Vincent Siasoco, MD is medical director of Metro Community Health Centers (NY). MCHS employs between 90 and 100 staff to care for 220 patients daily across its five FQHCs. MCHS is working with its physicians, some of whom also work for other healthcare providers, to help them meet the various stages of Meaningful Use. “Gathering data can be challenging,” Siasoco explains, “however, we continue to work with our providers to meet MU measures. We’re also considering submitting for MIPS as an ACO.”
In addition to its focus on MU and MIPS, MCHC implemented population health management technology from HealthEC to stratify risk, identify high utilizers of care, and give its physicians access to benchmarking tools and analytics. The organization is also working on adding specialized templates for behavioral health to its EClinicalWorks software, as well as dental-specific software developed for ECW. “We’re implementing a new VOIP phone system to better track and log calls and voicemails to the health centers,” Siasoco adds. “We’re also collaborating closely with the residential leadership of the Cerebral Palsy State Association to develop workflows to transmit clinical information digitally from their group homes to our health centers.”
Why did Metro Community Health Centers decide the time was right to implement population health management technology? What benefits do you hope to gain from deployment?
As an FQHC, we routinely monitor over 12 different clinical quality metrics through our EClinicalWorks EHR with the support of the Comprehensive Primary Care Initiative data reporting system. CPCI draws clinical, operational, and financial data nightly from our five health centers’ EHRs. Some of the quality metrics include HgBA1C, colon cancer and cervical cancer screenings, obesity, and tobacco use and education. We monitor these metrics on behalf of all primary care providers on a monthly basis and review at our QA meetings. Moreover, we break down the metrics even further by presenting each PCP with an individual, custom report disclosing quality metric scores for their seen patients. Internally, the metrics have been exceptionally beneficial, gauging not only each health center’s performance including practice variations and patterns, but also providing insights to help our physicians identify high-risk and rising-risk patients.
Besides serving as senior medical director of MCHC, I’m also the medical director of our ACO, Alliance for Integrated Care of New York. Through the ACO, we use the HealthEC population health management platform to access a tremendous amount of patient data via Medicare claims. A large number of our ACO patients have intellectual and developmental disabilities and live in group home settings. One of the challenges of providing services for IDD patients is that the group homes have their own nursing triage system in place. Therefore, although we have an after-hours on-call service, the decision to send patients to the ER is made by the group home’s nursing staff. While this triage system works well for the group home, our health center providers are not always aware of the date and time when patients are transported to the ED, nor the reason why. We usually learn about ED visits when these patients are seen at follow-up visits. Access to HealthEC data has changed this scenario in that we now track outside care administered to our patients. In fact, we can use the data to pinpoint which patients use the ED the most, which EDs treat the majority of our patients, and which patients have incurred the highest overall health spending. This valuable information has led to the enhancement of individualized care management plans and the ability to appropriately identify and address barriers to care.
The data also helps us achieve the Triple Aim’s three goals of improving the health of populations, enhancing the patient experience of care, and reducing costs. With a network of five health centers throughout NYC providing services to a highly complex patient population, MCHC’s implementation of population health technology is key to providing the best care possible for our patients. Knowing exactly when and where our patients are receiving care outside our network empowers our physicians and medical staff to appropriately coordinate with those providers and gain critical information. Essentially, we can collect all the pieces needed to view a holistic picture of a patient’s health to make more informed health decisions.
Aside from population health management technology, what other types of health IT is MCHC looking at?
I view telehealth as another promising solution to better coordinate care and expand the reach of healthcare delivery. Medical information can be exchanged as clinicians remotely diagnosis, consult, monitor and treat patients via electronic communications. Studies show that telehealth applications can enhance information access, improve the quality of care, increase patient and provider satisfaction, and reduce costs. However, equipment startup costs, as well as the billing and reimbursement rules applicable to telehealth delivered services, present several ongoing challenges for FQHCs. We’re looking at the possibilities of employing telemedicine at our FQHCs and how it could enhance our after-hours on-call service. We’re also exploring the chronic care management module and how best to support using it.
Given your ACO efforts and diverse patient populations, what coordinated care initiatives are underway?
We’re a Level 3 NCQA recognized Patient Centered Medical Home. As a result, systems are in place to ensure we provide continuous, comprehensive, and well-coordinated care. For example, our processes track referrals for labs, diagnostic tests, and outside specialists; monitor high-risk groups; and track transitions of care. We’ve implemented pre-visit planning huddles to ensure the clinical team can best prepare for patient visits.
How is MCHC working with staff to help everyone adjust to the adoption of the new technologies you’ve mentioned?
Metro’s move from paper to digital documentation has eliminated many inefficiencies and restructured our service delivery model to maximize the collective strength of our care team members. We’re now engaging RNs, LPNs, and MAs to help with care provision and management, pre-visit planning, care transitions, health education and patient self-management support, and accessing community-based supports and services. The challenge (or rather excitement) is to determine how we can make the most of advanced technologies. We’re aiming to institute a good plan for workflow transitions. For example, we organized a number of team meetings and on-site training sessions for our staff to begin using eClinicalWorks for our pre-visit planning huddles. Our goal is ensuring our staff has the necessary support managing successful transitions.
What advice can you share with other physicians who are looking to adopt PHM technology and programs?
Talk with other physicians who are involved with similar projects. Compare programs and health centers, and discuss and share best practices so you can identify what works best and is specific to your healthcare organization’s needs.
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