MiPCT ADT PO User Group
Patient Ping Overview
AGENDA
1. MiPCT ADT Current State Recap
2. Interactive Patient Ping Demonstration
a) Firm History and Existing Clients
b) Patient Ping Product Demonstration
c) MiPCT ADT Vendor Functionality Review
3. Discussion and Feedback
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4
ADTs: From Alert to Care Delivery
Care Mgr
Receives
Electronic
Alert
• Alert appears in
web-based
member listing
• Care Manager
acknowledges
• Repeat
reminders to
prompt activity
Care
Manager
accesses
available
patient
info.
• Care Manager
accesses health
system EMR,
discharge
summary, or
available clinical
information
• Care Manager
communicates
with facility
discharge
planning
contacts or via
call to patient
Initiate
Near Real
Time
Transition
of Care
Activity
• Medication
reconciliation
and TOC
activites
• Identification of
patient needs
and initiation of
follow-up care
• Bill (G/CPT) if
applicable
MiPCT/MiHIN ADT Notification
POs
Patient to Provider Attribution
(ACRES)
Care Manager Mapping
MiPCT ADT
Vendor
Health Systems
Patient
Health
Provider
Directory
Primary Care
Care
Coordinator
1) Patient goes to hospital which sends ADT message via substate to MiHIN
2) MiHIN checks MiPCT patient-provider attribution file (ACRES) and matches with ADTs received
3) MiHIN sends matched ADT to MiPCT ADT Vendor
4) MiPCT ADT Vendor matches MiPCT ADTs with PO-provided Care Manager mapping
5) MiPCT ADT Vendor sends ADT to mapped Care Manager
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Two Functionalities Provided Now to
MiPCT/MiHIN ADT Partners
1. Web-based MiPCT Member List with:
•
•
•
•
Patient name
Date of Birth
Diagnoses
Payer
•
•
•
•
•
HDHP flag
Risk scores
ED, inpatient utilization history
Care manager
Etc.
2. Admission, Discharge, Transfer (ADT) Alerting for
MiPCT Patients
Alerting for MiPCT patients at HFHS, U of M, Trinity, Beaumont, and
McLaren (Sparrow and St John’s in process of integration)
• Inpatient Admission
• Inpatient Discharge
• ED visit
• Observation patient
Functionality Enhancements: Clinical
Summaries to Follow ADT
Transmission
• Via partnership with MiHIN, MiPCT/MiHIN
ADT PO partners will be the first roll-out (in
Fall 2015) of the medication reconciliation
module upon pilot completion
ADT Progress –Sample Alert Contents
Message Types
Patient ID / Medical Record (MR)
Patient Name
Date of Birth
Administrative Sex
Address
Phone number – home
Patient Account Number
Patient Death Indicator
Primary Care Physician (ID, Name)
Patient Class
Assigned Patient Location (Room / Bed)
Prior Patient Location
Attending Physician (ID, Name)
Referring Physician (ID, Name)
Consulting Physician (ID, Name)
Admit Source
Admitting Physician (ID, Name)
Patient Type
Discharge Disposition
Admit Date
Discharge Date
Plan ID / Name
Group Number
Policy Number
Beaumont HS
Henry Ford HS
All
X
X
X
X
If Available
If Available
X
If Applicable
X
IP, ER
X
N/A
IP Only
X
X
X
IP Only
X
IP Only
X
X
X
X
X
All
X
X
X
X
If Available
If Available
X
If Applicable
X
OBS, IP, ER
X
N/A
IP Only
X
X
X
IP Only
X
IP Only
X
X
X
X
X
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The Vendor Field is Changing
• New vendors are entering the field
• The MiPCT is in process of due diligence with
the MiPCT/MiHIN ADT PO Users’ Group to:
▫ Explore alternatives, their feasiblity and
desirability
▫ Goal is to identify the best tool for facilitating
timely information for prompt transition care for
MiPCT patients
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Background and Clients
• Founded in 2013
• Founder from CMS Innovation Center where he helped
designed ACO, CPCI, Bundles, and other new payment
models. Team includes physicians, policy, and IT
product development experts
• Company backed by Google and Fidelity
• Current Clients
▫ Michigan: MedNetOne, OPNS, Reliant ACO, Great
Lakes OSC, Michigan Pioneer ACO, DMC PCPs, POMACO (SNF only), Total Health Care, many soon to join
▫ Massachusetts: Nearly all of the state’s POs/ACOs
▫ Pennsylvania: Largest POs in state
▫ Connecticut: Largest PO in state
THE PATIENTPING VISION:
COORDINATE CARE EVERYWHERE
Our vision is to create a national care coordination community
Emergency
Room
Physicians
Organization
Specialty
Clinic
Specialty
Surgery
Center
Hospital
SNF
LTACH
Home Health
By connecting providers through real-time admission and discharge
notifications, we aim to help providers transform the way care is delivered
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HOW CUSTOMERS USE
PATIENTPING
Providers receive real-time notifications (“Pings”) when
patients are admitted or discharged anywhere
PINGS
POINT-OFCARE
GUIDELINES
Who gets Pings? Care coordinators, hospital social workers, health plan case
managers, physicians, practice managers, or any other provider
On which Patients? MiPCT, PGIP, ACO, bundles, commercial risk lives, all
patients discharged from a hospital or other facility, or any other patient roster
When and Where? When patients are admitted to/discharged from any ER,
hospital, SNF, LTACH, or home health agency
Admitting facilities receive guidelines from the care
team upon admission and discharge
Who sees Guidelines? Admissions coordinators at hospitals, SNFs, home
health agencies, and other admitting providers
What’s in a Guideline? Patient’s full care team with contact information,
instructions on how to work with care team, and history of hospital and other
facility visits
Pings + Guidelines is a lightweight care coordination solution that empowers
providers to improve quality and meaningfully impact total cost of care
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PINGS
A patient’s entire care team is notified in real-time when the patient
is admitted, discharged, transferred, or deceased at any facility
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REAL-TIME PINGS
Lightweight, clean panel to track patient visits anywhere. Raw data available if
recipient prefers to render notifications in existing technology platform.
MedNetOne
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VIEW INDIVIDUAL PATIENT DETAILS
Expanded view makes it easy to see patient demographics and care history
MedNetOne
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VIEW PINGS BY FACILITY
User: Care Coordinator
[email protected]
Pings
Patient Roster
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EASILY EXPORT PINGS
User: Care Coordinator
[email protected]
Pings
Patient Roster
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SORT COLUMNS
User: Care Coordinator
[email protected]
Pings
Patient Roster
///
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FACILITATE TEAM COLLABORATION
User: Care Coordinator
[email protected]
Pings
Patient Roster
Jane Smith
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PINGS: FLEXIBLE ROUTING
PO
Practice
PCP/Nurse
PatientPing Web
Application
Mobile Notification
Existing System
Integration
Equip practices and physicians to better manage care by sending them
real-time Pings on their patients through a variety of mechanisms
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GUIDELINES
Admission sites receive care guidelines and patient visit history
upon admission and discharge
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PATIENT IDENTIFICATION
User: Admissions Coordinator
PatientPing collects
data on admissions
and discharges
HL7 ADT feeds or
web application
User: Admissions Coordinator
Loveland ACO
Admit Site identifies
patient’s Care
Coordinator
PO:
Your PO
@lovelandaco.com
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GUIDELINES AT ADMISSION SITE
User: SNF Admissions Coordinator
Patient: Giacomo G.
PO: MedNetOne
Care Team:
PO care coordinator: Mr.
Alberts
PCP: Dr. Jane
Instructions from PO:
High risk, call PO nurse at
734-555-4567
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SAMPLE CARE GUIDELINES
Purpose
Loveland
ACO
Patient:
James
Lovejoy
PO: Your PO
Care Team Resources:
Nurse
Care Manager:
@lovelandaco.c
Karen
omPhillips, 617-234-1923
PCP:
Mary Pizatto, MD
Discharge Instructions
Request
additional
data
Please contact [PO Care
Coordinator Name] at [Phone
Number] to discuss details of the
patient’s prior hospitalization.
Please contact [PO Care
Coordinator Name], the [PO
Name] Care Coordinator, at
[Phone Number] to discuss the
patient’s discharge instructions.
Request
action be
taken
Call [PO Care Coordinator] to
discuss any transition of care out
of your facility in advance of
transition.
Please have the patient’s nurse
contact [PO Care Coordinator] to
discuss a warm handoff.
Preferred HHA: Loveland HHA
Upon discharge, fax the PCP’s
office, [Fax Number], the following:
Guide
future care
transitions
High Risk Patient Support:
Steven Wendor, 781-909-9321
Instructions:
Call Kate within 24 hours of admission
Admit Instructions
Provide
conditional
contacts
Coordinate
specific
patients
Preferred Hospice: Good Hope
Preferred Neurologist: Eve
Levine, MD
Call [PO Care Coordinator] with
medication questions or
concerns.
If you have other questions,
please contact [RN Care
Coordinator] at [Phone number].
Please contact [High Risk RN] at
[Phone Number] within 2 hours if
CHF or COPD patients show
signs of deteriorating health.
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Discharge Summary, Discharge
Instruction Sheet and Discharge
Medication List
Call the PCP office contact [office
contact] at [Phone Number], to
schedule a transition of care
appointment within 24 hours of
discharge.
Please notify [High Risk Nurse]
within 24 hours of discharge for all
patients flagged as high risk.
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IMPLEMENTATION IS RAPID
AND SIMPLE
PINGS
POINT-OFCARE
GUIDELINES
PO sends PatientPing:
1. Care manager-to-patient mapping (ACRS)
2. List of facilities from which it would like Pings
3. How PO would like to receive Pings
PatientPing will:
• Confirm any ACRS updates
• Onboard post-acute facilities not in Community (via existing
relationships with PAC chains and other onboarding
techniques)
PO sends PatientPing:
• Care guidelines to render at Admission Sites by adding
additional columns on to the ACRS file
POs will be live after transmitting one Excel spreadsheet within 2 weeks
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TODAY VS. TOMORROW
AVAILABLE NOW
•
•
•
•
ADT Pings when patients go to hospitals that are sending data to MiHIN
ADT Pings to SNFs and HHAs in PatientPing Community
Clean user interface that creates longitudinal encounter history, exporting, and
reporting capabilities
24x7 live support with monthly participation in user group to discuss
enhancements
ON THE NEAR-TERM ROADMAP
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•
•
•
•
More visibility into where patients receive care by onboarding more provider
types: urgent care clinics, pharmacies, retail clinics, specialty clinics, and more
More context to Pings with diagnosis, medication lists, and CCDs
Smart Pings to prioritize high risk patients
Clear identification of TCM eligible patients with solution to simplify TCM billing
More robust analytics on utilization, readmissions rates, length of stay, and
quality of care
PatientPing releases product enhancements on a 2-4 week cycle
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STRICT HIPAA COMPLIANCE AND
DATA SECURITY
 The PatientPing platform is fully HIPAA compliant
•
•
All technical, physical, and administrative safeguards are in place
The PatientPing system is backed by data, security, and privacy insurance
 Absolutely no one who is not explicitly authorized to view patient
data will have access to it
•
Our database is designed to make improper data sharing virtually
impossible
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