Some patients on the island of Hawaii live in communities far apart from each other and from physicians and hospitals, with few methods of transportation except the family vehicle.
Like other rural areas, this situation puts patients with diabetes and other chronic conditions at greater risk of costly hospitalization.
The Hawaii Island Beacon Community is focused on improving care for individuals with complex chronic conditions to avoid hospital re-admissions and engage these patients to better understand and get involved in their care.
Physicians, community clinics and hospitals embracing electronic health records (EHRs) and health information exchange are critical to making that happen, according to beacon staff members, who spoke with Government Health IT at their office here in Hilo, Hawaii. The group has also engaged physicians to transform their practices to be more patient-centered.
“The real need is for helping patients avert disaster” among those with advanced stages of diabetes and other chronic conditions and the populations behind them that indicate a similar path, said D. Michiko Fried, a nurse and managed care coordinator for Bay Clinic family health centers on the east side of the island.
The Hawaii beacon, which received a $16 million three-year grant, is one of 17 model communities around the nation using health IT to improve individual patient outcomes and population health and in the process lower costs. It partners with 15 hospitals, physician practices, community clinics, including one that focuses on Native Hawaiian health care, and payers on the island of Hawaii, known as the Big Island.
While the mention of Hawaii typically conjures up scenes of big-city Honolulu and well-known crowded beach resorts, the rugged Big Island offers a different kind of paradise. Eco-adventures thrive thanks to access to continuous lava flows from Kilauea, the home of Pele, the goddess of fire in Hawaiian mythology, and two large dormant volcanos running down the middle of the island.
One of those volcanos, the 14,000-foot Mauna Kea, hosts the world’s largest astronomical observatory and telescopes operated by astronomers from 11 countries to research the heavens.
Down below, Hawaii beacon is working to exchange data with geographically spread out clinics and hospitals within the Big Island to coordinate care so patients can avoid the onset and advancement of diabetes and related conditions.
Prevention is especially critical for the Big Island. Hawaii works on a hub system in which critical care patients are flown from neighbor islands to Honolulu for more advanced treatment, with air transport increasing costs further.
[Infographic: Healthcare quality revolution on Hawaii.]
Two sides of the bridge together
Health IT infrastructure is the bridge for clinical intervention and coordination, said Jeff Jendrysik, beacon project manager. Beacon participants use Wellogic’s electronic health record and health information exchange tools, and eventually analytics about clinical outcomes.
For example, the North Hawaii health information exchange, in testing since December and the first HIE in the state, goes live officially in September with North Hawaii Community Hospital, Hamakua Health Center, which is the nearby safety net provider, as well as labs and other physicians’ groups.
The beacon’s objective is to get 60 percent of Big Island primary care providers and nurse practitioners to adopt and use EHRs in a meaningful fashion.
“If you get that base working, you’ve got folks starting to feed data and keying it into their system correctly, we can exchange data,” Jendrysik said.
North Hawaii Community Hospital has put in place hospital discharge planning, for instance, to get patients connected with care coordinators in Hamakua when they leave the hospital. Both providers will share the same technology platform.
“So we can take clinical interventions and start overlaying them on top of the technology we’re building. Hospital and care coordinators on the same platform sharing the same data across their EHRs with all that data connected,” Jendrysik said. “It’s the two sides of the bridge coming together at one point.”
Technology is a significant piece of how Hawaii beacon is driving care coordination to reduce the fragmentation in the current healthcare system and build capacity in the care community, said Cynthia Ross, beacon clinical program facilitator.
“We’re streamlining the process so that instead of the patient going through the system like a bumper car, they’re going through smoothly and receiving the help and services that they require,” Ross said.
Almost 500 patients sign up for coordinators
Beacon provider partners have signed up 463 patients so far with diabetes and other chronic conditions and matched them with care coordinators to help them manage their care. But Hawaii beacon is going a step further by figuring out patient needs beyond solely medical ones to create a care coordination neighborhood, Ross said.
As a result of a learning collaborative that took place during the summer among providers and community organization professionals, beacon participants chose one complex patient from each of the Big Island’s north, east and west regions to track them over 30 days to identify all the services that these selected patients use, whether health or human services or transportation. They anticipate reporting at the end of this month on gaps that exist and brainstorm on how to bridge them, she said.
(Pictured above, at right: Hilo Medical Center, a beacon partner.)
For example, a patient may miss an appointment because the car broke down. The island county offers little public transportation because of the relative small population and isolation of communities, but there are services that could be tapped to assist them.
In the beginning it was difficult to schedule busy physicians and community professionals for conference calls to build a care coordination neighborhood, but after the first one and relationships were started, they were eager to share phone numbers with each other and meet at each other’s office. “It happened that organically,” Ross said.
The relative isolation of the island and the sense of community lend itself to a care coordination neighborhood. “There is a need here, and that’s why this site was selected. Of all the places where we can apply some viable solutions, I think that’s part of why they looked at Hawaii Island. They saw a potential here for success,” Ross said.
Additionally all the right players are at the table, said Jessica Yamamoto, community engagement manager. “Aloha is a source of collaboration and people willing to talk story. Talk story can be different for everyone, but for me it is if you come, you share, we listen,” she said, referring to two cultural concepts of respect and welcome that run deep on the Big Island.
On the mainland, many of the physician practices and hospital partners in other beacon communities also compete with each other for patient business, said Melinda Nugent, beacon’s clinical program manager.
“We don’t have enough physicians on the island, and our hospitals are so far away from each other that there is not really a competitive nature,” Nugent added. “That lends itself to a collaborative environment,” Nugent added.
In another example of streamlining, the three island hospitals are using a tool called CarePass, in which they provide patients with simplified and standard information when they are discharged to smooth care transitions, Yamamoto said. The yellow form contains medication reconciliation medical issues, patient identifier and the clinicians the patient will see over the next week.
“Right now it’s a paper template. But once they are able to realize that it works, then the next step is to create technology alongside it,” she said.
Fostering patient-centered medical home
Hawaii beacon is also helping physicians to redesign their practices to a patient-centered medical home model. Currently, 19 physicians around the island have made significant progress through a guided process from TransforMed to better coordinate, plan and manage care and encourage patient involvement, Nugent said.
TransforMed online consultations, webinars and training covers change management, high-performing clinical teams and office workflow. TransforMed also gives physicians access to a website where they can compose questions about the model and receive answers and feedback from other practices.
The participating physicians also meet and collaborate for a day over practice redesign and decide what comes next.
“On the west side of the island in Kona, where we have really small practices, some just a single physician and one staff member, this gets them to see themselves together as a unified group instead of isolated practices,” she said.
One of the beacon partners, the National Kidney Foundation, has hired coaches to help physicians, such as with assignments they must complete or further explain material in the training webinars.
Hawaii beacon does not offer any incentives to physicians to encourage them to sign up to convert to a patient-centered medical home except the free help. “But they know reform is coming,” Nugent said. Also, Hawaii Medical Service Association, the major payer, is involved.
All of the beacon projects map to the patient and are coming together, Jendrysik said. “All of these tracks run in parallel and have their own pilots," he added. "But we’re going to see more of them coming together around the patient."