South East Michigan Beacon Community Collaborative

1. Advancing Quality Healthcare Through National, State and Local Community Collaboration Robert Jackson MD, MMM Board Chair and President, Southeastern Michigan Health Information Exchange (SEMHIE) South East Michigan Beacon Community Collaborative

2. Hugh Macleod “The only people who can change the world are people who want to. And not everybody does.”

3. The Concept of the Beacon Community Improved Quality & Efficiency Care Delivery Innovations Provider Feedback & Measurement Payment Reform HIT Foundation: Meaningful Use of EHRs and HIE 3

4. The Ultimate Goal is Improved Health Sustainable Health Outcomes: Quality, Efficiency, Population Health Innovative Care Delivery Processes and Payment Reform Health IT: Electronic Health Records and Information Exchange 4

5. Achieving the National Beacon Vision:ONC Focuses on Five Domains • Leadership & Stewardship • HIT & Meaningful Use • Clinical Transformation • Data & Performance Measurement • Sustainability and Payment Reform 5

6. Achieving the National Beacon Vision:31 Month Roadmap Phase 1: Program Launch (September 2010-October 2010) Phase 2: Implementation & Refinement (October 2010- Dec 2012) Phase 3: Evaluation & Dissemination (Jan 2013- Mar 2013) 6

7. Dr. David Blumenthal Presents Beacon Award To ‘Team Detroit’

8. Andre Gide “The most decisive actions of our life - I mean those that are most likely to decide the whole course of our future - are, more often than not, unconsidered.”

9. Team Detroit $16.2M Beacon Award • Grant Awardee: • SEMHA, the Southeast Michigan Health Association, is the fiduciary for SEMHIE, the Southeast Michigan Health Information Exchange • Beacon Implementation: • SEMHIE will implement Beacon through the Southeast Michigan Beacon Community Collaborative (SEMBCC) • Beacon Funding: • $16.2 Million from HITECH Act • $27.8 Million non-federal funds (stakeholder in-kind & cash)

10. Vision • The Detroit area has a patient-centric electronically connected system of care that that emphasizes holistic care management, where there are no barriers to the flow of patient health information to the appropriate care providers, are well-informed and actively engaged in managing their health

11. Project Mission: • The overarching purpose of our project is to improve Diabetes Mellitus (DM) care and associated outcomes while reducing costs. at the place and time needed.

12. Strategy • Guided by culturally oriented behavior change models, we will do this by: • Expanding interoperability and health information exchange • In our underserved and disadvantaged community • To bring comprehensive and actionable clinical information to providers.

13. Beacon Team Detroit: Project Objectives • Improve continuity, quality and safety of care for underserved patients with chronic diabetes in • Detroit, Hamtramck, Highland Park, Dearborn and Dearborn Heights, Michigan • Diabetes has a very high prevalence among the target population: 12.8 percent of adults, or 93,000 people.

14. Project Objectives • Improve the quality and efficiency of diabetes care and reduce cost • Redesign patient care work processes • Develop community-wide patient care coordination • Apply quality improvement and other change management strategies

15. Team Detroit’s Technical Goals • Make comprehensive patient information available at point of care • Leverage existing advanced technologies • Extend SEMHIE’s SSA architecture for Beacon • Increase technical interoperability among providers • Include a broad spectrum of community health care settings (health systems, emergency departments, primary care physicians, FQHCs, free-clinics)

16. The Beacon Community Project Will Address • Outcomes of healthcare in the U.S. are poor compared to most developed countries • Care process quality is sub-par; impacting health outcomes • Care cost is very high and rising • Patient satisfaction is low • Clearly healthcare can perform better

17. Causes of Quality Issues • Quality data is scattered and not in easily usable formats • Providers are paid for service utilization, not quality results • Shortage of Primary care physicians • Costs of chronic care are prohibitive to many patients • High number of un-/under-insured

18. Provider Incentives are Misaligned • Health payment is heavily weighted to volume rather than quality of services. • Each health plan is different. • Different metrics • Different weights • Patients don’t have the information to judge quality of care

19. Mother Teresa “Yesterday is gone. Tomorrow has not yet come. We have only today. Let us begin.”

20. How Will Beacon Impact Care? • To help patients negotiate the transitions of care smoothly • An ER visit will trigger the navigator to help the patient follow up with their PCP “home”. • Patients will be assisted in these transitions by these patient navigators. • VODI has already used this model effectively; we will expand and hope to enhance it.

21. Beacon Will Provide Care Coordinators • More clinical, a nurse; will facilitate the PCP • For instance they will help the patient achieve the care quality landmarks needed. • Encourage compliance by educating and actively engaging the patient on an ongoing basis. • Reducing perceived or actual barriers that prevent a patient from optimal care.

22. Beacon Will Experiment • With methods to more fully engage the patient will messaging back and forth • Likely will use cell phone technology as it is somewhat ubiquitous • We need to work with them on their terms to engage. • We will learn from the other 17 Beacon communities and continually transform

23. Sam Levenson “You must learn from the mistakes of others. You can't possibly live long enough to make them all yourself.”

24. Next Steps for Beacon Team Detroit • Complete data evaluation baseline – Nov 2010 • Continue roll-out of SEMHIE’s SSA architecture for Beacon • Initiate provider assessments • Engage additional core team participants from key stakeholder groups for balance – Join us!!

25. Summary • Team Detroit will enhance the care of patients with Diabetes Mellitus in these 5 cities • Activate providers of healthcare and patients • Support them with Patient Navigators for care transitions • Engage and Educate patients with Care Coordinators • Measure quality and improve it • Support these efforts with Information Technology.

26. Beacon Team Detroit Contacts • Gary Petroni, SEMHA, Center for Population Health Director; Fiduciary, Beacon Grant gpetroni@semha.org • Robert Jackson, M.D., Chairman, SEMHIE; Initial Beacon Executive Medical Director rjacksonwwp@gmail.com • Helen Hill, Program Manager, Public-Private Initiatives, SEMHIE; Initial Beacon Program Director hhill1@hfhs.org

27. Major Stakeholders in SE Michigan Beacon Community Collaborative • AFL-CIO Employer Purchasing Coalition • Ascension Health • Beaumont Hospitals • Blue Cross Blue Shield of Michigan • CareEvolution, Inc. • CSC • Detroit Medical Center • Detroit Wayne County Health Authority • General Motors • Greater Detroit Area Health Council • Health Alliance Plan • Henry Ford Health System • HIMSS • HIMSS IHE • Joint Venture Hospital Laboratories

28. Major Stakeholders in SE Michigan Beacon Community Collaborative • Juvenile Diabetes Research Foundation • Internet2 • M-CEITA • my1HIE • Michigan Academy of Family Practice • Michigan Coalition of HIT • Michigan Department of Community Health • Michigan Department of Technology, Management and Budget • Michigan Health and Hospitals Association • Michigan Health Information Management Association

29. Major Stakeholders in the SE Michigan Beacon Community Collaborative • MPRO • Oakland County Medical Society • Oakwood Healthcare System • Oakwood Primary Care Physicians PC • Object Management Group • Picis • PRISM • MI-HIMSS • Michigan Organization of Diabetes Educators • Michigan Primary Care Association • Michigan State Medical Society/MSMS Connect • Michigan State University Institute for Health Care Studies • Molina Healthcare

30. Major Stakeholders in the SE Michigan Beacon Community Collaborative • Trinity Health • University Bank • Visiting Nurse Association of Southeast Michigan • Wayne County Medical Society of Southeast Michigan • Wyandotte Independent Physicians Association • Voices of Detroit Initiative • Promia • Southeastern Michigan Health Association • Southeast Michigan Health Information Exchange • St. John Providence Health System • Summit Health Institute for Research and Education • Thomson Reuters

31. Mark Twain “Let us live so that when we come to die even the undertaker will be sorry.”

32. Core Team Participants

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39. Thank You!The People of SEMHIE and team detroit are excited to serve this community