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Brooklyn Health Home and Healthix

Tapping into a Health Information Exchange to Manage the Healthcare Needs of a Complex Population

Brooklyn Health Home and Healthix Success StoryPatricia M. was found lying on a street corner in Brooklyn and brought to Maimonides Medical Center’s emergency room. Maimonides participates in Healthix, a health information exchange that receives and aggregates patient data from hundreds of provider organizations across the greater New York area. As Patricia’s records were updated in the emergency department at Maimonides, updates were also sent to Healthix.

Patricia’s emergency encounter triggered an alert, sent by Healthix, notifying Patricia’s care manager at Brooklyn Health Home (BHH) of the ER event. Patricia, with a history of diabetes, heart failure, and schizophrenia, obtains all behavioral, medical, and social services from BHH. Within hours, Patricia’s care manager visited her in the hospital. Prior to discharge, the care manager worked with the hospital and Patricia’s social worker, psychiatrist, and other providers to create an appropriate care plan – one that would help Patricia remain healthy and out of the hospital.

BHH is a New York State Medicaid Health Home, a network of organizations working together to coordinate care for over 8,000 Brooklyn individuals. Many, like Patricia, have important mental health needs along with multiple complex illnesses and/or HIV. To manage a population that includes the homeless and others requiring housing and nutritional services, BHH relies on Healthix health information exchange services for community-wide clinical event notifications and clinical summaries from providers. Healthix coordinates health information sharing among more than 150 organizations, over 10 million patients, and almost 8,000 physicians across Manhattan, Brooklyn, Queens, Staten Island and Long Island.

Enhancing Communication Through Clinical Alerts
Through interoperability between Healthix and the BHH Care Coordination system, BHH providers receive information regarding member care transitions. Healthix Clinical Event Notifications alert care managers, care navigators, primary care providers, and/or psychiatrists when consenting members are admitted to the ER, hospital, or mental health facility as well as when they are discharged. BHH also relies on Healthix-provided information to help inform post-hospitalization care coordination services.

All data integration and sharing activities within Healthix use the InterSystems HealthShare® informatics platform. HealthShare provides Healthix with the technological foundation to interface with a wide range of electronic health records and other clinical systems, allowing exchange members to access more comprehensive patient records. Healthix, through HealthShare, links hospitals, health systems, behavioral health organizations, nursing homes, rehabilitation centers, labs, radiology centers, home care agencies, Medicaid, public health organizations, and New York’s organ donor network. BHH will also soon receive incarceration and release alerts from Rikers Island Correctional Facility, which are critical to the successful engagement of this population.

Strengthening Collaboration and Engagement for Better Outcomes
BHH encourages its members to consent to participating in the Healthix network, and members appreciate the assistance from BHH in managing their own health. BHH uses the notification system to help ensure coordinated and comprehensive care, not only during acute phases, but for all phases of care.

Response times from care managers have steadily improved after implementing Healthix alerts in the BHH Care Coordination system. Within the first seven months of using Clinical Event Notifications, BHH care manager response on the first day of a member’s admission to a psychiatric clinic or hospital rose from 20% to almost 60%. After seven months, case manager encounters within the first week of discharge were also close to 60% following a discharge notification.

The faster the response to a member’s health crisis, the greater the opportunity to avert a preventable hospital admission and to create a timely care plan that meets the unique needs of the patient, and plan for care after discharge. For BHH, Healthix real-time alerts are therefore an important catalyst for realizing better patient outcomes. By improving provider collaboration, medication management, and member engagement, BHH is helping its population receive the right care at the right time and receive support to improve outcomes during and after hospital stays. They get the support they need to remain as healthy as possible, and decrease emergency room visits, hospital admissions and readmissions.