NYC Health Home Program (Care Management Agency)

---

CCN General Medicine offers a comprehensive range of medical specializations for both chronic and acute conditions. It participates in the Health Home Program management by NYC CMA (Care Management Agency). Health Home program run by CMS is one of the most complicated outreach programs designed to address mental health patients with 1 or more chronic conditions. The program is delivered by a lead community agency, namely ‘Lead Health Home’ and CMAs.

Program Accountability

To be part of the program, patient needs to be enrolled in Medicaid. CCN General is responsible for maintaining the eligibility. Patient assignment is dynamic and managed by CMS and Lead Health Home. Roster management is a big deal for CCN General as patients can be added and/or dropped without their knowledge. Also, physical acknowledgement of the patient is required on a quarterly basis. In order to get reimbursed for the services provided, CCN General needed a system that can record and report monthly assessments and outreach activities.

In order to manage this population and provide timely care coordination, CCN General, chose Equipo’s Care Coordination system. The goals of the system were many:

• Maintain eligibility
• Manage patient roster
• Conduct patient outreach
• Keep up with the changes in assessment
• Show patient progress
• Keep patients out of ER and Hospital
• Keep high morale of the Care Team
• Produce reports for Lead Health Home
• Provide timely care

Equipo’s care management platform solved the needs by providing an integrated care delivery system. Now, CCN has replaced numerous spreadsheets with active roster management and monitoring of all care activities. The system’s key components include:

• Customizable assessments and care plans allow for staying in sync with CMS mandates and regulations
• Easy activity and task management with alerts enables care teams to plan their daily activities
• Role based reporting and activity tracking allows management to plan for resource workloads and to monitor operational efficiency
• Intake of social statistics of patients and integration with their clinical data allows to identify care gaps and take action immediately

Outcome

Increase in patient enrolment by 500% in 2 years

Achieved 90% reporting compliance for billing

Drop in ER and hospital visit by 40%

Increase in patient satisfaction by 18%

Increase in program manager’s efficiency by 24

Large Community Hospital: Connectivity Through Electronic Referral

---

Large Community Hospital is the largest voluntary, not-for-profit health and teaching hospital system serving the South and Central Bronx. It is also among the largest providers of outpatient services in New York City, with more than one million visits annually and an ER that is responding to 139,000 visits, one of the busiest in New York. Large Community Hospital is now completing the third year as a Performing Provider System (PPS) lead in New York State’s Delivery System Reform Incentive Payment (DSRIP) Program. The DSRIP program (entitled Bronx Health Access) is providing Large Community Hospital and its community partners with the opportunity to adapt to a value-based payment system, with an emphasis on keeping patients and the community healthy. Large Community Hospital’s DSRIP Performance is also in the top six of all Performing Provider Systems in New York State.

Accountability and Connectivity

Until recently, the system was plagued with a severe backlog for medical sub-specialty appointments. For example, the wait time for a gastroenterology appointment was 2 months. Referrals were paper-based and faxed or hand-delivered; sometimes the referral was never received, and the patient never scheduled. If a patient needed an expedited appointment, the primary care provider (both internal and external) had to spend time trying to contact a specialist to advocate on the patient’s behalf.

In order to address the backlog, Large Community Hospital, chose Equipo’s electronic referral management and consultation system (e-Referral). The two primary goals of the system was to:

• Track referrals so that there was accountability for referrals.
• Reduce wait times.

The technology platform was custom made to fit to the hospital’s needs by the Equipo Team. Together with the provider relations staff from Large Community Hospital, Equipo successfully spread the eReferral system to more than 150 primary care providers/medical specialty clinics and services, including radiology services, home care, and diabetes support groups. The system’s key components include:

• All referring clinics must use the eReferral system to refer to participating specialty services.
• A centralized, electronic queue for each participating specialty service.
• Each participating specialty service has a designated specialist clinician reviewer (associate) with dedicated time to review and respond to referral requests. The reviewer can use the system to schedule appointments, triage patients, request clarification of the consultative question, and provide guidance for pre-visit evaluation.
• The referring provider and associate can communicate in an iterative fashion using the eReferral system until the patient’s clinical issue has been addressed, with or without an appointment.
• The eReferral system is tightly integrated with the hospital EHR so that all information exchange is documented in the patient’s chart in real time.

The following flow diagram depicts how the eReferral system works.

Large Community Hospital believes that one of the primary values of the eReferral system is facilitation of communication between primary care and specialist providers (both internal and external). Such communication shortly led to workflow efficiencies at both ends. Primary care providers now receive guidance on evaluation and management in a timely fashion, while specialists who see patients in clinic receive clear consultative questions. This information connectivity not only reduces unnecessary specialist appointments but gives PCPs more opportunity to learn and treat their own patients’ clinical issues. Community PCPs are satisfied with the eReferral system. Equipo’s eReferral system recently received accolades and is promoted as a successful system. The following results demonstrate that the system’s goal of reducing wait times has been achieved.

Outcome

• Increase of referrals by 10% in 6 months
• Reduced wait time by 30%
• 8% reduction in hospitalization and ER
• Increased employee retention and job satisfaction (visibly less friction due to efficient workflow)
• Record implementation time, 50% partner added in the system in 3 months (best in history)

New York City IPA: Moving to Value Based Care

---

Value based care is complex process. A true care model requires collaboration from every participating entity. Equipo integrates the whole care delivery system to help achieve value-based care model. New York City IPA practice leaders realized payment reform was a reality; they needed transformation into a new model of care.

Challenges

• Several providers with disparate EMRs. Missing unified repository for a unified view.
• Organization lacked real time access to patient data through participating providers.
• Providers had no easy way to find out their performance and to act on gaps in care.
• Data unavailable from external entities like Hospitals, MCOs, Community Labs and pharmacies. Providers unaware of hospitalizations or ED visits.
• MCOs needed visibility on real-time progress and manage outliers for improved care.

Solution: A comprehensive integrated solution that compiles all data in real time, analyzes the data and provides actionable insights for continuous improvement.

Equipo Story

• Integrates data from individual providers in near real-time.
• Integrates data from MCOs (Roster, Medication Adherence, Care Gap, High Flyer list).
• Integrates Transition care data in real-time.
• Integrates Medication data in real-time.
• Integrates Eligibility data in real-time.

Once all the data elements are compiled, Equipo runs its quality analysis for finding out gaps in care, risk gaps, gaps in medication adherence, gaps in transition care. Data is presented as a task list for the care team to act on.

• Filter to identify most critical patients
• Identify and act on most impactful cases
• Generate real-time monitoring alerts
• Task management for care managers
• Automate reminders and follow ups

Outcome

• 22% increase in reduction of Care Gaps
• 28% increase in Roster Enrollment
• 16% decrease in Inactive patients
• 12% increase in Medication Adherence
• 90% adherence in Transition Care
• 24% overall cost savings

Remote Patient Monitoring

---

Traditional care requires in-person visits. In contrast, remote monitoring programs passively and continuously collect and transmit patient-generated health data (PGHD) from in-home medical devices to providers and care teams. PGHD, when compared to health data collected exclusively during in-person doctor’s visits, more accurately and holistically reflects lifestyle choices, health history, symptoms, medication, treatment information, and biometric data such as heart rate, blood glucose, blood pressure, temperature, oxygen levels, and weight. As a result, provider organizations are adopting remote patient monitoring (RPM) services – inclusive of data from home health devices – as a new standard of care.

St Anthony Home Health – a leading healthcare provider in South Texas manages a patient population that have chronic conditions like Diabetes and Hypertension. Its providers can now have actionable information gleaned from the data presented via the Equipo Platform. Equipo identifies data trends, elevate critical data points, and help aggregate, summarize, and visualize PGHD in meaningful ways. It allows both patients and providers to easily share, view, and act upon the insights. This makes PGHD useful at the point of care, while encouraging health professionals of St Anthony’s to embrace the available data and further benefit its patients.

For many of St Anthony’s patients, healthcare is episodic. They are treated for the issues that are discussed in in-person doctor’s visits and their providers base treatments around the data collected at that time. It implies that once they leave after receiving treatment for an acute health event, they are largely disconnected from their provider and the continuing care they may need. In contrast, RPM improves outcomes in post-acute care by helping patients and providers manage short-term care after in-person treatment with remotely collected data. Programs educate patients on their condition and recovery needs while providing regular reminders, early interventions, post-discharge information, or medication adherence tracking. With the information garnered from PGHD, St Anthony’s providers are able to evaluate the effectiveness of treatments and customize care plans between patient visits.

Routine monitoring allows for intervention and education as early and as often as needed to keep the patient engaged, healthy, and adherent to their treatment programs. By continuously tracking the routine and biometric measurements of people with chronic conditions, providers are empowered to intervene earlier in disease progression, which helps prevent complications that can result in unnecessary in-person or hospital visits. Equipo simplifies these interventions so that they can be executed by a physician assistant; by a nurse or care manager. It empowers a care team with technology to more effectively intervene and manage treatments.

How Equipo Impacts Health Systems

People with chronic conditions are rising at a staggering rate which pressurizes healthcare stakeholders to improve access to care with reduced number of resources, at the same time providing efficiency and effectiveness. Integrating such programs of care allows providers to improve health outcomes, lower costs, and take advantage of reimbursement opportunities. These programs also create space for operational efficiencies that:

• Relieve stress on overburdened providers
• Ensure doctors spend more time with high-risk patients
• Improve operational efficiency by reducing manual or redundant tasks
• Reduce costs associated with readmission penalties, emergency department visits, and administration
• Improve quality metrics and patient satisfaction scores
• Engage patients in planning, goal-setting, and self-management of care
• Identify trends and outliers which creates opportunities for more effective data analysis and monitoring. This offers the potential for earlier data-driven diagnosis, interventions, and treatments.

TERMS OF USE

---

The websites of Equipo Health Inc, including but not limited to equipo.io, are internet-based online information and communication services provided by Equipo Health Inc. This website is intended for users above the age of thirteen. User participation on the website is voluntary and all information shared with Equipo’s website is solely upon the user’s own initiative.

By using this website, you agree to the latest Terms of Use as well our Privacy Policies. The Terms of Use may be revised from time to time upon the sole discretion of Equipo Health and will be made effective immediately. You also acknowledge and agree that any activity on this website is subject to monitoring by the company at any time, and that it may use the results of such monitoring without limitation, subject to applicable law.

The access and use of this website are also subject to the terms and conditions as below. If you do not abide by the same, please do not continue to use this website. Your authorization to use this website automatically terminates on any breach of the following terms and conditions.

Copyright Notice

Equipo Health owns or licenses all materials on this website. The materials are copyrighted and/or trademarked, and any unauthorized use of the materials may violate copyright, trademark, and other laws. Users may view and download the materials only for their personal, non-commercial use, provided all copyright and other proprietary notices contained in the materials or on any copies of the materials are provided. Users are not authorized to reproduce, publicly display, distribute or otherwise use them for any public or commercial purpose.

Trademark

Equipo^® is a registered trademark of Equipo Health Inc. No right, license, or interest to such trademark is granted hereunder, and you agree that no such right, license, or interest shall be asserted by you with respect to such trademark.

Usage Restrictions of This Website

You agree not to use the Website:

• In any way not explicitly permitted by these terms or the text of the website itself.
• In any way that violates any federal, state, local or international law or regulation (including any laws regarding the export of data or software to and from the US or other countries).
• Not to misrepresent your identity or provide us with any false information in any part of this website.
• To engage in any conduct that restricts or inhibits any party’s use of this website, or which may harm the company or users of this website or expose them to liability.
• To access or attempt to access any portion of this website to which you have not been explicitly granted access.
• Use any device, software or routine that interferes with the proper working of the website.

Limitation on Liability

YOU ACKNOWLEDGE AND AGREE THAT IN NO EVENT AND UNDER NO LEGAL OR EQUITABLE THEORY, WILL THE COMPANY, ITS AFFILIATES OR LICENSORS, SERVICE PROVIDERS, AGENTS, EMPLOYEES, SHAREHOLDERS, OFFICERS, OR DIRECTORS BE LIABLE FOR DAMAGES OF ANY NATURE, UNDER ANY LEGAL THEORY, ARISING OUT OF OR IN CONNECTION WITH YOUR USE, OR INABILITY TO USE, THE WEBSITE, OR ANY WEBSITES LINKED TO IT, ANY CONTENT ON THE WEBSITE OR ANY SERVICES, SUCH OTHER WEBSITES, INCLUDING ANY DIRECT, INDIRECT, SPECIAL, INCIDENTAL, CONSEQUENTIAL OR PUNITIVE DAMAGES, INCLUDING BUT NOT LIMITED TO, PERSONAL INJURY, PAIN AND SUFFERING, EMOTIONAL DISTRESS, LOSS OF REVENUE, LOSS OF PROFITS, LOSS OF BUSINESS OR ANTICIPATED SAVINGS, LOSS OF USE, LOSS OF GOODWILL, LOSS OF DATA, AND WHETHER CAUSED BY TORT (INCLUDING NEGLIGENCE), BREACH OF CONTRACT OR OTHERWISE, EVEN IF FORESEEABLE.

Indemnification

You agree to defend, indemnify and hold harmless the company, its affiliates, licensors and service providers, and its and their respective officers, directors, employees, contractors, agents, licensors, suppliers, successors and assigns from and against any claims, liabilities, damages, judgments, awards, losses, costs, expenses or fees (including reasonable attorneys’ fees) arising out of or relating to your violation of these Terms of Use or your use of the Website, including, but not limited to, any use of the Website’s content, services and products other than as expressly authorized in these Terms of Use or your use of any information obtained from the Website.

GOVERNING LAW

This Agreement is made under, and in all respects shall be interpreted, construed and governed by, and in accordance with, the laws of the State of New Jersey. Any cause of action arising out of or related to this Agreement may only be brought in the local court of applicable jurisdiction in the State of New Jersey, and you hereby submit to the jurisdiction and venue of such court.

LAST MODIFIED DATE

December 1, 2019.

Privacy Policy

---

Equipo Health is committed to safeguarding the privacy and security of its users. We intend to provide you with personalized internet experience that delivers the information, resources and services that are most relevant and helpful to you. In order to achieve this goal, Equipo Health collects information you provide us if you access, voluntarily enter information into, or sign up for or request certain services from us on our Website.

The only personal information Equipo Health obtains about individual users to its website is that supplied voluntarily by users. When we may need personal information to provide users with customized content or to inform them about new features or services, users are explicitly asked for that information.

Equipo will share your information only as described in this Privacy Notice, or as permitted by law. Equipo will not sell, lease, rent, or trade your personal information to any third party for that party’s marketing or promotional purposes, unless you give your consent.

SUBMISSION OF INFORMATION

You may choose to provide us information when you fill out a form on the website or otherwise contact us. We may also obtain information about you that is publicly available. This information may identify you personally. For example, we may collect your name, company name, address, email address, phone number, position, title, and similar information.

By using our Website, you consent to the use of cookies.

• If you provide us with your information on your interest in our products or services, we will use such information to reach out to you about our products or services.
• We may use your information for our own marketing, promotions, invitations, newsletters, respond to your questions, provide customer support, share news and product updates.

We will not retain your information longer than necessary to fulfill the purposes for which it was collected or as required by applicable laws or regulations. We take reasonable and appropriate administrative, physical, and technical security safeguards to protect the information that you share with us from loss, theft, misuse and unauthorized access, alteration, destruction, and disclosure. In addition, we enter into agreements which require that care and precautions be taken to prevent loss, misuse, or disclosure of your information. Nevertheless, transmission via the internet is not completely secure and we cannot guarantee the security of information about you.

SECURITY OF PERSONAL INFORMATION

Equipo Health has security measures in place to protect the loss, misuse and alteration of the information under our control. We employ strict security measures to safeguard online transactions. All personal information is stored in a secured database.

We use technical, organizational, and physical measures designed to protect the integrity, confidentiality, security, and availability of personal information. Among other measures, only authorized personnel of Equipo Health and of our third-party service providers with a legitimate need to know are provided access to personal data and are required to treat this information as confidential where applicable. Despite these precautions, we cannot guarantee that unauthorized persons will not obtain access to your personal data.

If you arrange for services through this website, it may be necessary for us to transfer your personal information to our affiliates or third-parties for the purpose of assisting us with fulfilling the services.

SOCIAL MEDIA AND TECHNOLOGY INTEGRATIONS

We offer some parts of our Website through other platforms and services operated or controlled by separate entities. In addition, we integrate technologies operated or controlled by separate entities into parts of our Website. Some examples include:

• Our Website includes links that hyperlink to websites, platforms, and other services not operated or controlled by us.
• Liking, Sharing, and Logging-In: We may embed a pixel or SDK on our Website that allows you to “like” or “share” content on, or log in to, your account through social media. If you choose to engage with such integration, we may receive information from the social network that you have authorized to share with us. Please note that the social network may independently collect information about you through the integration.
• Brand Pages and Chatbots: We may offer our content through social media. Any information you provide to us when you engage with our content is treated in accordance with this Policy. Also, if you publicly reference our Website on social media (e.g., by using a hashtag associated with equipohealth in a tweet or post), we may use your reference on or in connection with our Website.

Please note that when you interact with other entities, including when you leave our Website, those entities may independently collect information about you and solicit information from you. The information collected and stored by those entities remains subject to their own policies and practices, including what information they share with us, your rights and choices on their services and devices, and whether they store information in the U.S. or elsewhere. We encourage you to familiarize yourself with and consult their privacy policies and terms of use.

NEWSLETTER SUBSCRIPTIONS

From time to time, we provide information to our customers and potential customers in the form of electronic newsletters and similar updates. When you subscribe to these updates, you will be added to our mailing list and will receive announcements and information about us. These will be emailed to the address(es) that you provide when you subscribe. You may opt out of receiving these communications by following the “unsubscribe” instructions that are contained within the communications that we send to you.

MINORS

The website covered by this privacy policy is not intended for or targeted at children. Equipo Health will not knowingly collect and maintain personally identifiable information from children of age thirteen years or younger. If you are a parent or guardian and think that we have collected personal information from a child under the age of 13 through this website, please contact us.

COMMUNICATION PREFERENCES

Equipo Health may send commercial emails to you advertising our products and services. You can also subscribe to various product and service-specific communications on our websites. If you receive direct marketing email from us and wish to discontinue these mailings, you may unsubscribe at www.equipohealth.com/unsubscribe and/or in any unsubscribe opt-out method provided in the communications.

Where allowed by applicable law, the unsubscribe options provided to you may not apply to communications primarily for the purpose of administering order completion, contracts, support, product safety warnings, software updates where you are provided with appropriate choice in accordance with applicable law, or other administrative and transactional notices, the primary purpose of which is not promotional in nature. This means that even if you opt-out of receiving direct marketing communications, we may still need to retain some of your personal information necessary to communicate with you on these topics where required for these purposes. We do not share your personal information obtained through this site for the purpose of third-party direct marketing.

CHANGES TO THIS WEBSITE PRIVACY POLICY

Changes made to this policy will appear on this page of our website. We will also provide appropriate notice and choices to you, on this website and in other appropriate locations, based on the scope and extent of changes. You may always visit this policy to learn of any updates.

EFFECTIVE DATE

The effective date of this policy is December 1, 2019.

For any questions click here Contact Us