Networking Meeting Goals Identify and develop best practices for - - PowerPoint PPT Presentation

Networking Meeting Goals

Identify and develop best practices for utilizing Electronic Health Records (EHRs) and associated technology to engage:

• Older adults in their own healthcare
• Community-Based Organizations

(CBOs) across silos of care

Introductions

• Name
• Institution & GWEP
• Role
• Brief comment on your current use
• f the EHR
• Fun fact about you

Engaging CBOs in EHR/Coordination: Current Protocols and Lessons Learned

Duke University Dartmouth Centers for Health and Aging Rush University Medical Center Rush partner Shawnee Alliance

Duke GWEP www.geriatriceducation.duke.edu

Geriatric Workforce Enhancement

Communities Caring for Seniors

GWEP

Seniors Community Agencies

Primary Care

Health System

Trainees

Duke GWEP www.geriatriceducation.duke.edu

The GWEP: Who are we?

Partners:

• GWEP faculty—Nursing,

Medicine, PA, RD, Epi, Educ, SW

• Triangle J AAA
• Community Resource

Connection (CRC)

• Senior PharmAssist
• Durham Partnership for Seniors
• Duke Connected Care
• Senior Advisory Panel (SAP)

identify current resources identify needs and gaps

Connect practices, geriatrics, and community agencies

Duke GWEP www.geriatriceducation.duke.edu

The GWEP: What do we Do?

Activities:

• Form partnerships
• Host CE programs to develop

geriatric expertise in primary care (GRTs)

• Provide virtual geriatric

consultations (ICTs)

• Train A-GNP and MD fellows in

geriatrics

• Evaluate impact on trainees and
• utcomes at population level

identify current resources identify needs and gaps

Connect practices, geriatrics, and community agencies

Duke GWEP www.geriatriceducation.duke.edu

Improved care

• f older adults

GWEP Faculty and community partners

GRT Educational Program

Communication: IPCP training workshop Competencies: Best practices: dementia care, medications, transitions Continuous Improvement: Focused projects Connections: Referrals to ICT, community agencies

Duke GWEP www.geriatriceducation.duke.edu

Interagency Care Team

• Team: Geri Kanne, NP; Marilyn Disco, PharmD, CGP; Melissa

Black, MPH; Katie Huffman, MA; Rhonda Mack-Minnifield, MA; Mitch Heflin, MD

• Referrals: Over 60, problems with cognition, medication

management, high risk transitions

• Process:

– Call to patient and family member – Chart review by team members – Team discussion identifying resources

• Products: Notes generated for GRT and for patient

Duke GWEP www.geriatriceducation.duke.edu

ICT Referral: Results

Issue Addressed # of Cases

• ut of 22

Referral Agencies Cognition/Depression Social Isolation 17 Behavioral Health; Senior Centers; Duke Family Support; Silver Linings Med Management 14 Pharmacy consult; Senior PharmAssist; Information to pt; RN home visit to check meds Food Insecurity 11 Meals on Wheels; Food Bank; More in My Basket; SNAP

• Adv. Directives

10 Legal aide; recs to PCP Disease Management 9 Recs to PCP; Lifestyle Medicine Clinic; Just For Us Personal Safety 9 PT/OT; in home aide; Vestibular Clinic; HELP (health equipment loan program) Incontinence products 6 Diaper Bank; Caswell Co Senior Ctr; Wilmington Medical Supply; ActiveStyle Vision 3 Services for the Blind; Low Vision Rehab; OneSight Respite Care 3 Durham Center for Senior Life respite care; Respite Care Vouchers thru NC Respite Care Coalition; C.A.R.E program through DFS Poor Dentition 2 UNC Dentistry Palliative Care 1 Duke HomeCare Bridge Program Life Alert 1 SeniorPharmAssist to order

Duke GWEP www.geriatriceducation.duke.edu

ICT Challenges/Solutions

• Referral process e-consult
• EMR access for community partners and non-Duke

practices

• PCP “permission” to contact patient (input of SAP)
• Confidentiality in handling info “outside the system”
• Consultation with Compliance Officer
• “Minimum necessary information”
• Ownership and follow up of recommendations
• Communication back with PCP and seniors

Duke GWEP www.geriatriceducation.duke.edu

E-Consult for Geriatrics

Duke GWEP www.geriatriceducation.duke.edu

EMR Access for Community Partner

1. Establish a Business Associates Agreement between Duke and Senior Pharm Assist (SPA) 2. Work with Duke’s OIT to create agreements for remote access using MedLink to Maestrocare (an Epic system) 3. Develop survey to gauge the impact of the EHR on pharmacists at SPA and participants

• “Pre-EHR” survey: Pharmacist seeing senior without prior

to access to EHR. (Goal=20)

• “Post-EHR” survey: Pharmacist seeing senior with access

to EHR. (Goal=20)

• Survey of seniors gauging attitudes regarding use of EHR
• n care.

Duke GWEP www.geriatriceducation.duke.edu

EMR Survey: Impact on Participant Care

Duke GWEP www.geriatriceducation.duke.edu

Duke GWEP www.geriatriceducation.duke.edu

EMR Survey: Participant Survey

N=37 completed by phone (12 in the “Pre-EHR” group and 15 in the “Post-EHR” group)

• Majority “fine with” (33/37) SPA having access to electronic

records and think that it is “better care” (30/38)

• Others did not object---indifferent or did not understand

question

• Among those in the EHR group, 12/15 felt it was “fine” ---
• thers were indifferent or did not feel it helped.

• Connecting Agencies, Practices and Seniors

through a Trusted Online Network (CAPSTONe)

• Secure, online referral system for older adults

and their caregivers, community-based

• rganizations, and referring providers
• Hypotheses:
• Curated resource templates will increase referrals

to community resources

• Providing a guaranteed referral outcome is

valuable to stakeholders

CAPSTONe Pilot

Duke GWEP www.geriatriceducation.duke.edu

Next Steps

• New cohort of GRTs for fall 2017
• EMR-based identification of “at risk” seniors
• E-Consult now activated
• Review of outcomes
• Completion of referrals
• Costs to community agencies
• Impact on process measures---e.g. high risk

medications

• Clinical outcomes--- ED visits, readmissions
• Continued development of online community

resource referral mechanism

Duke GWEP www.geriatriceducation.duke.edu

Helen Featherson sontab14@gmail.com Mitch Heflin mitchell.heflin@duke.edu Geri Kanne geraldine.kanne@duke.edu Laura Previll laura.previll@duke.edu Gina Upchurch gina@seniorpharmassist.org

Using the Electronic Health Record to Engage Patients & Community Providers

Thomas N. Williamson Kristi Saunders, MD Daniel S. Moran, MSN, APRN Ellen Flaherty, Ph.D, APRN, AGSF

Electronic Health Record (EHR) of Electronic Health Record (EHR) of Dartmouth-Hitchcock

• Dartmouth-Hitchcock’s branding of Epic (eD-

H)

• Patient Portal (myD-H)
• Proxy access via myD-H
• Epic CareLink (D-Hconnect)

21

Patient Portal (myD-H)

• Patients use myD-H to:
• Communicate securely with their health care team
• Review office notes
• Request, reschedule or cancel appointments
• Receive appointment reminders
• Request prescription renewals
• Receive lab or other test results
• Complete any needed health questionnaires
• View account balances and make payments
• Have proxy access
• Search our health library

22

Proxy Access (myD-H)

• Proxy access allows a patient representative,

with the informed consent of the patient or power of attorney, to securely communicate with the patient’s care team and have access to all the tools of the patient portal

• The proxy must use their own login credentials
• They should not use the patient’s login

credentials

23

Epic CareLink (D-Hconnect)

• Read-only access to the patient’s full

electronic medical record for Community Based Organizations (CBOs)

• Users who regularly need access to patient’s

record who are not employed by Dartmouth- Hitchcock Medical Center

24

D-Hconnect Account Information

• Signed agreement between your organization and

Dartmouth-Hitchcock

• Paper form
• Active Directory Federation Services
• Identity Provider (IdP) – authenticates users through

security tokens

• Minimal requirements for computer capability
• Easy and intuitive to navigate
• Variety of training tools
• Medical director designates appropriate individual

users

25

Accessing D-Hconnect

• Uses secure Citrix Portal
• Available on iOS, Android, Chrome, Linux,

Windows Phone

• Emergency Department access with patient

consent

• View only access to all records including

radiology images

• Allows entry of referral orders to request

labs and appointment for specialty care

26

Communication with D-Hconnect

• Cannot send electronic information unless it is

attached to a referral

• Receive secure messaging in D-Hconnect In

Basket

• Availability to receive e-mail notification of new D-

Hconnect In Basket message

• Several types of In Basket messages (i.e., encounter

report from a specialist and staff messages)

• Designate users to access and mange your In

Basket

• Clinical data available in real time

27

Geriatrics Workforce Enhancement Program – Connecting with CBOs

2017

NowPow Community Referrals

• NowPow is a third-party tool with strong Epic

integration

• Rush care givers can create social referrals to a

wide range of community-based organizations based on social determinants of health and patient conditions

• Closed-loop referrals with trusted
• rganizations would allow us to increase

communication to and from the CBO

NowPow Community Referrals

Users can find CBOs based on service category

NowPow Community Referrals

Closed loop referrals can be tracked by both maker and receiver

EpicCare /Healthy Planet Link

• For Community Based Organizations, we will

evaluate whether they will be a candidate for EpicCare / Healthy Planet Link:

– Volume of patients in partnership – Appropriateness of CBO chart access for clinical partners – Need for documentation back into Epic chart via HP Link questionnaires / progress notes

CareLink Opportunity Program Background Target Timeline User Role List First Access? Managed Access functionality? Referrals? Healthy Planet Link Functionality? Primary Rush Operations contact? Primary Organization Contact? Legal Approval? Contacted? Demo'd? Users built? Trained? Users provisioned? Example 1 31-Oct Care Managers Yes Yes Example 2 Yes Yes Example 3 Example 4 VRQC coming in for a few days to shadow physicians and nurses, and then audit charts 27-Oct EpicCare Link View Only No List of MRNs - Kevin Allen to manually add to Patient Group No No Bob Bulk account request submitted Example 5 Example 6 Example 7 GWEP CBOs

Beth Robertson, Director Information Systems/Information Technology Carol Aronson, Director Social Services

Shawnee Health Service: CATCH-ON

Closing the Loop

M.D. Referral Home Visit Care Coordinator Comprehensive Assessment Return Comprehensive Summary to MD Assessment Resource Referrals Care Plan Case Management Close the LOOP

Shawnee Alliance: What do We Bring to the Table?

• Through the Comprehensive Assessment, the Care

Coordinator (CC) is able to give a clear picture back to the provider of the social determinants impacting the clients health. “Holistic care planning and treatment”.

• Providers are informed of barriers and supports.
• Providers can alter traditional treatment plan to

meet the individualized needs and limitations of the patient: physical, environmental, financial, etc..

• **Most importantly, we provide the patient with

resources, services, assistance and the value of a team caring for them, as opposed to the silos of yesterday.**

Shawnee Alliance Steps

• Referral is received from provider, logged, and then

authorized to a community based Care Coordinator (CC).

• CC reviews the case with a supervisor prior to home

visit

• CC completes the assessment in the home with the

clients permission

• All referrals to resources and networking entities are

approved by client

• Summary completed and reviewed with a supervisor
• Comprehensive Assessment Summary returned to

referring provider with client permission.

Shawnee Health Service (Clinics)

• A policy and work instructions have been written

and board approved during July 2017 board meeting.

• Explanation, discussion, and training have been

completed with Medical Providers, Behavioral Health staff, Case Management staff, and Nurses.

• Shawnee Alliance has representation at the

monthly Carterville Clinic location staff meetings.

• Feedback and open discussion for process

improvement

• Expansion to all Shawnee Health Service Clinics for

holistic and continuity of care planning and treatment is upcoming.

Policies and Procedures

Policies and Procedures

Policies and Procedures

Policies and Procedures

Discussion

How can you apply what you learned in your organization? What are gaps/needs you have identified?

Overview of AGS Recommendations and Guidelines

Irene Hamrick, MD University of Wisconsin – Madison Associate Professor of Family Medicine

Discussion

What functionality do we need to communicate with CBOs?

Engaging Older Adults in Technology

Tom Kamber, PhD Founder and Executive Director of OATS

Indiana Geriatrics Education & Training Center Indiana GETC

Epic Initiatives and Lessons Learned

I N D I A N A U N I V E R S I T Y

1

• Processes were automated, changing

visual cues and communication

• Disciplines varied in screen views and

access

• Individual dashboards
• Value of site-based interdisciplinary

process improvement team (GLEE Club) Epic is a tool, not the process

Wellness Initiative

I N D I A N A U N I V E R S I T Y

1

• Changed focus on disease visit to

wellness visit

• Phone scripts and personal connections
• Patient letters
• Epic template
• Multiple templates to view
• Challenge of interdisciplinary documentation

I N D I A N A U N I V E R S I T Y

1

Center for Consumer Engagement

Consultation grant to improve consumer engagement in GWEP work

Overarching Lesson: Changing the view of aging

I N D I A N A U N I V E R S I T Y

1

Older adults are flexible, creative, active learners…and happy https://www.youtube.com/watch?v=ebD_drW YVaI

Discussion

How can we apply what we learned to the EHR?

Breakout Session

What are the key take-aways from today? What are three things you want to focus on tomorrow?

Discussion

What did each group find important?

Wrap-up

• Debrief of Day 1

– Thoughts/feedback/changes for Day 2?

• Discuss plan for Day 2

Lessons Learned from Day 1

Objectives

• Create recommendations for all

GWEPs regarding engaging CBOs and

• lder adults
• Create a site specific implementation

plan for what each attending GWEP wants to take forward in their own institution

Design Session

Kimberly Brennsteiner, MA Director of Program, OATS

• Insert Kim’s slides here

Breakout Session

How can we use the EHR to engage older adults and CBOs?

– Recommendations for all GWEPs – Resources for GWEPs

Discussion

What recommendations did you discuss for all GWEPs? What are resources all GWEPs should have access to?

GWEP Teams Meet: Implementation Plan

• What are we going to do?
• Who is going to do it?
• What resources do we need?
• What are the expected outcomes?
• What are potential barriers and

solutions?

Wrap-up/Next Steps

• Discuss next steps for disseminating

resources/recommendations

• Discuss journal articles/presentations

together

• Determine timeline for completing the

GWEP-CC report