Integra Community Care Network and Rhode Island Quality Institute team up to streamline coordination of health care for 140,000 Integra patients

LAURA ADAMS, PRESIDENT and CEO of Rhode Island Quality Institute talked to PBN about the expansion of RIQI's Care Management Alerts and Dashboards system to Integra Community Care Network. /PBN FILE PHOTO/BRIAN MCDONALD
LAURA ADAMS, PRESIDENT and CEO of Rhode Island Quality Institute talked to PBN about the expansion of RIQI's Care Management Alerts and Dashboards system to Integra Community Care Network. /PBN FILE PHOTO/BRIAN MCDONALD

PROVIDENCE – On June 23, the Rhode Island Quality Institute and Integra Community Care Network, an accountable care organization that includes Care New England Health System, Rhode Island Primary Care Physicians Corp. and South County Health, announced the recent launch of Care Management Alerts and Dashboards, an innovative service that helps health care providers proactively coordinate health care for 140,000 of Integra’s patients in Rhode Island.

The Care Management Alerts identify in real time when a patient visits a hospital emergency department, is admitted to and discharged from the hospital and the reasons for such medical interventions, RIQI president and CEO, Laura Adams, told Providence Business News. There are three ways for health care providers to get this up-to-date information: Alerts flow into an email inbox monitored by a nurse care manager; a nurse care manager or health care provider can sign into the Dashboard, with comprehensive data about each patient as well as cohorts of patients; and Alerts are fed directly to the patient’s electronic health records, with a flagged notation alerting the provider that new information exists.

The Dashboard, said Adams, allows a health care provider or nurse case manager to review the hospitalization histories on a patient or a panel of patients to evaluate whether the provider is getting better at keeping them healthy and avoiding unnecessary ED visits and hospitalizations. If, for example, the Dashboard shows that a patient with asthma recently visited the ED, but to get stitches for a cut finger, the nurse case manager need not devote time and resources to following up with the patient on managing her asthma.

RIQI first piloted the Care Management Alerts and Dashboards in January of this year with a limited, high-risk cohort of Thundermist Health Center patients and later with other community centers, said Adams, but this Integra launch is massive. The 140,000 Integra patients selected for this launch are those who are constantly interacting with health care providers and really need care coordination, said Adams, or those for whom Integra’s providers receive value-based payment, where they receive a lump sum of money to keep their Medicaid/Medicare patients healthy in a cost-effective way.

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“RIQI’s Care Management Alerts and Dashboards support Integra’s goal to constantly provide a better patient experience, better health care, and, most important, better health,” said Dr. James E. Fanale, executive vice president, Physician Enterprise, and chief clinical officer for both Care New England Health System and Integra Community Care Network. “Dashboard data is near real time and we have created a process to notify providers’ care teams when a patient’s status has changed and so they can respond appropriately and immediately to help them manage their health and focus on preventive care.”

“The right hand has to know what the left hand is doing; you can’t be hospitalized and not have your primary care physician not knowing until your next visit three weeks later,” Adams explained. RIQI data indicate that patients whose providers receive Alerts are about 20 percent less likely to be have an avoidable readmission to an ED and about 12 percent less likely to be readmitted to the hospital, within 30 days, she said.

Although hospitals have long been required under HIPPA to send information about ED visits and hospitalizations to patients’ health care providers, the Alerts and Dashboards automate this information delivery system in a much faster and more efficient fashion, Adams said. A patient’s full medical information – on lab tests and results, prescriptions, past hospitalizations, etc.  –  is available only if that patient enrolled in CurrentCare, RIQI’s health information exchange that is, said Adams, “stricter than HIPPA.”

CurrentCare, Adams said, is the only such system in the nation that was permitted to include alcohol and substance abuse treatment information to create a comprehensive record, given Rhode Island’s strict patient privacy controls. To date, about 500,000 people have enrolled in CurrentCare, and Adams would like to see everyone enrolled.

Users can tweak the Alerts and Dashboards to fit their needs, said Adams, and we will constantly upgrade and improve them as hear from clients over time about what they need the software to do.

The existence of a giant data base is both good news and bad news, said Adams, so RIQI is working on yet another new “sift and serve” initiative, a sophisticated system by which the provider only receives specific targeted information that has been requested.

RIQI is working now, said Adams, on a “sift and serve” initiative with Lifespan, such that RIQI will sift a patient’s CurrentCare data to retrieve only that information related to his or her opioid abuse disorder to send to the patient’s electronic health records. Rather than receiving a giant data base of information, a provider can review this specific notation in the electronic health record in 30, 45 or 60 seconds, said Adams.

And, looking to the future, Adams hopes to implement a Siri-type voice query for data, so that a physician can be in an examining room with a patient and verbally request information.

“There’s lots of interest in what we’re doing with [all these initiatives], said Adams, who noted her recent and upcoming presentations in New York City, Palm Springs, Florida and Shanghai, among other venues.

To enroll in CurrentCare, visit http://currentcareri.org

Nancy Kirsch is a PBN contributing writer.