spreading the adoption of electronic consultation ... · health metrics number of patients who had...
Transcript of spreading the adoption of electronic consultation ... · health metrics number of patients who had...
BluePath Health Inc.; Client Proprietary and Business Confidential 1
March 21, 2016
spreading the adoption of electronic consultation (eConsult)
in California's healthcare safety net
Presenter:Rachel WickProgram Officer, Health Care and Coverage
blueshieldcafoundation.org
BluePath Health Inc.; Client Proprietary and Business Confidential 2
eConsult spread strategy
51%
innovating with relationships
policyshared measurement
SFGH/UCSFSafety Net Institute (PRIME)
Center for Connected Health PolicyBluePath Health
Institute for High Quality Care
BSCF grant $, funding partnership with CHCF, and wisdom from 2014 expert stakeholder convening
YOU! Leadership, commitment and local partnerships
leveraging technology
BluePath Health Inc.; Client Proprietary and Business Confidential 3
eConsult evaluation overview
Goal: spread innovation that works
Learn from: early adopters
Demonstrate value through: Quadruple Aim framing
Inform and be informed by: policy environment
Build grantee consensus around: shared measurement and metrics
Collect & submit data to: UCSF/SFGH
UCSF/SFGH aggregates data for: field and Foundation impact
BluePath Health Inc.; Client Proprietary and Business Confidential 4
stages of planning & implementation
Should/could we do it?How do we do it? Let’s
do it and learn.How (quickly) do we scale
up?
How do we improve/innovate
further?
Contra CostaSan Joaquin
KernMontereySan Diego
San Bernardino CCASBC San Bernardino IEHP
AlamedaSanta ClaraSan Mateo
Los Angeles-LA Care
Los Angeles – LAC DHSSan Francisco
FeasibilityPlanning &
PilotingSpread &
Scale
CQI & Innovation
BSCF Interviews & UCSF/SFGH Survey
Build consensus on metrics
Collect and aggregate data
UCSF eReferral TA Team
Delphine Tuot, MDCM, MASNwando Olayiwola, MD, MPH, FAAFPIguehi James, MPHAlice Chen, MD, MPHElizabeth Murphy, MD, DPhil
Evaluation Framework: Impact of eConsult
BluePath Health Inc.; Client Proprietary and Business Confidential 6
Evaluation Framework: Impact of eConsult (1)Arm of the Quadruple
Aim
Informs Reimburse
ment
Directly related to
GPP
Directly related to PRIME
Measure Ascertainment DefinitionWhy measure
this?
CORE METRICS
Financial X X# specialty
touches/population served
eCR platform & health system
metrics
in-person specialty visits + eConsults (all back-and-forth included in one
eConsult)/empaneled primary care population
indirect measure for business case; access to specialty
care; look at trends and
whether supply induces demand
for consults
Population Health
X
Time to third next available new in-person appt for
eConsult specialties
health system metrics
third next available new patient appointment
access to specialty care; direct
measure of impact
XDemographics of the
population servedhealth system
metrics
race/ethnicity breakdown, insurance status of entire empaneled primary care
populationgeneralizability
XDemographics of
patients who received an eConsult
eCR platform & health metrics
race/ethnicity breakdown, insurance status of patients who received at least one
eConsult Program reach;
impact on equity
X X X% of patients who received specialty
expertise via eConsult
eCR platform & health metrics
number of patients who had an eConsult (regardless of management strategy)/total
empaneled primary care patientsProgram reach
XPCP ability to manage
eConsult specialty conditions
PCP survey
% of PCPs who complete eConsult satisfaction survey question, including
question about educational implications of eConsult
effectiveness of eConsult; indirect
measure of program impact
X X X eConsult management eCR platform
% of eConsults that result in in-person visit/total eConsults (per specialty); % of eConsult that are never scheduled/total
eConsults (per specialty)
effectiveness of eConsult; direct
measure of impact
BluePath Health Inc.; Client Proprietary and Business Confidential 7
Evaluation Framework: Impact of eConsult (2)Arm of the Quadruple
Aim
Informs Reimburse
ment
Directly related to
GPP
Directly related to
PRIMEMeasure Ascertainment Definition
Why measure this?
Population Health
X# of specialties offering eConsult and what they are
eCR platform raw number of specialties offering eConsultAccess to specialty care; direct measure of impact
X X Unclosed loop by PCP
eCR platform
# of specialist responses that are not read by PCP/total number of specialist responses via eConsult
patient safety; unanticipated impact
XUnclosed loop by specialist
eCR platform
# of eConsults that did not receive a specialist response/total number of eConsults
patient safety; unanticipated impact
X XAverage time to eConsult response
eCR platform
average lapsed number of hours between time eConsult was generated and time specialist responded
Access to specialty care
Care team experience
XPCP satisfaction/dissatisfaction
survey
% of PCPs who have high satisfaction with process on survey (topics include questions about work flow, eConsult process, educational materials, eConsult templates)
program sustainability
XSpecialist satisfaction/dissatisfaction
survey
% of specialists who have high satisfaction with process on survey (survey topics include questions about work flow, eConsult process, educational materials, eConsult templates)
program sustainability
X
MEA/RN/referral coordinator satisfaction/dissatisfaction survey
% of non-MD team primary care team members who have high satisfaction on survey(survey topics include: eConsult work flow, process, eConsult templates)
program sustainability
SUPPLEMENTARY METRICS
Patient experience
X XSatisfaction with access to specialty care
focus groups patient self-report GeneralizabilityAcceptability/concerns related to eConsult
XTravel/time saved by patients for avoided clinic visits
BluePath Health Inc.; Client Proprietary and Business Confidential 8
DHCS Waiver Programs Supporting eConsult
David Lown, MDChief Medical OfficerCalifornia Health Care Safety Net Institute
BluePath Health Inc.; Client Proprietary and Business Confidential 9
The DHCS Medi-Cal 2020 waiver supports the expansion of eConsult through 3 programs
Public Hospital Redesign in Medi-Cal (PRIME) - $3.73b
— Builds on programs improving care delivery in designated public hospital (DPH) systems
DPH: 12 public (county run) health care systems and 5 UC medical centers
— Incentive payments earned based on achievement of targets based on specified benchmarks
— Requires aggregate DPH achievement of targets demonstrating increasing adoption of Alternative Payment Methodology(APM)
Global Payment Program (GPP) – PY1: $1.14b
— Care for the post-ACA remaining uninsured by public health care systems (PHS)
—Movement away from cost-based payment to point based payment structure with an overall global budgets
— Emphasizes ambulatory care with inclusion of previously unpaid-for services such as…electronic consultations
Whole Person Care Pilots (WPC) $1.5b
— Provide options to integrate care for beneficiaries who are high risk, high utilizers
— Pilot sites will share data between systems and coordinate their care in real time
http://www.dhcs.ca.gov/provgovpart/Documents/Waiver%20Renewal/Waiver_Webinar_012516.pdf
BluePath Health Inc.; Client Proprietary and Business Confidential 10
PRIME incorporates eConsult to increase access to specialty care through non face-to-face encounters
Program Overview
Goal: Improve the quality and value of care provided by CA’s safety net hospitals and health systems, including increasing access
to outpatient specialty care.
Population: ≥2 primary care encounters (independent of coverage) or Medi-Cal Manage Care assigned lives for Primary Care
Entities: All DPHs and most District and Municipal Hospitals (DMPHs)
Funding: Federal Funds and non-federal share from DPH & DMPH
Effective: July 1, 2015 through June 30, 2020
eConsult-Related Goals and Objectives Reimbursement Model
• Partner with PCMH to improve health outcomes in
acute and chronic disease
• Increase patient and provider access to high quality,
effective specialty expertise – delivered in the most
effective means to meet the need.
• Implement alternatives to face-to-face patient-provider
encounters, including the use of telehealth solutions
• Provide resources to increase PCP capacity to care for
complex patients
Payments made based on mid-year and annual reporting of metric
target achievement.
First report due September 2016.
Project Metrics include:
• Referral reply turnaround rate
• Specialty Care Touches: Specialty expertise requests managed
via non-face to face specialty encounters
• Closing the referral loop: receipt of specialist report (CMS50v3)
Measure stewards include:
• Los Angeles County Department of Health Services (LACDHS)
• San Francisco Health Network (SFHN)
• UC Davis Medical Center (UCDMC)
PRIME measures align with BSCF eConsult pilot measures to incentivize alternative specialty care touches
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Global Payment: Supporting uninsured patients, increasing timely access to services through eConsult
Overview Point Value Establishment Criteria
Goal: Support public health care systems in providing services to the uninsured and to promote the delivery of more cost-effective and higher-value care
Population: Uninsured
Entities: Public health care systems and their affiliated and contracted providers
Funding: Disproportionate Share Hospital (DSH) and UncompensatedCare Pool (UC Pool). Incorporates DSH cuts. UC Pool TBD for PY 2-5. Payments for services
Effective: July 1, 2015 through June 30, 2020.
i. Service Cost
ii. Timeliness and convenience of service to patient
iii. Increased access to care
iv. Earlier intervention
v. Appropriate resource use for a given outcome
vi. Health and wellness services
vii. Potential to mitigate future costs
viii. Preventive services
Service Categories (Examples)
Category 2: Complementary Patient Support and Care Services: non-traditional outpatient encounters, where care is provided by non-traditional providers or in nontraditional settings., including:
• Panel Manager; Group Visits; Paramedicine Treat & Release
Category 3: Technology-Based Outpatient – This category includes technology-based outpatient encounters that rely mainly on technology to provide care:
• RN Call line
• Telephone and email consultations between provider and patient
• Provider-to-provider eConsults for specialty care
• Real Time Telehealth (provider - provider)
Encourages DPHs to provide non-traditional and technology based services to provide greater primary and preventive services – higher value care as compared to the high cost care of avoidable ER/acute inpatient care
BluePath Health Inc.; Client Proprietary and Business Confidential 12
Whole Person Care: coordinating health, behavioral health and social services to increase access to care, incorporating eConsult
Overview Required Participants
Goal: Coordination of health, behavioral health, and social services, in a patient-centered manner with goals of improved beneficiary health and well being through a more efficient and effective use of resources.
Population: Medi-Cal, high utilizers of multiple systems
Funding: $300m/yr in fed funds. Payments for infrastructure.
Lead Entity: County agency, designated public hospital, or district municipal public hospital
Schedule: Applications due to DHCS July 1, 2016
• Medi-Cal managed care health plan,
• Specialty mental health agencies,
• Other public agency (may include county alcohol and substance , criminal justice/probation, and housing authorities, human services agencies, public health departments) and
• (2) Community partners- physician groups, clinics, hospitals, and community-based organizations
Strategies
WPC Pilots shall include specific strategies to:
• Increase integration among county agencies, health plans, and providers, and other entities within the participating county or counties that serve high-risk, high-utilizing beneficiaries and develop an infrastructure that will ensure local collaboration among the entities participating in the WPC Pilots over the long term;
• Increase coordination and appropriate access to care for the most vulnerable Medi-Cal beneficiaries;
• Reduce inappropriate emergency and inpatient utilization; and
• Improve data collection and sharing amongst local entities to support ongoing case management, monitoring, and strategic program improvements in a sustainable fashion
BSCF pilot/CAPH member DPHs are participating in the application process for this cross-county program encouraging collaboration, coordination and reduction of unnecessary ER/inpatient utilization
BluePath Health Inc.; Client Proprietary and Business Confidential 13
Evaluation Framework: Impact of eConsult (1)Arm of the Quadruple
Aim
Informs Reimburse
ment
Directly related to
GPP
Directly related to PRIME
Measure Ascertainment DefinitionWhy measure
this?
CORE METRICS
Financial X X# specialty
touches/population served
eCR platform & health system
metrics
in-person specialty visits + eConsults (all back-and-forth included in one
eConsult)/empaneled primary care population
indirect measure for business case; access to specialty
care; look at trends and
whether supply induces demand
for consults
Population Health
X
Time to third next available new in-person appt for
eConsult specialties
health system metrics
third next available new patient appointment
access to specialty care; direct
measure of impact
XDemographics of the
population servedhealth system
metrics
race/ethnicity breakdown, insurance status of entire empaneled primary care
populationgeneralizability
XDemographics of
patients who received an eConsult
eCR platform & health metrics
race/ethnicity breakdown, insurance status of patients who received at least one
eConsult Program reach;
impact on equity
X X X% of patients who received specialty
expertise via eConsult
eCR platform & health metrics
number of patients who had an eConsult (regardless of management strategy)/total
empaneled primary care patientsProgram reach
XPCP ability to manage
eConsult specialty conditions
PCP survey
% of PCPs who complete eConsult satisfaction survey question, including
question about educational implications of eConsult
effectiveness of eConsult; indirect
measure of program impact
X X X eConsult management eCR platform
% of eConsults that result in in-person visit/total eConsults (per specialty); % of eConsult that are never scheduled/total
eConsults (per specialty)
effectiveness of eConsult; direct
measure of impact
BluePath Health Inc.; Client Proprietary and Business Confidential 14
Drilling down on two examples….
Arm of the Quadruple
Aim
Directly related to
PRIMEMeasure Ascertainment Definition Why measure this?
Financial X
# specialty touches/
population served
eCR platform & health system metrics
in-person specialty visits + eConsults (all back-and-forth
included in one eConsult)/empaneled primary
care population
indirect measure for business case; access to specialty care;
look at trends and whether supply induces demand for
consults
• Feasibility: align with PRIME• Numerator
• eConsult definition?• Denominator
• Empaneled primary care population• Specialty care population
BluePath Health Inc.; Client Proprietary and Business Confidential 15
Drilling down on two examples….
• Ultimate goal of eConsult programs is to improve access to care• Not directly aligned with DHCS waiver programs• TNAA is a commonly used measure for access, but very dynamic• Is this feasible and meaningful? What might be a more meaningful
measure of access?
Arm of the Quadruple
AimMeasure Ascertainment Definition Why measure this?
Population Health
Time to third next available new in-person appt for
eConsult specialties
health system metrics
third next available new patient appointment
access to specialty care; direct measure of impact
BluePath Health Inc.; Client Proprietary and Business Confidential 16
Evaluation Framework: Impact of eConsult (2)Arm of the Quadruple
Aim
Informs Reimburse
ment
Directly related to
GPP
Directly related to
PRIMEMeasure Ascertainment Definition
Why measure this?
Population Health
X# of specialties offering eConsult and what they are
eCR platform raw number of specialties offering eConsultAccess to specialty care; direct measure of impact
X X Unclosed loop by PCP
eCR platform
# of specialist responses that are not read by PCP/total number of specialist responses via eConsult
patient safety; unanticipated impact
X Unclosed loop by specialisteCR platform
# of eConsults that did not receive a specialist response/total number of eConsults
patient safety; unanticipated impact
X XAverage time to eConsult response
eCR platform
average lapsed number of hours between time eConsult was generated and time specialist responded
Access to specialty care
Care team experience
XPCP satisfaction/dissatisfaction
survey
% of PCPs who have high satisfaction with process on survey (topics include questions about work flow, eConsult process, educational materials, eConsult templates)
program sustainability
XSpecialist satisfaction/dissatisfaction
survey
% of specialists who have high satisfaction with process on survey (survey topics include questions about work flow, eConsult process, educational materials, eConsult templates)
program sustainability
XMEA/RN/referral coordinator satisfaction/dissatisfaction
survey
% of non-MD team primary care team members who have high satisfaction onsurvey (survey topics include: eConsultwork flow, process, eConsult templates)
program sustainability
SUPPLEMENTARY METRICS
Patient experience
X XSatisfaction with access to specialty care
focus groups patient self-report GeneralizabilityAcceptability/concerns related to eConsult
XTravel/time saved by patients for avoided clinic visits
BluePath Health Inc.; Client Proprietary and Business Confidential 17
Example: PCP Satisfaction Question
Since the start of eConsult, how satisfied were you with your ability to get specialists appointments for your patients in:
Very satisfied Satisfied Neutral Dissatisfied Very dissatisfied
eConsult clinics 5 4 3 2 1
Non- eConsult clinics 5 4 3 2 1
BluePath Health Inc.; Client Proprietary and Business Confidential 18
Example: Specialist Satisfaction Question
How satisfied are you with the ease of the eConsult process?
Very Satisfied Satisfied Neutral Dissatisfied Very dissatisfied
Overall 5 4 3 2 1
Reviewing consults 5 4 3 2 1
Responding to consults 5 4 3 2 1
Tracking consult requests 5 4 3 2 1
Integrating with workflow 5 4 3 2 1
Reimbursement/ work credit 5 4 3 2 1
Your ability to communicate withthe referring provider regarding patient
5 4 3 2 1
BluePath Health Inc.; Client Proprietary and Business Confidential 19
Timeline: Expected Deliverables PRIME & eConsult
APRIL PRIME: 4/4/16 – 5-Year Project Plan Due eConsult:
Which metrics are feasible? What numerator and denominator makes sense?
May PRIME: April – May refinement of PRIME Metric specs (see below) eConsult: finalize shared metrics for impact evaluation with definitions & survey edits
June PRIME: 6/3/16 DHCS approves or disapproves each Plan PRIME: 6/30/16 payment of 25% of DY11 $$ for approved Plan
July eConsult (est): administration of on-line satisfaction surveys
September PRIME: 9/30/16 Baseline data due on all project metrics eConsult: submit baseline data to UCSF/SFGH
October PRIME: 10/31/16 (est.) payment of 75% of DY11 $$ for reporting all baselines