Partnered agencies, the focus of this Session.

- ACCEL’s phased strategy for
- Health Information Technology

**Notes:**
This slide shows the phased implementation of Care Pathways, and of our HIE.  I want to point out that a significant portion of both the Coordination Infrastructure, and the Technical Infrastructure underlying Care Pathways is the same as the infrastructures needed under an HIE.  Before establishing working Care Pathways, we had to develop Coordination Infrastructure such as shared policies and documents, and MOU’s on Privacy, Data Security, Data Sovereignty.  On the Technical Infrastructure side of things we had to deal with Data transmission language, Interoperability Standards and the like. This work has to occur before either shared Care Pathways, or an HIE is undertaken. Developing that infrastructure begins with convening the partners and developing a willingness of partners to work together.  Trust happens over time, if actions foster it.   Sustainability of the process will follow if the outcomes support it. 
We believe that having gone through the process of developing six collaborative Pathways, and now that we are successfully operating our pilot EMPI (Electronic Master Patient Identifier), we have valuable collaborative experience which is foundational to our HIE.  By phasing our project in this manner, we have a built in readiness which will allow us to move into the HIE more quickly, and we believe more successfully than had we plunged directly into the HIE from the start.

## Converting pathways from paper-based system to shared electronic records

- Training,
- Launch,
- &
- Quality Review

- Configuration
- &
-  testing

- Business rules
- & technical requirements

- Workflow mapping
- & redesign

- Multi disciplinary team from ACCEL’s participating organizations, staffed by project managers with technical expertise, was formed to oversee development and implementation of electronic pathways

- ACCEL Steering Committee adopted policies and procedures developed by
- Privacy and Security workgroup, including common language for NPP.

**Notes:**
Back to Care Coordination...back to the Pathways....This slide outlines the steps we needed to complete for Care Pathways.  It is an outline of the nature of the process, and from it, one can infer, it’s not a walk in the park.  Before going into the detail of the slide, it is worthwhile to review several basics, which left untended, will cause the effort to fail.
The Process needs the buy-in of Authoritative Leadership of each Partner Organization.... must be on board with the goal of our project, and must be willing to direct subordinates to avail themselves to the development process.   
Remember, Care Pathways provides a method to reverse a thirty to fifty year bad habit, if not a tradition in Medicine, of poor coordination of care for  underserved patients, between private and public agencies.  In defense, of private Partners I would say that in general, without too much arm-twisting, they have provided free or greatly reduced care for this population of patients, during this fifty years.  But, also, in general, they considered writing and sending documentation of treatment, diagnosis, history, or results, to other agencies which might interact in care of these patients, to be beyond the call of duty.  Just providing the care was enough. Changing these habits and attitude takes time, and it takes face to face meetings! 
In our coalition, each of the end-users, who were key in developing Care Pathways for our project were doing this in addition to doing their regular jobs.   Without process analysis, planning, coordination, training, the development process might have failed. Because all of the end-users have regular job responsibilities, we wouldn’t have been successful without outside help and facilitation. We have been quite fortunate to have Sandra Dunn as our Project Director.  Sandra is one of those unusual people who is able to connect with CEO’s and with entry level employees.  She has been able to guide this process, and sense when we need more work and when we’re able to move on. 
One last thing before we move to the development process,  I would like to point out that developing and changing the workflow processes is much more detail than I as a Physician tend to want to deal with. Physician partners tend to want things done, and done yesterday...in ACCEL, we have two engaged Physician Champions, me in Lake Tahoe, and Jon Lehrman on the Western Slope.  We also have a Provider Capacity workgroup consisting of 8 to 10 physicians who make monthly noon meetings to provide clinical input.  These clinicians provide essential clinical advice, and they ground and validate the importance of the Pathways in providing clinical care.  Without clinician buy-in, this process will not work... but generally, Clinicians are not the ones most capable of getting the job done.  That task must be delegated to someone not distracted and impossibly busy providing primary clinical patient care.
So to go over the slide, our approach has been to first identify, and then to create the steps of a Care Pathway
In the beginning, we brought the End-Users from each Partner organization together.  We started with “Getting to Know You, Getting to Know All About You”, and progressed to analyze, then achieve consensus for workflow mapping and redesign. The Workgroup doing this work met monthly at first, now much less often. 
Business rules were developed, and Tech standards and requirements were developed by IT folks.  
The process is configured, tested, and then the Care Pathways process is implemented first on paper, then electronic.   Prior to go-live with either paper or electronic, the Process, the Business rules, and the tech plan were all reviewed and accepted by the Steering Committee, which is our Governing Body, made up of leadership of Partner Organizations. Leadership needs to be in the loop, but they don’t have the time to do the work.  Partners had to not only agree on the paper process, but they had to see to it that the process was operationalized within their organizations. We developed a county-wide NPP, data transmission and security standards.  We used the Markle Foundation’s Connecting for Health documents along with input from our Partners, and finally legal blessing from Gerry Hinkley from Davis, Wright and Tremaine.  Concurrent to this, we researched and selected an electronic application which would meet our needs, iREACH.  We then had to customize the software, implement interfaces to existing software applications and platforms within each partner organization.  It was arduous, but a necessary process.  After implementation, we had weekly post implementation OPS/TECHNICAL meetings to identify, prioritize and address issues.  
Finally, I want to point out in the last arrow, the Quality Review.  Quality Review is an important and a periodically repeated part of our process.  With employee turnover, with outside distractions, we need to periodically assess and sometimes modify process and performance of steps within each Care Pathway.  This Quality Review keeps our data reliable, it demonstrates the benefit, and the need for sustainability to our partnering organizations, and it keeps the end users engaged and working toward the common goals of the individual Care Pathways and the goals of the ACCEL Initiative itself.  
I don’t mean to make this appear too daunting, but I do want you to understand that to be successful, you have to realize and work through the detail.

## Care Pathways Dashboard

- ACCEL Dashboard offers a 30,000 ft view
- Each Pathway is distinct: the problem addressed, the clients served, the outcomes measured, completion timeframes vary due to the complexity of the problem being addressed
- Detailed trending QA reports to support (agency site issues, user compliance, etc.) will be available beginning in October

**Notes:**
So let’s move to our results, but first I want to orient you to our Care Pathways Results Dashboard, and then show some actual results.

##  89% completed successfully

**Securing  Health Care Coverage (WS & SLT)**
** ****89% completed successfully**

**Notes:**

....go over results

## Pediatric Mental Health Consult

**Pediatric Mental Health Consult**
**51% completed successfully**

**Notes:**
...go over results

## (Newborns) Utilizing a Medical Home

**(Newborns) Utilizing a Medical Home**
**56% completed successfully**

**Notes:**
...go over slide

## Obtaining a Medical Home

**Obtaining a Medical Home**
**83% completed successfully**

**Notes:**
...go over results...I am not going to show the results for the last two Pathways, annual review and renewal of insurability, and the Pathway for Securing Newborn Healthcare Coverage.  We are still five months away from our one year anniversary of electronic implementation, so  Annual renewal process has fewer numbers, and in the case of NBSHCC,  the results roughly mirror those of SHCC, and we only have so much time.

## Lessons Learned from Care Pathways

- It’s hard, it takes time: and now collaboration is the norm.

- Solid upfront commitment from senior leaders is essential
- Educate, communicate, educate, communicate -- it’s a continuous process
- Transparency and allowing for airing differing views helps build a team
- Decentralized implementation model focusing on common outcomes goals respects differences among participants
- Clearly defined workgroup charters, processes, and processes for issue escalation helps manage scope creep
- Approaching work incrementally helps to mitigate the “overwhelm” factor

**Notes:**
So, what did we learn?  Go over the points,
The processes which we have gone through has allowed us to have a successful start in Coordinating IntraAgency Care...we are chipping away, trying to break that 50 year bad habit of poor coordination between  Partnering entities.  We were funded by AHRQ to create something other rural areas can replicate.  These processes can be duplicated in other rural areas.  It’s a challenge, but having gotten a start, others will be able to do it faster.  Now lest you think that what we have accomplished in El Dorado County, is just because “it never rains in California” , we have other issues, some of which make it easier, some of which make it harder.
Next slide, next slide, next slide

##  Winter can make travel tough!

## Care Pathways is a methodology which promotes working together

**Notes:**

But, by Partners approaching care coordination together, we are establishing a methodology for working across agencies, and have made in-roads into changing our 50 years of  bad habits thorough Care Pathways.

## We need to squeeze, ferment, and share!

**Notes:**
So, in the future, we will be squeezing our data, we will ferment and analyze it in our minds, and then will share our results!

## Thank You

- ACCEL
- _[http://](http://www.acceledc.org/index.asp)__[www.acceledc.org/index.asp](http://www.acceledc.org/index.asp)_
- Gregory Bergner, M.D.
- bergner@sbcglobal.net
*The project was supported by grant number UC1HS016129 from the Agency for Healthcare Research and Quality.  The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality.*