1. Use of a Registry for Chronic Disease Management in a Small County Behavioral Health Setting Karen Stockton, Ph.D., M.S.W., B.S.N. Health Services / Behavioral Health Director, Modoc County

2. Platform Selection: The Small County Challenge Be able to accomplish with minimal technological support Be able to embed as a normal part of service delivery Be simple enough that MH Specialists and Peer providers can use Be able to produce and interpret basic reports without statistical expertise – Note: as a very small county, we were exempt from PEI evaluation

3. Background We were looking for an inexpensive system that was appropriate for small county data management to measure outcomes across all programs and funding requirements. Desired an application that had promise for real-time quality improvement at all system levels, was appropriate for integrated health care, and that would also have capacity to submit data to oversight entities. We decided early on to set the security level to comply with HIPPA & 42CFR – and manage access by release of information.

4. Our journey in search of an alternative to pencil and paper tracking Pencil & Paper Spreadsheets – Stand alone with limited use for general population or interface with other programs EHR – The primary use of an electronic health record is mostly to process billing and supporting documentation. – Much of the data is not in searchable fields. Chronic Disease Management Registry

5. Adaptability A registry is designed to be more adaptable to collect needed information. Data available at all levels of program (client, groups of the population) Makes job easier – no paper chart Makes it possible to do things that we couldn’t do before – Plan with our beneficiaries their treatment based on their progress reports – Staff use individual data for planning and intervention while in session

6. Testing chronic disease management registries (PECSYS & eCiMH CC Tracker) Registry is a tool to help you keep track of people and manage their health.

7. Interfaces Data Input – Direct data entry via web access Data entry notices/reminders Mobile system entry with web access – Data import From providers’ systems under testing through EHR interface Data Output users – Data exports Canned reports Custom reports Role based interfaces (front desk, clinician, QA, billing, IT, management) – System administration – Users support

10. Content & Outcomes Structure and Process Information – Can collect any measurable information that is predetermined and assigned a field Outcomes Information – Client Outcomes Core measures (across programs) Custom measures (specific to a program) – Program Outcomes Milestones G&O – If assigned a numeric value

13. Annotated Time Series

14. Santa Maria County Mental Health

15. Data Utilization of the Registry Use data proactively manage health and wellness for a chronic condition Collect and use data for integration of whole health and shared care plans Collect and analyze data that is useful for quality improvement Demonstrate individual progress and program outcomes Guide delivery of, and monitor adherence to, best practices and protocols

16. Provide a mechanism to share key information across the integrated team through VPN or HIE – ACA data exchange requirements With appropriate releases of information, through VPN access, integrated team members can bi-directionally exchange information “real time”. Client level data in aggregate is very useful for demonstration of program/department and collaborative outcomes Fixed data elements in “searchable fields” have significant potential for TIMELY outcome measurement, evaluation and/or research at all system levels while remaining HIPPA/and 42CFR compliant.