EMHC is the home care and hospice division of the EMHS. The health system is an IDS with hospitals, ambulatory care practices, LTPAC providers (home health, hospice, SNFs, and assisted living) and ancillary services. The home care division includes three agencies and seven offices serving both urban and rural areas covering two-thirds of Maine. EMHC also provides telehealth services to patients in the health system and has been successful in reducing hospital admissions and ED visits.
EMHS is both an innovator and a leader in health care having received grants to test new models of care and payment, and industry awards and recognitions. HIT has been a key factor in supporting their innovative practices and a strategy to manage health care for a population that covers a large urban and rural geography. The State of Maine has an operational statewide HIEO, called HealthInfoNet (HIN). Both the EMHS and EMHC participate in HIN.
Grants, Policy Drivers and Other Funding Models Advancing HIE
Medicare is the primary payer for both the Eastern Maine HHAs and hospice providers (approximately 75% of their payer mix collectively). Medicaid, private insurance and self-pay make up the remainder of the EMHC payer mix. The EMHS has received grants and other funding to test new models of care and payment specifically through improved care coordination and case management including community services. The grants have supported a number of programs and HIT enhancements to facilitate communication and coordination.
As described below, EMHS participates in several grants, new payment models and policy initiatives that have driven improvements in the HIT infrastructure supporting communication and care coordination across providers and services:
CMS Hospital Readmission Reduction Programs. The EMHS focuses on reducing hospital readmissions not only to comply with the CMS program requirements, but also as a way to improve quality of care and reduce costs. To reduce hospital readmissions, the hospital and LTPAC providers are improving coordination and communication prior to discharge; access was improved to hospital EHR data to facilitate transitions; case management/care coordination meetings are occurring across health care settings and with community service providers, and the telehealth is used to monitor the clinical status of targeted high-risk populations.
ONC Beacon Grants. EMHS received an ONC Beacon Community grants funded by the ONC to build and strengthen local HIT infrastructure and test innovative approaches to make measurable improvements in health, care and costs.
The Bangor Beacon Community's grant helped to support a HIT infrastructure used for testing new accountable care and payment models and manage patient populations. The goals of the Bangor Beacon Community grant were to use HIT effectively to improve the health of people with select chronic diseases, reduce costs associated with hospital admissions and ED visits, reduce variations in care, and improve population health related to immunizations and sharing immunization data.n
The Beacon grant supported the acquisition of a single EHR application across the multiple home care agencies in the EMHC division, which improved information access and sharing. The grant also supported the acquisition of new telehealth equipment to expand the program and its use for monitoring the target population. It also supported expansion of the Maine HIEO, HIN, to include submission of selected home care data to the exchange (ADT alerts and the home care POC).
U.S. Department of Agriculture (USDA) Grant to Expand Telehealth. One of EMHC's agencies in rural Maine received a $50,000 federal grant from the USDA's Rural Utilities Service to expand its telehealth program with matching funds. The agency was able to purchase an additional 28 telehealth units.
New Care and Payment Model Programs to Advance Care Coordination and Reduce Costs. EMHS is currently participating in two programs to test the development of new care delivery and payment models to improve care coordination and reduce costs.
EMHS was selected as one of 32 ACOs under this Center for Medicare and Medicaid Innovation (CMMI) initiative. Under this 3-year arrangement with CMS, the EMHS ACO shares Medicare savings in year 1 and moves to a capitated rate per beneficiary in years 2 and 3 if they meet the following reporting and/or performance requirement:
- 1st Performance Year. Report 33 measures to share in up to 50% or 60% (depending on their model) of Medicare shavings.
- 2nd Performance Year. Report eight measures and be paid for performance on 25 measures.
- 3rd Performance Year. Paid for performance on 32 measures and paid for reporting on one survey measure related to functional status.
The 33 quality measures used to assess performance have been endorsed by the NQF and are reported across all 32 Pioneer ACOs. Appendix L provides a detailed list of these measures, along with the NQF measure identifier and corresponding data submission requirement. The primary domains for the 33 measures are patient/caregiver experience, care coordination/patient safety, preventive health, and at-risk populations.
EMHS developed its HIT infrastructure over time. The HIT infrastructure provides the ability to manage the health for their population. This includes initiatives to use the same EHR applications across its HHAs, expand Maine's HIEO, and expand home care's use of telehealth. Care coordination initiatives have also been implemented to manage the population's health and reduce costs. The care coordination initiatives include: use of primary care managers through the PCMH, and CCTs to help engage appropriate HCBS for patients in need; and implementing regular care coordination meetings across the sites of care including LTPAC and LTSS.
In addition to being a Pioneer ACO, EMHS also participates in two PCMH projects. The State of Maine established 22 PCMH projects and CMS demonstration project for Multi-Payer Advanced Primary Care Practice.
The PCMHs are reimbursed by three types of payers: Medicare, MaineCare, the state Medicaid Program, and commercial insurers. Medicare and MaineCare pay $7 per member per month for care management in the medical home and $3 per member per month for community-based care management. Maine is projecting it will achieve budget-neutrality by decreasing patient inpatient admissions by 6%-7%, decreasing ED visits by 5%, and decreasing specialty consultations and imaging by 5%.
In EMHS's PCMH, a patient care manager is embedded in the primary care clinic to work directly with individuals and their care team to develop a personalized POC. They partner with applicable care providers and care coordination teams across settings such as inpatient care managers, cardiology care managers, mental health care managers, home care and home health service and palliative care to manage risk, costs and transitions. The personalized POC includes individualized services, custom plans based on patient needs, co-management goals, and self-management plans. The patient care managers also perform outreach to other services and providers such as community-based services and LTPAC providers. Accessing updated electronic information and ADT alerts through the HIEO, sharing information with health care providers and coordinating community-based services are all crucial to the coordination of care efforts of the PCMH.
Community HIE Organization
Maine has a statewide HIEO known as HIN, an independent, non-profit organization that was established as the state's HIE in 2006. HIN has been operational exchanging clinical data since June 2009. In 2010, Maine received grants from several sources to expand the technology infrastructure including a state HIE Collaborative grant, an ONC Regional Extension Center (REC) grant (HIN is the REC), and the Beacon Community grant.
All 38 of Maine's acute care hospitals are under contract to connect to the HIEO. HIN has connected 34 of the 38 hospitals, 376 ambulatory provider sites including primary and specialty care practices, all/some FQHCs, 12 mental health agencies, two HHAs (both are part of IDSs) and two long-term care providers. The information available on HIN includes patient demographics, medications, medication history, allergies, lab and test results, vital signs, image reports, transcribed reports, problem lists, and ADT alerts.
EMHC participates in HIN by sending electronic ADT alerts and home care plans of care, and accessing electronic information to support start of care, assessment and care planning activities. A future project is planned to transmit the home health lab results to HIN and medication information from Miller Pharmacy which provides medications to EMHS's SNFs.
Summary of EHR and HIT Systems and Development Plans Related to HIE
EMHS has multiple software applications supporting their operations. The EMHC division does not use the same EHR application as the health system hospitals and physician practices. The hospitals and physicians use the Cerner EHR application. The home care division uses the McKesson Horizon Homecare application. Cerner has an application known as PowerChart that supports organizations with multiple entities. PowerChart provides quick access and viewing of the most frequently used and/or clinically relevant information.
EMHC currently uses Phillips Healthcare Telehealth Solutions as their telehealth vendor. The telehealth tools include in-home devices (a base unit and the measurement device) and a cloud-based software application.o The telehealth data collected includes clinical data, questionnaire responses, and risk screen results. EMHC is currently working on an interface to bring the telehealth data into the agency's EHR system.
EMHC is in the process of developing a physician portal to the HHA's EHR to streamline the process of sending their patient's health information to the physician for signature. Physicians will log into the McKesson EHR system to access the records that require review and signature. Once implemented, physicians will have the capability to review other patient medical record information and write progress notes and orders (medication, treatment or other types).
Health Information Routinely Exchanged
As an IDS, EMHS maintains an IT network that allows affiliated providers to access information in different EHR systems and through PowerChart. EMHC also exchanges information with non-affiliated partners including hospitals, physician practices, community service providers, and other LTPAC providers primarily through telephone, e-fax, and secure e-mail. HIN provides another source of information on patients which is particularly useful for background information at the start of care/assessment process. Health information is routinely be communicated and shared at transition of care process and continuously during a patient's stay. Section 4.2.1 in this report and Appendix J provide additional information on the information routinely exchanged.
o. See http://www.healthcare.philips.com/goto/telemonitoring.
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