MRHA Conference Sunday, October 20, 2019 Part I – Taking an Innovative Idea to a Funded Project

Ernest Carter, MD PhD Lori Werrell, MPH, MCHES Acting Health Officer, Prince George’s County, Maryland Regional Director, Population and Community Health Principal Investigator, PreventionLink MedStar St Mary’s Hospital/MedStar Southern Maryland Hospital Center Interim Director, Clinical Resource Management Medstar St Mary’s Hospital Co-Principal Investigator Laurine Thomas, PhD Independent Health Services Research & Evaluation Consultant Lead Process Evaluator, PreventionLink

MRHA Conference Sunday, October 20, 2019 Presentation Objectives

• Describe the project that led up to the innovation that will be discussed later during this session • Share 3 strategies for formulating innovative project ideas based on prior work • Share 3 strategies for turning innovative project ideas into a funded project From Project to Innovation

Evolution a Population Health Improvement Strategy Population Health Improvement Population Health Strategy Management Implementation Strategy Development Population 1. Population Health Health Pilot 2. Health Information Technology -Health 3. Partnerships Enterprise Zone Prince George’s County HEZ St. Mary’s County HEZ What was the HEZ?

• Health Enterprise Zone jointly administered and funded by the Community Health Resources Commission and Maryland Department of Health from 2013 to 2017 • Five zones funded • Prince George’s – focus on Capitol Heights zip code 20743 • Anne Arundel • Dorchester and Caroline • St Mary’s • West Baltimore Greater Lexington Park Health Enterprise Zone (HEZ) Project Vision Establish accessible, integrated, culturally competent healthcare in the HEZ supported by clinical care coordination, prevention services, community outreach and education Core Disease States Diabetes, Asthma, Hypertension, Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, Behavioral/Mental Health Diseases Provider Recruitment • Care Coordination Primary Care and Get Connected To Health • Community Health Workers • Primary care with Psychiatry • Transportation • Safety net clinic on “Big Blue” • Dental • Primary Care • Behavioral Health • Trainings, classes, events and screenings • Health Disparities/Hispanic outreach/Cultural Competency

8 East Run Major Program Components • Inpatient (readmission risk factors triggers Care Coordinator) Hospital encounter • Emergency Room (follow up by Community Health Worker)

• Home visits, care plans, phone support, medication reconciliation Care Coordinator • Working with other care coordination programs and primary care

• Removing Barriers to self management and health prioritization Community health • Transportation (shuttle and medical specialty routes) worker Outpatient Care Primary / • PrimaryCoordinator and specialist appointments, Dental Specialist/ Outpatient Ancillary Care Care • PT ,Dialysis, Cardiac Pulmonary Rehab etc

• Walk with Ease, CDSMP, NDPP, diabetes self management program, Self management support groups, Walden Sierra programs programs Participant Impact • Readmission rate of RN Care Coordinated patients - 7.03% • State data has the overall zone Readmissions rate dropping from 13.4% to 6.8% (around a 50% drop) • Emergency Room Visits are down (this is still a challenge) • PQI Composite scores are below state averages

• # of new clients served by CHWs – 271 • # of client encounters with CHWs – 4421 • A set of 4th year HEZ clients (N=383) showed a reduction in ED and inpatient utilization of approximately 210 visits in the 6 months after most recent intervention compared to the 6 months prior to intervention for an estimated reduction in charges of 420K.

• Shuttle ridership – 7497 • Medical Specialty rides – 440

• # of patients served behavioral Health – 656 • # of unduplicated Psychiatric patients– 87 • # Dental patients seen – 42 • # Primary Care patients seen - 2105 Challenges

• Lost Key partner for sustainability • Incentives did not work • Pressures on hospital budgets Prince George’s County HEZ Program Goals

• Increase access to healthcare and expand the primary healthcare workforce • Improve chronic disease health outcomes for residents • Reduce preventable hospitalizations and Emergency Department visits • Reduce unnecessary healthcare costs Prince George’s County HEZ Strategies

• Coordinate transitions from hospital, emergency department, nursing home or skilled nursing facility to home • Public Health/Health Department Services • Community/County resources and services • Community Health Workers • Health Information Exchange & Technology • Insurance Connection • Preventing illness and treating chronic diseases Prince George’s County HEZ Accomplishments • Established 5 Medical practices (patient-centered medical homes) with a minimum of 1 physician and nurse practitioner per PCMH within 4 years • Served over 41,600 unduplicated patients by December, 2016, with over 58,450 appointments, and approx. 17,249 patients seen in Zip Code 20743 • Care Coordination Team (CCT and CHW Program) • Health Department CHW integrated into the 2 hospitals and Primacy Care Practices • Established Community Care Coordination Team (CCCT/Oversight) • Health Literacy Campaign and Community Steering Committee • Behavioral Health Intervention-Prime Time Sister Circles • Behavioral Health and Social Services Integration • Reduction in inappropriate service utilization- hospital costs –20-40% hospital visits- 42-54% Questions Leading to Innovation • How to take our project to scale? • How can we leverage the individual strengths of different stakeholders? • How can our efforts fit with what is happening statewide and nationally? • Can we implement care community coordination that is regional in focus but adapted to local communities? • How to address multi-jurisdictional care seeking? • What kind of evidence do payers need in order to reimburse our model? Strategies for formulating innovative project ideas

•Strategy 1: Network with like minds • Leveraging regular all zone meetings •Strategy 2: Conduct ongoing gap analysis • Need for community care coordination •Strategy 3: See the larger picture • Need for a regional approach Innovative project ideas into a funded project: 3 Strategies: 1. Population Health 2. Health information technology 3. Partnerships The Population Health Model

A well-developed care management program is the key to better outcomes and cost savings, especially in populations with chronic disease

http://www.urgentcareadvisors.com/population-health-management-vs-accountable-care-organizations/ 12 Strategy 1: Population Health Management Primary Components of Care Coordination

Health Care Coordination Clinical

Medication Behavioral Management

Social Determinants

21 Health System’s Approach to Care Coordination & Population Health “Uncoordinated Coordination”

Private Practices ACOs These health entities are Hospital Non profit Systems Care located both Coordination Hospital inside and Primary Care Networks EMS Mobile outside Southern Maryland Population Integrated Care Southern Maryland SNFs Long-term Non Profit Care FQHCs Clinics

Each health entity lives in it’s own definition (bubble) of

care coordination leaving large gaps in care. 22 Population Health Improvement Advisory

Community Care Coordination Transformation = Population Health Improvement Advisory (PHIA) In 2019 GOAL:

Triple Aim - The simultaneous pursuit of improving the patient experience of care; improving the health of populations; and reducing the per capita cost of health care.

SCOPE:

Non-clinical oversight organization that holds providers and community accountable for the care coordination and quality of care for Southern Maryland population 23 within a global budget. “Coordinate the Coordination” Population Health Management Model

A well-developed care management program in Partnership Network Partnership Southern Network for Maryland is the for Research and key to better Monitoring outcomes and cost Development savings, especially and Evaluation in populations with chronic disease Community Stakeholders, Ambulatory, Hospital, Pharmacy, LTC, SNF, Case mgmt., EMS, BH, Social Services, Home Health, Academia,

Care management and risk stratification infrastructure

Hospital Ambulatory Long Term Care and System Care SNF Care Care Hospice Care Coordination: Coordination Coordination: Coordination TLC, Nexus, ACO’s, Private Hospital Practices, EMS, sponsored QCN’s, Team Based Care 24 Population Health Management Model

Care management and risk stratification infrastructure

Hospital System Care Long Term Care, SNF Non profit Care Ambulatory Care Coordination: and Hospice Care Coordination: Coordination: TLC, Nexus, Hospital Coordination Health Alliance, ACO’s, Private sponsored Team Based EMS, Practices, QCN’s, Care, Health Alliance Cohesive delivery system

<30 >30 days days 25 Strategy 2: Health Information Technology

Patient Portals, Mobile Apps Population Health Management Software

MD Hospitals (49)

Public Health Central Referral System (CRS) Connectivity, Security, Management, SSO

Electronic Health Records MD Ambulatory Providers

National Diabetes Medication Management Care Management Behavioral Health Services Prevention Programs Services Strategy 3: Partnerships • HEZ led to the creation of a project (PreventionLink) that spans the region covering urban, suburban, and rural communities • PreventionLink has: • 3 health system partners • 3 care coordination entities • 4 academic partners • MRHA • CRISP- health information technology • HQI – the regional QIO • 9 Diabetes Prevention Programs (DPP) The Resulting Innovation: PreventionLink

• A 5-year cooperative agreement between the Centers for Disease Control and Prevention (CDC) and the Prince George’s County Health Department to lead the collaborative development of regional infrastructure for chronic disease prevention and care across Southern Maryland. • PreventionLink combines evidence-based prevention and care approaches, technology, and communications strategies to create a multi-faceted integrated system for improving health and wellness related to chronic disease in Southern Maryland. • The ultimate goal is an effective, sustainable and replicable model worthy of statewide and national attention. Part II – Introduction to PreventionLink: A Regional Approach to Chronic Disease Management

Ernest Carter, MD PhD Acting Health Officer, Prince George’s County, Maryland Principal Investigator, PreventionLink

Lori Werrell, MPH,MCHES Regional Director, Population and Community Health MedStar St Mary’s Hospital/ MedStar Southern Maryland Hospital Center Interim Director, Clinical Resource Management Medstar St. Mary’s Hospital Co-Principal Investigator, PreventionLink PreventionLink Overview • Purpose- PreventionLink seeks to build a primary care network and community of practice for chronic care patients in Southern Maryland.

• The program will bring together contiguous counties in a collaborative builds on the work of the Health Enterprise Zone (HEZ) by expanding the integration of public health and clinical practice to improve prevention and health outcomes for patients at all levels of risk for chronic disease, from persons at risk for diabetes and heart disease to high-system utilizers with frequent hospitalizations. Geographic Focus Four (4) Counties in Southern Maryland: • Prince George’s • Charles • Calvert • St. Mary’s

Prince George’s Charles Calvert St. Mary’s TOTAL Population 912,756 159,700 91,502 112,667 1,276,625 % Rural 2.00% 29.50% 38.70% 50.40% 12.34% Rural Pop 18,255 47,112 35,411 56,784 157,562 PreventionLink - Data

• 10% of chronic disease patients in the project area are responsible for 80% of chronic care costs.

• Chronic disease is a leading cause of death in this country, accounting for 7 out of 10 deaths, according to the U.S. Department of Health and Human Services.

• 75% of typical primary care visits are for multiple chronic illnesses.

• Barriers to health care access in the region include transportation, low health literacy, lack of finances (and lack of adequate health insurance), and lack of social support.

Centers for Disease Control and Prevention. National diabetes statistics report: estimates of diabetes and its burden in the United States, 2017. Atlanta, GA; US Department of Health and Human Services, Centers for Disease Control and Prevention, 2014. PreventionLink - Data

• Prediabetes is treatable and, in • Primary care physicians and care most cases, reversible teams lack the time and training • In 2017, 30.3 million (9.4%) in to provide intensive lifestyle the U.S. population had diabetes counseling to their patients with 23.1 million diagnosed and while treating acute illnesses 7.2 million undiagnosed. Only and condition. 10% of these individuals are • The Diabetes Prevention aware of their condition. Program Research Group has • If current trends continue, shown the effectiveness of clinical practices will see 32% lifestyle interventions on more patients with type 2 reducing the incidence by 58% diabetes in 5 years and by 2050, (compared to 31% reduction by one in three to one in five U.S. metformin). adults might have diabetes

Centers for Disease Control and Prevention. National diabetes statistics report: estimates of diabetes and its burden in the United States, 2017. Atlanta, GA; US Department of Health and Human Services, Centers for Disease Control and Prevention, 2014. In 2017, nearly a third of a million adults had been PreventionLink - Data diagnosed with hypertension in the Adults with Doctor-Diagnosed Hypertension, 2017 PreventionLink area. 33.5% 33.1% • Of those, national 33.0% 32.9% estimates show that 32.5% 32.3% roughly half, or over 31.9% 150,000 residents, do not 32.0% have their blood pressure 31.5% under control. 31.0% MD: • In addition, an estimated 30.5% 30.6% 13 million or 5% of U.S. 30.0% adults have undiagnosed 29.5% hypertension. This translates to nearly 50,000 29.0% unaware residents in the Prince George's Charles Calvert St. Mary's PreventionLink area. Source: Maryland BRFSS

Centers for Disease Control and Prevention. National diabetes statistics report: estimates of diabetes and its burden in the United States, 2017. Atlanta, GA; US Department of Health and Human Services, Centers for Disease Control and Prevention, 2014. PreventionLink Background • In September, 2018, CDC awarded funds to State and Local Health Departments to design, test, and evaluate innovative approaches to address the significant national health problems of diabetes and heart disease and stroke. • Awardees funded by this new 5-year cooperative agreement include (29 total) – o 22 State Health Departments o 5 Large City/County Health Departments o 2 Consortia of City/County Health Department PreventionLink: The Goal Recipients will develop and evaluate innovative approaches with: 1. Diabetes Management and Type 2 Diabetes Prevention

2. Cardiovascular Disease Prevention and Management Diabetes Management and Type 2 Diabetes Prevention Strategies • Increase access to, enrollment in & retention of people in a National Diabetes Prevention Program (DPP) in an underserved, high-burden area • Eliminate barriers to participation in a National DPPP lifestyle change program • Tailor communications and messaging • Advanced training for National DPP lifestyle coaches • Expand telehealth to increase access to DSMES services • Early detection of CKD • Increase bi-directional e-referral between health care systems and CDC- recognized organizations delivering the DPP Cardiovascular Disease Prevention and Management Strategies • Track and monitor clinical measures shown to improve healthcare quality and identify patients with high blood pressure and high blood cholesterol. • Implement team-based care for patients • Test innovative ways to engage non-physician team members. • Link community resources and clinical services that support bi-directional referrals, self-management, and lifestyle change for patients with high blood pressure, high blood cholesterol, and/or who have had a cardiac event through – • Engagement of patient navigators/community health workers (CHWs). • Bi-directional referral between community programs/resources and healthcare systems. • Expanded use of telehealth including mobile health technology. • Innovative ways to enhance referral, participation, and adherence in cardiac rehabilitation programs in traditional and community settings, including home- based settings. Category A Outcomes – Diabetes Management & Type 2 Diabetes Prevention • Implement all 16 strategies under both Categories A and B in all four counties in both urban and rural underserved settings. The long term outcomes that we have set for our efforts are as follows:

• For Category A our long-term outcomes achievable at the end of Year 5 are: • 25% increase over baseline in the number of people with pre-diabetes enrolled in a CDC recognized lifestyle change program who have achieved 5-7% weight loss. • 25% decrease in the number of patients with diabetes with A1C >9. • additional long-term outcomes for all Category A activities - reductions in hospitalizations, emergency department (ED) and urgent care visits, and hospital readmissions within 30 days for patients with diabetes. Our goal is to decrease such utilization by an average of 10% per year. Category B Outcomes – Cardiovascular Disease Prevention & Management • For Category B the long-term outcomes are: • 50% increase in the number of patients with known high blood pressure who achieve blood pressure control • 50% increase in the number of patients at risk for cardiovascular events whose cholesterol is controlled • We also propose the following service utilization outcomes: reduction in hospitalizations, emergency department (ED) and urgent care visits, and hospital readmissions within 30 days for participating patients experiencing avoidable cardiovascular disease events. Our goal is to decrease such utilization by an average of 10% per year

Population Health Management Model – Diabetes, Hypertension and Stroke

<30 >30 days days Practice Transformation

Public Health Central Referral System (CRS)

National Non Medication Behavioral Social Cardiac Diabetes Physician Health Information Exchange Therapy Determinants Rehabilitation Prevention Team Health Management of Health Programs Management Provider Providers Q & A MRHA Conference Sunday, October 20, 2019 Part III – Innovations in Chronic Disease Management

Karen Shiner, MSHA, CPC, CRC Director of Physician Services, Health Quality Innovators

Barbara Banks-Wiggins, MSA Executive Director, The Prince George’s Healthcare Alliance

Brandon Neiswender, MBA Vice President and Chief Operating Officer, Chesapeake Regional Information System for our Patients (CRISP)

Sade’ Osotimehin, Pharm D, BCACP Director of Operations, Center for Innovative Pharmacy Solutions, University of Maryland School of Pharmacy Karen Shiner, MSHA, CPC, CRC Director of Physician Services Health Quality Innovators About HQI

HQI is a non-profit healthcare quality consulting company which has been leading the way in healthcare since 1984.

Virginia & Maryland’s Quality Innovation Network-Quality Improvement Organization (QIN-QIO) for CMS

Virginia’s Regional Extension Center (REC) for ONC

Participant in AHRQ EvidenceNow Heart Health Collaborative

Southeast Practice Transformation Network (PTN) for CMS

4 About HQI

Southeast Practice Transformation Network (PTN) for CMS

• Assisting over 1,450 clinicians prepare for value-based payment, including assistance with: • Merit-based Incentive Program (MIPS) • Workflow optimization • EHR optimization • Implementation of evidence-based interventions • Quality reporting • Quality Improvement methodology • Chronic care management implementation • Care coordination/referral management workflow • Opioid crisis, including patient education

Familiar with more than 30 different EHR software systems

5 Practice Transformation Process

Thrive as a Use Evidence-Based Achieve Achieve Guidelines, Practice Business via Set Aims Progress on Benchmark Redesign and Data to Pay for Value Drive Improvement Aims Status Models

6 Improved Patient Care through Transformation

Traditional Approach Transformed Practice Patient’s chief complaints or reasons for visit Systematically assess all our patients’ health determines care. needs to plan care. Care is determined by today’s problem and Care is determined by a proactive plan to time available today. meet patient needs. Care is standardized according to evidence- Care varies by time and memory/skill of the based guidelines. clinician. A prepared team of professionals coordinates Patients are responsible for coordinating their patient’s care. own care. Clinicians know they deliver high quality care Clinicians know they deliver high quality care because they measure it and make rapid because they are well trained. changes to improve. It is up to the patient to tell us what happened Track tests, consults, and follow-up after ED to them. visits and hospital stays.

7 Contact Information

Karen Shiner, MSHA, CPC, CRC Director, Physician Services

804.289.5350 [email protected]

8 Barbara Banks-Wiggins, MSA Executive Director The Prince George’s Healthcare Alliance Maryland Rural Health Association Conference

Community Health Workers: The Role of Community Health Workers in Chronic Disease Management Barbara Banks-Wiggins, MSA Executive Director

Healthy People, Healthy Communities The Prince George’s Healthcare Alliance is an award winning, 501(c)(3) non-profit organization created to continue the successes of the Prince George’s County Health Department’s Health Enterprise Zone Project to establish a new community care coordination system for high risk, high need patients.

By assigning Community Health Workers to vulnerable patients to address their clinical, behavioral and social determinants of health, we realized reductions in hospital/ED visits and costs for this population.

11 Our Mission

Our mission is to decrease over utilization of health system resources and to the maximize quality of care for high need, high utilizers. Our vision is to help patients change their health behaviors, to achieve their best health, and to optimize community health.

12 Evidence-Based Care Transitions and Care Coordination – Who We Serve . High risk patients in poor control of their chronic illness . High risk patients needing connections to family and social services . High risk patients with unmet behavioral health needs . High risk patients in need of medication management . Patients with no Primary Care Physician . Patients who have not seen a PCP in > 12 months . Patients with no health insurance . Patient with care gaps . High risk patients with a hospital readmission within 30-days for the same condition . Very high need patients who have 3 or more Operations Team inpatient visits in one year . Social Workers, Community Health Workers, Insurance Navigators, . Patients with multiple ED visits System Analysts . Patients with multiple 9-1-1 calls for non-emergent reasons 1 3 Best Practices Community Health Workers focus on helping patients address the social challenges adversely impacting their health, and provide solutions. . Gain Trust – Conduct home visit assessments and wellness checks – Assist with obtaining Insurance, selecting primary care provider, scheduling appointments, and provide health literacy education – Arrange transportation to appointments – Serve as patient advocate, accompanying to appointments – Reinforce health education through cultural competence: language and culture, learning and comprehension abilities . Create connections between vulnerable, at-risk, hard to reach population and community providers and healthcare systems – Build relationships with social service agencies – Gain support from community providers and non-profits – Establish referral protocols and processes to expedite resource connections . Engage patient and family – Establish support roles and accountabilities – Teach family how to support and reinforce healthy behaviors – Facilitate use of mobile technology and telehealth visits . Achieve Outcomes – Evidence-based pathways – Intervention tracking – Routine monitoring, motivation and encouragement – Re-education and assessment of new barriers and challenges 14 Case Example Real Case CHW Intervention . 49 y.o. AA female . 27 contacts, 3 home visits . Referred to CHW from Health Department . Pathways Completed: . Issues – Insurance coverage – Asthma – Connect to primary care provider – Arthritis – Medical referral to behavioral health – Heart Disease – Transportation – Cerebrovascular accident (history of two heart – Medication Assessment attacks – Food security - SNAP – Uncontrollable diabetes – Nutrition: Household appliances – Referral for Adult Evaluation Review Service – Hypertension – Income: Linked to Shabach Empowerment Center and – No insurance Employment Service Agencies – No medication – Food insecurities – Witness Protection Program

Outcomes: Adherent to PCP visits, specialty visits, medications, employment Client is engaged and progressing independently with managing her healthcare. Healthcare Alliance Interventions reduce Hospital Utilization and Costs

Utilization and Cost Reductions Reduction in Hospital Reduction in Hospital Achieved Visits Cost Inpatient Admissions 26.45% 34.73% ED Visits 27.17% 42.25% Observation Stays 24.13% 41.42%

Total Change in Before CHW After CHW Reduction and Cost Patient Visits and Referral Intervention Savings Costs

Hospital Visits 718.17 532.80 (185.37)

Hospital Costs $3,293,148 $1,289,265 ($2,003,883)

Per Patient Visits 6.47 4.8 (1.67) Per Patient Costs $29,668 $11,615 ($18,053)

Data Source: CMS Medicare Part A Claims Medicare and Dual Eligible Beneficiaries 111 Patient Referrals July 2018 – December 2018 Prepared by Health Quality Innovators (QIO) Care Coordination System

. HealthEC® . Best In KLAS . Population health care coordination system that supports our efforts: – Built in assessments with smart technology that creates documentation of patient’s problems, goals, barriers and interventions – Guides Intervention scheduling – Comprehensive care plan, snap shot view of client’s case – Tracks patient contacts and productivity

17 Referral Protocols The Prince George’s Healthcare Alliance, Inc. is a flexible care coordination entity.

. All risk categories . No exclusions • Insured and uninsured • Commercial, Medicaid, Medicare, Dual . No restrictions . No time limits • Hospital transitions – typically 30 days • Transitional care services/clinics – typically 60 days • Healthcare Alliance – no time limits: clients average 4-6 months to modify and improve their health behaviors Program Process Measures

. Evidence-based pathway interventions (AHRQ) . Resource connections . Contacts and outreach . Home visits and assessments . Care conferences . In FY2019 Healthcare Alliance Community Health Workers utilized 25 pathways to: – 2,961 enrolled in health insurance – 1,965 interventions completed – 550 problems addressed for 1,326 barriers – 3,142 phone calls – 455 home visits – 314 text messages – 196 emails – Participated in 373 provider contacts and care conferences. 19 Contact Information

Barbara Banks-Wiggins, MSA Executive Director 9475 Lottsford Road, Suite 270 Largo, Maryland 20774 Office: 301-276-2622 Cell: 240-460-1622 email: [email protected] website: http://pghealthcarealliance.org Brandon Neiswender, MBA Vice President and Chief Operating Officer Chesapeake Regional Information System for our Patients (CRISP) CRISP Overview

Sunday, October 20, 2019

7160 Columbia Gateway Drive, Suite. 230 Columbia, MD 21046 877.952.7477 | [email protected] www.crisphealth.org About CRISP

Regional Health Information Exchange (HIE) Guiding Principles serving Maryland, West Virginia, and the District of Columbia. 1. Begin with a manageable scope and remain incremental. Vision: To advance health and wellness by 2. Create opportunities to cooperate even while deploying health information technology participating healthcare organizations still solutions adopted through cooperation and compete in other ways. collaboration 3. Affirm that competition and market-mechanisms spur innovation and improvement. 4. Promote and enable consumers’ control over their own health information. 5. Use best practices and standards. 6. Serve our region’s entire healthcare community.

23 CRISP Core Services

1. POINT OF CARE: PDMP, Clinical Information (Health Records, Patient Snapshot, Embedded Apps) • Search for your patients’ prior hospital records (e.g., labs, radiology reports, etc.) • Monitor the prescribing and dispensing of PDMP drugs • Determine other members of your patient’s care team • Be alerted to important conditions or treatment information 2. CARE COORDINATION: Encounter Notification Service (ENS) • Be notified when your patient is hospitalized in any regional hospital • Receive special notification about ED visits that are potential readmissions • Know when your MCO member is in the ED 3. POPULATION HEALTH: CRISP Reporting Services (CRS) • Use Case Mix data and Medicare claims data to: o Identify patients who could benefit from services o Measure performance of initiatives for QI and program reporting o Coordinate with peers on behalf of patients who see multiple providers 4. PUBLIC HEALTH SUPPORT: Partnerships with Maryland MDH, District of Columbia DHCF, and West Virginia through the WVHIN 5. PROGRAM ADMINISTRATION: Technical and administrative support for Care Redesign Programs

24 CRISP Systems (MIRTH Connect, MPI, Consent, ULP and ENS)

PATIENT PANEL Direct Email Yellow: Provider Light Blue: Note Dark Blue: CRISP Green: DPP Sea Blue: PGCHD

Provider confirms Provider Clicks the patient info and adds CRISP sends referral PGCHD CRS staff Provider Logs into Referral tab in the ULP four (5) data points info to PGCHD central assigns patient and CRISP ULP to select referral types with note before referral system (CRS) sends referral to DPP submitting

Referral is pre-populated Referral will capture with the patient weight, A1C, blood DPP contacts patient Login to CRISP ULP for information pressure, BMI, & for enrollment referral and/or review of cholesterol referral outcomes Referral selection is built into the drop down, All fields editable, example DPP submits provider selects from it. note provided, patient enrollment and patient consent included, can go info to Workshop back after “Submit” Wizard

Provider Logs into CRISP sends ENS alerts PGCHD CRS submits PROMPT and filters on to all subscribers for CRISP loads roster in Mirth enrollment roster (.csv) Care Program to see enrollment notification Connect and ENS to CRISP weekly DPP specific and appointment(s) updates/notifications missed 3 Widgets on Provider Logs into PGCHD CRS will use SnapShot Update: CRISP posts Report will provide CRISP ULP/Snapshot to Workshop Wizard for • Encounters from appointments made enrollment date, see appointments enrollment roster and ADT update in SnapShot subsequent visits dates, and • Care Alert made to program reporting using the widget any missed dates • Care Team (3 widgets) CRISP template Thank You!

Brandon Neiswender Chief Operating Officer and Vice President, CRISP [email protected]

27 Sade’ Osotimehin, Pharm D, BCACP Director of Operations Center for Innovative Pharmacy Solutions University of Maryland School of Pharmacy P3 Program Overview

• The Patient-Pharmacist Partnership – P3 Program is the clinical arm of the Center for Innovative Pharmacy Solutions at the University of Maryland School of Pharmacy. • P3 has delivered effective Medication Therapy Management (MTM) services in mitigating the rising healthcare cost and less than optimal patient outcomes across the United States since 2006. • The program leverages the expertise of specially trained and Board Certified clinical pharmacists.

Impact of Inappropriate Medication Use/Medication Related Problems (MRPs)

• Contributes to more than 1.5 million preventable, medication-related adverse events each year

• Accounts for an excess of $177 million in morbidity and mortality. (1,2)

References 1. Ernst FR, Grizzle AJ. Drug-related morbidity and mortality: Updating the cost-of-illness model. J Am Pharm Assoc. 2001; 41:192–9. 2. Institute of Medicine. Report Brief: Preventing Medication Errors. Washington, D.C.: Institute of Medicine; July 2006 P3 Program Medication Therapy Management (MTM) Services

• Medication Reconciliation – Uses information from medication review to generate best possible Patient Medication List (PML)

• Assessment – Explores all information available, clinical and non-clinical to identify any potential and actual problems with medications and/or health conditions such as social determinants of health (SDoH) barriers to medication use, incorrect, or ineffective medication, or administration technique, etc.

• Plan of Care – Developed around issues identified in a collaborative manner with the patient and other members of the patient’s health care team

• Implement Plan of Care – Carried out in a patient centered approach and in collaboration with other care team members

• Monitoring and Evaluation of Plan – Follow up to assess plan efficacy and adjust plan in collaboration with patient and other care team members. P3 CLINICAL INITIATIVES & PROGRAMS

The P3 (Patients, Pharmacists, Partnerships) Clinical Initiatives & Program at the University of Maryland School of Pharmacy is the clinical initiative arm of the Center for Innovative Pharmacy Solutions. The P3 program utilizes specially trained and certified clinical pharmacists, who offer a model of care that involves effective medication therapy management solutions to your unique population (Federal, State or Commercial). Our program is tailored to identify any potential medication related problem, health care risk and mitigate those risks. Many patients have benefited from the P3 program since 2006. See chart below regarding the current and past clinical initiatives of the P3 Program.

Current and Past P3 Clinical Initiatives & Programs Transitions of Collaborative Medication Medication Mobile Care (TOC) Drug Therapy Therapy Reconciliation Technology/T Management Management elehealth (CDTM) (MTM)

McCormick & Co, Inc. √ √ √ √

University of Maryland Quality Care Network (UM QCN) √ √ √ √ √

West Baltimore Mobile Integrated Health Community Paramedic (MIH-CP) √ √ √ √

Totally Linked Care in Maryland (TLC-MD) Transitions of Care (TOC) Program √ √ √ √

University of Maryland Transform Health Maryland Care Transition Organization √ √ √ √ (UM THMD CTO)

Prevention Link of Southern Maryland: CDC funded Cardiovascular Disease √ √ √ √ Prevention and Management program

University of Maryland Regional Capitol Health at PG Health Center (UMRCH- √ √ √ √ √ PGHC) Care Transition Organization (CTO) Inter-professional Care Transitions Clinic (ICTC) at the University of Maryland √ √ √ √ Regional Capitol Health at PG Health Center (UMRCH-PGHC) FOR MORE INFORMATION:

The P3 (Patients, Pharmacists, Partnerships) Program Center for Innovative Pharmacy Solutions University of Maryland School of Pharmacy 110 N. Pine St., Room 109, Baltimore, MD 21201 [email protected] www.pharmacy.umaryland.edu/p3 PreventionLink Program Case Study Case: 45 YO AAM who has uncontrolled diabetes and hypertension is admitted to the Emergency Department after his 5th severe episode hyperglycemia in 5 months.

Pt departs the PreventionLink PCP makes a The CHW After the hospital and partnered** PCP referral that is connects pt to patient’s barriers primary care decides to delve sent to a patient- several resources to care have provider (PCP) deeper into the care hub, where including MTM been addressed, receives an ENS cause and the patient is telehealth the CHW refers CRISP notification treatment of the assigned to a services, which the patient to a patient d/t Community are offered DSMES program frequent hospital Health Worker through the bi- to promote visits (CHW) directional e- consistent blood referral system glucose control.

Finally, CRISP offers a pre/post cost analysis to discuss the cost of care for this patient before and after PreventionLink.

**Note: Providers enrolled in PreventionLink collaborate with Health Quality Innovators (HQI) to offer CHW services and subsequently, MTM, DPP, and DSMES services. THANK YOU!

Questions and/or Comments?