Transcript Slide 1

Open Door Family Medical Centers
Care Coordination and Information Exchange
Presentation October 2010
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Open Door Family Medical Centers
• Began in 1972 as a free clinic.
• Now serves almost 37,000 users, reported over 169,000 visits in the
2009 UDS
• Operates 10 sites
– 4 health centers in Northern Westchester County
– 5 school based health centers in Port Chester, NY
– 1 mobile dental van
• Employees 268 individuals, 60 licensed providers
• Implemented an EMR and integrated practice management system
in 2007
• Recognized by NCQA as a Level III Patient Centered Medical Home –
December 2009
• HIMSS Davies Award – 2010
• Joint Commission accredited
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Open Door Family Medical Center
Clinic sites
Ossining, Mount Kisco, Sleepy
Hollow, and Port Chester
Open Door's dedicated team
of doctors, nurse
practitioners, dentists , and
clinical support staff seek to
provide excellent care in
collaboration with our
patients, involving their
families and the broader
community in the effort.
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Chronic Illness in America
• More than 125 million Americans suffer from one or more chronic
illnesses and 40 million limited by them.
• Despite annual spending of nearly $1 trillion and significant
advances in care, one-half or more of patients still don’t receive
appropriate care.
• Gaps in quality care lead to thousands of avoidable deaths each
year.
• Best practices could avoid an estimated 41 million sick days and
more than $11 billion annually in lost productivity.
• Patients and families increasingly recognize the defects in their care.
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Changing Outcomes
Requires Fundamental Practice Change
•Reviews of interventions in several conditions show that effective
practice changes are similar across conditions.
•Integrated changes with components directed at:
• influencing physician behavior,
• better use of non-physician team members, (Pt Advocates)
• enhancements to information systems,
• Safe and efficient information exchange,
• planned encounters (Planned visits)
• modern self-management support, and
• care management for high risk patients
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Patient Advocate Program
 Patient Advocates are a group of professionals, coming from
different experiences, professions and cultural backgrounds, all
having the common purpose to expand and share their knowledge
to serve the community.
 The goal of the patient advocate program is to improve the care and
clinical outcomes for patients with chronic disease.
 A patient Advocate functions as an extension of the health care
team:
 Coordinates services and follow-up on requested referrals
 Manages medical information and data to ensure planning, action, and follow
up.
 Provides education and self-management support
 Facilities and assist with Concrete Services
 (Medicaid Eligibility, Financial Assistance, Charity Funds opportunities)
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Patient Advocates at Open Door
 We employ 8 Patient Advocates and
one Supervisor at our 4 main sites.
 Each works in a medical or women’s
health unit supporting 3-4 clinical
providers.
 Appointments are made both in
advance and on the same day.
 Providers can refer at the time of the
visit and advocates review daily
schedules for appropriate
intervention.
 All together our Patient Advocates
see ~ 1000 visits per month.
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Patient Advocate EMR Template
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Patient Advocate EMR Flow Sheet
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The Patient Advocate Role
in Information Exchange
• Advocates document in a
progress note using templates.
• The note is easily accessible to
the provider and the entire
patient care team.
• Referrals are tracked in the EMR.
• The advocates provide the
specialist with the medical
summary information –
–
–
–
–
reason for the referral,
current problem list,
Medication list
Last visit information
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Using the EMR Referral System
Appointment
information
must be
documented in
the referral
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Re-scheduling a Referral Appointment
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The Referral Tracking Process
Where do we need to improve
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Closing the Loop
• Advocates reach out to specialists by
phone/email to obtain results by fax or mail.
• Providers can log into affiliated hospital’s EMR
to obtain consult reports and ER visit info.
• Medical records staff receives consults or test
results through EMR Fax In-Box or USPS mail
and attaches them to the order, then assigns
the order to the provider for review and
follow-up
• Advocates use the registry reports to identify
patients who need follow-up and/or reminders
• BridgeIT report writing tool is used to identify
missing information and improve data integrity
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Example BridgeIT Report:
Referral Status for Diabetic Patients
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Our Challenges - Where we need to improve
• We are still doing some tasks manually
through paper / fax / scanning.
• We need better ways to track down
missing results from outside referrals
• We need better communication with
patients to know when and where they
went for care outside Open Door.
• We need to have more control of the
EMR processes and the ability to
prevent data entry errors
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Technology and Collaboration
• Plans to implement Patient Portal to connect with our
patients
• P2P (Peer to Peer) EMR connection between providers.
• Open Door has collaborated with ThincRHIO in designing
and beginning health information electronic exchange with
health providers in the Hudson Valley
• Open Door has worked with CHCANYS and HCNNY in
improving the functional use and reporting abilities of the
EHR and practice management system.
• Open Door has collaborated with HITCH focusing on
diabetic care across the health care continuum; the
transitions in care when specialists and hospitalization is
needed.
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Summary – Technology and EHR
• The EHR has changed how we operate – information is readily
available, legible and allows for more transparency.
• Meaningfully using the data allows us to learn about the
patients and the community we are caring for.
• The technology allows us to engage more with our patients
and provide them with their information about their health.
• Reporting tools and structured data allows us to identify areas
that need improvement to improve care to our patients and
ultimately the community.
• The technology is a tool for our Patient Centered Medical
Home, meaningful use and care coordination efforts.
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Technology, Meaningful Use, Care
Coordination & Medical Home
Important for:
Quality Care
Incentive Reimbursements
Prestige
Recognition
Together, we can keep our promise to those
we serve and in doing so, strengthen and
expand the Open Door brand.
Building stronger, healthier communities… One patient at a time
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