Emergency department Observation Hospitalization Clinical pharmacy Rehabilitation Nursing home CARE MANAGEMENT Pre-admission Clinical summary Triage Admission Care plan Medication reconciliation Case review Shared decisions Discharge planning Care plan Instructions Clinical summary Treatment plan exists for all pts Local medication reconciliation by nursing staff Discharge instructions given to pt/caregiver Clinical summary provided to pt Local care coordinator manages transfers to nursing home/rehab Clinical summary shared with next provider &/or PCP Clinical summaries obtained for all high-risk pts admitted CCC conducts case review for high-risk pts during care Clinical pharmacist engaged in medication reconciliation CCC reviews discharge care plans with pts CCC engaged in pre-admission triage CCC engaged in care planning during admission Pts & providers engaged in shared decision making CCC actively engaged in discharge care planning for high-risk pts Level of care utilization improved 30-day readmissions & ED frequency reduced Medication safety outcomes improved Community setting Home Assisted living Domiciliary Rest home Home health Hospice Retail pharmacy TRANSITIONS OF CARE (ToC) CCC calls, visits high-risk patients Medication monitoring Care plan monitoring Health literacy & education Medications Life style changes Screenings Immunizations Pt engagement; pt self-management Local care coordinator reviews clinical summary & instructions prior to discharge Local care coordinator provides education as appropriate Local care coordinator conducts courtesy calls for high-risk pts, reviews CCC engages patient in care planning; assesses health literacy CCCs calls pts to monitor medication, care plan compliance CCC discusses life style changes CCC encourages home monitoring; educates pt on CCC calls & visits high-risk patients F/U calls for care plan monitoring; encourages through motivational interviewing & use of community services Retail pharmacist engaged in medication management Population health outcomes improvement Pts engaged in management
Health outcomes monitoring medication compliance potential solutions Retail pharmacist engaged in medication safety reviews CCC F/U on screening & immunizations (fill status notification) CCCs address special populations: Pre-natal Special needs children Nutrition Transportation Support groups Homemaker Respite Social services public health Housing Vocational Schools COMMUNITY RESOURCES Identification Utilization Directory Formal agreements Online availability checking Online arrangement for services Initiation of community resources identification Information exchanged with community resources about CCC & accountable care Agreements with services most used by pts CCC makes referrals to community resources, facilitated by directory of services, availability Many agreements across range of community resources CCC arranges for community resources directly online Active use of community resources Improved consumer experience of care Community resources included in shared savings
Electronic health record (EHR) Data mgmt. Workflow & Process mgmt. Health information exchange (HIE) Data warehouse Registry functionality Risk stratification Data analytics Financial modeling practice findings Telehealth Home monitoring device integration Personal health record (PHR) DATA & PROCESSES Access to data Use of data in clinical decision making Exchange of data Clinical quality measurement (CQM) reporting & improvement Data used for knowledge EHR MU initiated; CQMs reported via data abstraction Structured data required for MU in place Workflow & process management is recognized as a key factor for successful use of technology Limited (push via Direct email) HIE Registry functionality used for some clinical care tracking Pts encouraged to use home monitoring device MU functionality used by minimum required number of providers; eSubmission of CQMs Clinical summaries in structured data format (C-CDA) Adoption of standard vocabularies Limited clinical & financial data integration Workflow & process mapping initiated Participation in HIE (for pull/query support) by providers Registry used for preventive care Pts encouraged to maintain health diary & share through portal, Direct email, PHR Reimbursable telehealth services adopted EHR is meaningfully used by all providers Increased clinical & financial data integration to measure cost of care on core measures All providers & community services online 24x7 Workflows & processes continuously monitored for improvement Community services initiate participation in HIE Registry functionality used for all pt F/U Home monitoring device data integrated with EHR Telehealth integrated into accountable care model Integrated risk stratification Big data analytics provide feedback loop for clinical decision support Triple Aim outcomes compared to baseline &/or benchmarks for continuous improvement based