ACCEL (Access El Dorado)

1. ACCEL(Access El Dorado) El Dorado County Wide Health Initiative April 16, 2008 Greg Bergner, M.D. & Sandra Dunn, MSc

2. Briefing Topics • History & Evolution of Goals • Health Information Technology (HIT) Programs • Care Pathways • Privacy Practice • EMPI • 2008 ACCEL Focus

3. Background • ACCEL (Access El Dorado) is a county wide health collaborative serving the uninsured, • underinsured and residents of El Dorado County, approximately 178,000 people • Situated in east central CA, 1,805 square miles of rolling hills, mountainous terrain • (the Sierra Nevada range), topographically divided into two zones, Lake Tahoe Basin and • the Western Slope • ACCEL Participants • Hospitals: Barton Memorial & Marshall Medical • Clinics: Tribal - Shingle Springs Tribal Health • Rural Clinics - Divide Wellness & Barton Community Clinic • FQHC - El Dorado County Community Health Center • County: Department of Public Health & Department of Mental Health • Private Providers • Marshall Physician Services • Tahoe Family Physicians

4. 2006 2006 2003 2003 2004 2004 2005 2005 2007 2007 2002 2002 • New areas of collaboration between hospitals and small businesses • Joined CalRHIO • Mounted technology vendor RFI for CP • Community clinics share best practices • Regional Healthy Kids insurance • 1st Care Pathways implemented WS • Community needs assessment • Recommend health initiatives to improve access • ACCEL formed to improve EDC health • Outreach, enrollment program started to increase access • Provider network development • Education & practice management • Com. Clinics improved • Barton rural clinic expanded • FQHC opened • Care Pathways (CP) introduced • California Kids (Gap) insurance • HIT plan identified • EMPI & Health Info Exchange investigated • HRA employee screening • HIE business case developed • Formal governance established • Care Pathways implemented SLT • Vendor agreement • Technology Bs.Rules for Care Pathways & EMPI • Privacy & Security Policies/Procedures • Health Alliance convened by Board of Superv. Funding Tobacco Master Settlement (TMS) • AHRQ • Blue Shield Found. • Planning for future funding TMS TMS, TMS, HCAP,AHRQ (multi-yr) techn. Implem. grant TMS, HCAP, AHRQ, Blue Shield Found. ACCEL History Accomplishments AHRQ Planning Grant HCAP HCAP Grant to PHD

5. Improve access to medical care for individuals, particularly children and the uninsured, in El Dorado County by: Developing an outreach, enrollment and retention program to assist individuals enroll in low and no cost public health insurance Securing a ‘Gap’ insurance product for children up to 300% of FPL who did not qualify for public insurance Reduce the barriers to care for the publicly insured by: Increasing clinic capacity through clinic redesign Expanding rural clinics Establishing a new FQHC Developing public network utilizing private physicians Improve the quality of health care and administrative efficiency in El Dorado County by: Continuing to improve access to medical care through ongoing program nurturance and the development of enabling technology Creating county-wide shared patient records across institutions (EMPI & 1st Gen HIE) Establishing standardized processes with measurable outcomes (Care Pathways) to coordinate care at critical entry junctures Building community trust and program linkages Enhance health surveillance through the monitoring of aggregate data Public health early casefinding Chronic disease monitoring Identify long-term strategic goals Implement personal health record accessible to providers Create a county-wide Health Information Exchange which can link to CalRHIO Evolution of Goals And Objectives 2002 - 2005 Goals 2006 - 2009 Goals

6. ACCEL emphasizes implementation: Staged technology enabled programs: 1. Care Pathways, 2. EMPI, 3. HIE • Formal governance established • Privacy & Security Policies & Procedures • Long-term financial sustainability pursued • 2. EMPI: • Notification of Privacy Practices (NPP) • Initial ‘demographic’ data sharing • 1. Care Pathways: • Cross Agency Multiple Pathways 1st implemented (via paper process) • Vendor procured, business rules defined, IT specs, configuration & test, training dev, end user training, Go-Live Feb 2008 • NPP implemented simultaneously • 3. Health Information Exchange (HIE): • Business Case completed • High level clinical data Identified • EMPI is foundational to goal achievement • Technology vendor alternatives explored • 1st Gen demonstration project explored Health Information Technology Programs

7. Care Pathways

8. Care Pathways Constructs Adapted from Ohio CHAPs program Definition: Outcome focused Cross Agency patient case management with standardized processes (mimics industrial production line concept) Requires clear Identification of the Problem to solve and Outcome to achieve Uses a ‘coach’ (Community Health Worker) as the patient navigator Captures barriers, issues that stall patient progress and /or prevent Outcome completion Common language, patient eligibility criteria, cross agency work steps & user responsibilities defined Care Pathway Development Realities Focuses currently on children at or below 300% of FPL Takes 6-9 months to define & test Requires substantial time commitment from multiple Agency representatives Development / implementation time line is dependent upon Participant agencies level of engagement Problem selection should take into account the incidence of problem occurrence, more numerous problems support quantified value proposition more readily Current reimbursement policies are based upon payment for activities versus outcomes; without change sustainability may be jeopardized Care Pathway Background

9. ACCEL Care Pathways Securing Health Care Coverage (Newborns) Securing Health Care Coverage Obtaining a Medical Home Utilizing a Medical Home Pediatric Mental Health Consults Annual (insurance) Eligibility Review Defined Care Pathway Problem & Outcome Problem- no health insurance; Outcome - enrollment of child in public or privately funded health insurance Problem- no health insurance; Outcome- newborn enrollment in health insurance Problem- non urgent child presenting at ER for primary care; Outcome- child has one visit in new medical home Problem- no newborn medical home; Outcome- 4 well baby visits + IZs Problem- PCP needs consult for pediatric case w/ MH issues; Outcome- expedited MH visit with eval to PCP Problem- Insurance at term; Outcome- renewal supported, eligibility extended Care Pathway Background

10. Care Pathway Status Care Pathways Web software is live! Participant technology implementation has been staged to support training / QA, on-site testing and the simultaneous activation of NPP Barton Hospital is ACCEL’s technology hub. Barton’s Director of Technology is ACCEL’s Chief Technology Officer Public Health Department is ACCEL’s hub for Community Health Workers who educate, coach patients 2 of 6 Care Pathways are in use electronically. All should be in use by early summer.

11. ‘Securing a Medical Home’ Results Demo Start August 2006 Client Criteria Pediatric ( >1 yr / age at or below 300% FPL) non urgent patient presenting at ER w/out PCP Referral Source Marshall ER # of Clients 252 Outcome Medical Home secured w/ 1 visit with PCP post ER % Success 202 kids ((80%) Pending 9 kids (4%) Barriers no parent follow thru, moved out of county, no shows at clinic PCP assignment 60 % FQHC, 6% Tribal, 34% Private Providers

12. Privacy Practices

13. Process Taken to Address Privacy Practices • Guidance from key sources: Connecting for Health Framework • (www.connectingforhealth.org), Tennessee MidSouth eHEALTH • Alliance (http://www.regionalinformatics.org/, outside legal counsel, HIPAA, California State law • Workshop educated multi-disciplinary stakeholders on Privacy topics • Steering Committee adopted overarching principles • Notification of Privacy Practices NPP • Privacy & Security Policies are the driver for Technology not the other way around • Security addressed separately from privacy • Chartered Privacy & Security workgroup to recommend policy language to Steering • Committee • Participant Memorandum of Understanding, governance agreement was • Developed, adopted • Participant Operations Cost to implement ACCEL NPP were defined, e.g. changes to existing • privacy forms, printing, distribution and training with staff to implement, programming • of registration systems to capture/track ACCEL patient NPP status 7

14. Notification Privacy Practice (NPP) Principles • Definitions inclusive NPP process assumes patients confirms sharing of information to ACCEL Participant unless they specifically decline or “opt out” common language means that the wording for ACCEL NPP is identical across all network Participants regardless of registration process applies to all network Participants indicates that patient verified NPP outcome at any location applies to all ACCEL network Participants (“global vs.. local”) Rationale Maximum acceptance, simplicity and comparative ease of implementation outweigh potential risk of inadequate patient understanding Implications Participants insure their internal policies and procedures are current, apply to access to ACCEL System and use of ACCEL services Process for withdrawal of NPP must be developed across all Participants with cross agency communication process established Patient education and notification efforts should be consistent across all network Participants Participants will apply ‘consent, Opt-in’ for special patient categories

15. Notification Privacy Practice (NPP) Status • ACCEL NPP common language, Fact Sheet & Talking Points (for end users interface with patients) • Were created for use by Participants. Materials are in English and Spanish. • ACCEL NPP and Care Pathways technology have gone live in a staged manner. By April 21, 2008 • All Participants will be administering the NPP • Evaluation of NPP Opt-outs frequency will be viewed in total and by registration site 120 days • from April 21st by the Steering Committee

16. EMPI

17. EMPI • EMPI demonstration project is between Department of Public Health, Barton • Hospital, Barton Community Clinic and Tahoe Family Physicians • Objective for EMPI with NPP is that it will support pre populating patient demographic information into the Care Pathways technology and ultimately support a more efficient patient registration experience. A future objective is that ultimately the EMPI will serve as master patient rolodex for both the Care Pathways and HIE. • Tracking patient NPP status will be handled in the EMPI. Assuring that this occurs accurately and timely, requires thorough review of NPP patient scenarios to clarify business rules, that the rules are compliant with ACCEL NPP policy, and clear definition of technology programming specifications • Patient Data into EMPI will be from Participant NPP Go-Live date • Demonstration project sites have reviewed their patient types for any special • Patient carve outs • Data interface feeds will take 2 different formats (XML, HL7) given different Participant patient technology, in-house IT bench strength, etc. • EMPI Console, Participant specific repository will capture patient NPP changes and as well as inaccurate patient data to be amended in Participant MPI

18. 2008 ACCEL Focus • Complete implementation of Care Pathway’s technology at all Participant sites • Complete EMPI implementation demonstration pilot • Extend important foundational HIE work • Extend specialty referral network / patient access program,improving quality of referrals and confidence in primary care work up and treatment • Embark upon expanded community engagement with ACCEL • Revisit Governance Agreements and Policies, amend as needed • Define and commit to a long term Sustainability Plan

19. Thank you!ACCEL http://www.acceledc.org/index.aspGreg Bergner, M.D. bergner@sbcglobal.netSandra Dunn, MSc, (916-939-7039)sandadunn@mindspring.com This project was supported by grant funds from Blue Shield of California Foundation. And, 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.