Care Coordination Solution Case Study
Alaska Innovative Medicine, Inc. (AIM) was formed in 2014 by a group of primary care providers, hospitalists, specialists, and medical leaders in Anchorage, Alaska with the goal of improving health care delivery for patients through collaboration. AIM employs a team of medical case managers, social workers, and home nurses who work with some of the sickest patients in the region. AIM has over 100 physicians at nine practices participating in its program, including The Alaska Hospitalist Group (TAHG), Primary Care Associates, and Medical Park Family Care. Already a remarkable achievement, the number of participants is growing steadily and is a key to AIM’s success. Through its partnership with local physicians, AIM is able to help ensure these patients receive the care they need, when they need it.
AIM is partners with Premera Blue Cross Blue Shield of Alaska, one of the largest health insurers in the Pacific Northwest. Premera-insured patients in the Anchorage region are eligible for AIM’s services, and can be contacted by an AIM case manager if they receive treatment for a particular health issue. “Our goal is to help patients navigate the health care system and seek out the appropriate care with the appropriate resources,” explains Kristi Davis, Administrator at Alaska Innovative Medicine. Providing the care required to achieve this goal can be expensive up front, with potentially numerous hours spent making home visits, providing phone consultations, conducting health assessments, and attending doctors’ appointments with patients. However, this initial investment results in significantly improved outcomes by preventing expensive trips to the emergency room and repeated stints in the hospital, thus benefiting patients, insurers, and the greater medical community.
AIM knew they would need to leverage a sophisticated electronic system to help them coordinate and improve patient care in Anchorage. The tool had to be easily accessible both from the office, and more importantly, on-the-go from a mobile device. The group found pMD’s mobile care coordination platform to be the perfect fit. Ted Paprocki, clinical manager at AIM, explains, “pMD has been essential to getting our Care Management program up and running in our community.” AIM is using pMD to track patients, improve communication between care teams in the region, and provide a centralized repository for patient information.
Navigating the complex health system in the United States without assistance can be extremely challenging, especially for patients with serious health conditions. Chronically ill, high-risk patients frequently see multiple specialists in addition to their primary care provider. The lack of communication among these providers, coupled with the absence of a support system for the patients, can cause serious obstacles to recovery.
A patient will be cared for during their hospital stay by one or more hospitalists, who may have had no prior contact with the patient. Each provider often has to independently learn about the patient’s medical history, diagnose current conditions, and prescribe treatments and/or medications for those conditions. When caring for a patient with several serious problems, it can be overwhelming for a provider who may not know which issue they should focus on in the limited time they have with the patient. This might result in duplicated work, or worse, it could end with medications being prescribed or treatments being administered that conflict with one another.
Similarly, it can be extremely challenging for the various members of a patient’s care team to keep the patient’s primary care provider up to date on everything that is happening with the care of the patient. Doing so often requires navigating office phone trees, leaving messages, and sending faxes, all in addition to the medical work that the doctors are doing. “I’ve spent up to an hour waiting on hold while trying to contact a patient’s PCP,” says Emily Splinter-Felton, a social worker at AIM. “A physician doesn’t have the time to do that. Their job is to practice medicine. As a result, information gets lost.”
Many patients who are treated in the hospital don’t have a local primary care provider. In these situations, the hospital will sometimes recommend a few nearby practices for the patient to contact. But this list of doctors, if it is provided to the patient at all, is not tailored to the patient’s specific needs, preferences, or the location of their home. And rarely is any follow-up done to verify that the patient was able to successfully connect with a doctor to continue their care after leaving the hospital.
These communication challenges place a huge burden on the patient to understand and remember all of the health care information that they are receiving from their various providers. The patient and their family must act like information hubs, disseminating what they’ve heard to all parties involved in the patient’s care at any given time. Even for the healthiest of people, this would be extremely challenging. For someone who is very sick and is devoting much of their energy to coping with that illness, this task can be impossible.
In addition to the challenges around facilitating provider communication, chronically ill patients are often faced with ongoing systemic issues that they are not equipped to manage on their own. For example: what happens if an insurance company denies coverage for an important drug that was prescribed by a specialist? Or, who should the patient call if a symptom flares up in the middle of the night? And, what if there is no one available to drive the patient to their appointment with their primary care doctor? “The health system can be extremely challenging to navigate on your own. You usually arrive where you need to eventually, but it’s so difficult, takes so much time, and the cost is so much higher,” says Gigi Rygh, a social worker with AIM. There are countless potential issues that, without help, could easily result in a trip to the ER, an expensive hospital admission, or worse, the complete derailment of a patient’s road to recovery.
The founders of Alaska Innovative Medicine realized they had a unique opportunity to help fill the care coordination void in Anchorage and to improve the quality of care for patients in their region. As they set out on this ambitious mission, AIM knew that they would need equally forward-thinking technology to assist them if they were to be successful. Several of AIM’s founders were already utilizing pMD’s charge capture and secure messaging software, and after learning about pMD’s care coordination product, they recognized that pMD was exactly the tool they were looking for.
A patient’s journey with Alaska Innovative Medicine typically begins at the recommendation of one of the patient’s providers. For example, if a hospitalist at The Alaska Hospitalist Group (TAHG) identifies a patient as someone who would benefit from AIM’s services, the doctor can flag the patient within pMD. This is easily accomplished, as TAHG uses pMD’s charge capture software to manage their rounding and billing, and the hospitalists have the pMD mobile application on their smartphones. The TAHG billing team can also mark patients as AIM candidates using the pMD web portal.
Once the patient has been flagged, that patient’s record gets pushed to a special location on AIM’s patient census within pMD, and an automatic alert is sent to AIM’s care coordinators indicating that a new patient has been referred to them. This integration between the two companies replaces the need for a shared spreadsheet and saves time for both parties.
If the AIM team needs any additional information about the patient as they begin their outreach, they can respond to the referring doctor directly within pMD using pMD’s secure messaging functionality. This is accessible both on pMD’s web portal as well as within pMD’s mobile app. “pMD has allowed our participating providers to refer patients to us directly and has streamlined communication of critical patient information through secure texting,” says Paprocki.
After a patient has been identified as a candidate for AIM’s services, the real work begins. The first step is conducting an initial outreach to the patient to let him or her know about AIM and to find out if the patient is interested in participating in the program. A care coordinator is assigned to the patient in pMD, and an encounter is logged with the details of the call, such as time spent, topics discussed, and next steps. This is done for both tracking and reporting purposes.
In addition to the direct outreach to the patient, AIM will also gather a number of documents from the hospital, including a record of the History and Physical examination, the patient’s detailed chart, and a current medication list. These documents, along with AIM’s internal consent forms, are uploaded directly into pMD using pMD’s secure file storage functionality. They are linked to the patient record in pMD, as well as to the initial encounter that was logged. Prior to using pMD, AIM had a complex system of shared folders on their servers where these documents were housed. The system was slow to use and difficult to access. With pMD, the documents are easily accessible and quick to load. “It’s simple, easy to use, and fast. It’s great to have everything in one place,” says Paprocki of pMD’s file attachment feature.
Once a patient has decided to utilize AIM’s services, an AIM care coordinator will make a trip to the patient’s home in order to conduct a health assessment. These health questionnaires used to be done on paper, but this posed a number of problems. Documents had to be carried to the patient’s home, paper could get lost in transit back to the AIM offices, and reporting on the data was nearly impossible. Furthermore, there were often inconsistencies in the way that data was reported by the various case managers. “The charting wasn’t really where it needed to be. It was inconsistent across our patient population,” says Paprocki.
pMD’s software developers were able to work with AIM to build these assessment documents into custom templates within pMD. The data is now captured in a consistent format, and managed electronically. pMD also provides the ability to look at the patient’s specific diagnoses, and show only the assessment template(s) that are relevant to those conditions, further improving care coordinator efficiency. The data can be both entered and read from the pMD mobile app, as well as on the pMD web portal.
Encounters are logged in pMD each time a patient has an interaction with an AIM care coordinator, or with any other member of the patient’s care team. AIM team members meet with patients one-on-one, and also frequently attend doctors’ appointments with patients. Everything that happens in these meetings and appointments is recorded in pMD. This central source of information allows the care coordinator to help each provider stay in-sync with the others.
These notes are also passed along automatically to the patient’s primary care provider electronically within pMD. The PCP can see what’s happening with their patient in real-time, and can send a secure message to an AIM team member, or to the patient’s providers, using pMD’s secure messaging tool, if they want to discuss further. Dr. Noah Laufer, a primary care provider who participates in AIM’s program, says that he has been able to provide better care for his patients as a result of using pMD. “pMD works quite well. I’m able to receive automatic alerts for all Medical Park Family Care patients,” Laufer explains.
AIM has built a series of custom codes within pMD that allow them to track the various types of interactions they have with patients and their care teams; e.g. in-person, email, phone call from the patient, phone call to the patient, who else was present at the meeting, and how much time was spent. pMD also records the patient’s overall level of engagement with AIM. This data can be reported on in a variety of ways within pMD, which helps AIM with workload management and planning, and also allows them to submit records of their work to Premera Alaska for reimbursement.
As the number of patients that AIM works with continues to grow, the electronic tracking has become increasingly important. “We’ve done over 1,000 individual patient outreaches since January 1, 2015,” Davis notes. AIM expects their rate of growth to increase in 2016, making pMD’s reporting capabilities an even more essential component of AIM’s workflow.
Finally, changes in a patient’s health status can happen quickly, and it’s important for AIM to stay up to speed on everything that’s going on with a patient’s care. pMD was able to build a real-time alert to help with this. As much as AIM works to prevent hospital readmissions, they can happen when a patient’s illness becomes more than they can manage at home. In these cases, pMD sends an automated alert to the AIM care coordinator who is assigned to the patient when the patient is admitted to the hospital. This alert cut down a delay of up to 24 hours for this information to make it to the care coordinator. Now, AIM is able to step in immediately and help.
Alaska Innovative Medicine is changing health care in Anchorage. They are utilizing pMD to improve communication, facilitate the flow of information between caregivers, and to help patients navigate systemic hurdles in health care. “One of the biggest things is the fact that pMD has connected what was previously a very siloed medical community,” says Davis. The partnership between AIM and pMD has not only helped drive down the cost of caring for the city’s sickest patients, but it has also led to a higher quality of life for those individuals that AIM has been able to assist. pMD has been critical to that success. “Our program would not be where it is today without our partnership with pMD,” says Paprocki.
pMD allows physician specialists to record and securely share information on patient encounters from their mobile devices right at the point of care. Doctors using pMD are increasing their efficiency, ROI, and quality of patient care in a time where Medicare cuts, compliance regulations, and other costs are impacting medical practices. Through pMD’s care coordination, charge capture, secure messaging, and health information exchange services, doctors can spend more time being doctors and less time acting like accountants with expensive medical degrees. pMD provides free interfaces with most major electronic medical records, hospital information, and medical billing systems, including Allscripts Pro PM, Allscripts Tiger, athenaCollector by athenahealth, Cerner, eClinicalWorks, Epic, GE Centricity (formerly Millbrook and IDX), MEDITECH, MobileMD, NextGen, and Vitera Intergy (Sage). For more information, contact pMD.