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
ACCEL History
Accomplishments
AHRQ Planning Grant HCAP
HCAP Grant to PHD
5
Evolution of Goals And Objectives
2002 - 2005 Goals
2006 - 2009 Goals

• 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

6
Health Information Technology Programs
7
Care Pathways
8
Care Pathway Background

• 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

9
Care Pathway Background

• 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

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 ACCELs technology hub. Bartons Director of
Technology is ACCELs Chief Technology
Officer Public Health Department is ACCELs 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 ( gt1 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

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

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 Pathways
  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/i
ndex.aspGreg Bergner, M.D. bergner_at_sbcglobal.net
Sandra Dunn, MSc, (916-939-7039)
sandadunn_at_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.