Longitudinal Coordination of Care (LCC) Workgroup (WG)

LCC Standards Update for the HITPC MU SWG #3 Care Coordination

May 8, 2013

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Agenda

• Limitations in Care Coordination and Standards to support Transitions of Care and Care Plans

• IMPACT Project: Addressing C-CDA MU3 Transition of Care Gaps

• ONC S&I LCC WG: Advancing Transitions of Care & Care Planning

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Limitations in Care Coordination & Standards to Support Transitions of Care

and Care Plans

Failures of Care Coordination

• 150,000 preventable adverse drug events ($8 Billion wasted) nationwide each year occur at the time of hospital admission

• 1.5 Million preventable adverse events annually nationwide following hospital discharge

• Preventable readmissions waste $26B nationwide annually

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National care transitions experts overwhelmingly identified “improving information flow and

exchange” as the most important tool to improve care transitions. (ONC, 2011)

MU ToC & Care Plan Requirements

• CMS MU2 objectives require sending care summaries, including care plan content, during transitions of care

• ONC HIT Policy Committee received strong public support for referrals, transfers of care and care plans in MU3

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Why C-CDA Does Not Meet MU3 Needs

• Lack of ability to fully represent needed care plan content and relationships

• Insufficient C-CDA templates to fully meet the needs and responsibilities of Eligible Professionals and Hospitals as senders and receivers of information during transitions of care

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C-CDA MU3 Care Plan Gaps

• Limited support for critical Care Plan components: health risks and safety concerns, non-prescription interventions, patients’ overarching goals, barriers, nutrition assessment and diet orders

• No standard for…– Codifying all of the Longitudinal Care team members– Conveying when and how each section was last reconciled for a

given patient– Conveying the many-to-many relationships between the

components of the Care Plan– Applying a signature to a previously signed CDA document (e.g. a

Home Health Plan of Care)

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CMS, ASPE, CDE, VA and DoD need a CDA-based HHPoC, independent of MU

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IMPACT Project: Addressing C-CDA MU3 Transition of

Care Gaps

IMPACT Grant

• Improving Massachusetts Post-Acute Care Transitions (IMPACT) Grant Awarded in February 2011

• HHS/ONC State HIE Challenge Grant Fund

– MA (MTC/MeHI) one of four Challenge Grant Awardees focused on LTPAC HIE

– $1.7M total funding

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Datasets for Care Transitions

• Traditionally—What the sender thinks is important to the receiver

• Future—Also take into account what the receiver says they need

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“Receiver” Data Needs Survey

• Largest survey of Receivers’ needs• 46 Organizations completing evaluation• 11 Types of healthcare organizations• 12 Different types of user roles• 1135 Transition surveys completed

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Additional Contributor Input

• MA Universal Transfer Form workgroup• Boston’s Hebrew Senior Life eTransfer Form• IMPACT learning collaborative participants• MA Coalition for the Prevention of Medical Errors • MA Wound Care Committee• Home Care Alliance of MA (HCA)

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• NY’s eMOLST• Multi-State/Multi-Vendor EHR/HIE

Interoperability Workgroup• Substance Abuse, Mental Health Services

Agency (SAMHSA)• Administration for Community Living (ACL)• Aging Disability Resource Centers (ADRC)• National Council for Community Behavioral

Healthcare• National Association for Homecare and

Hospice (NAHC)• Transfer of Care & CCD/CDA Consolidation

Initiatives (ONC’s S&I Framework)

• Longitudinal Coordination of Care Work Group (ONC S&I Framework)

• ONC Beacon Communities and LTPAC Workgroups

• Assistant Secretary for Planning and Evaluation (ASPE): Standardizing MDS and OASIS

• ASPE/Geisinger/HL7 : LTPAC Summary Documents (using MDS and OASIS)

• Centers for Medicare & Medicaid Services (CMS)(MDS/OASIS/IRF-PAI/CARE)

• INTERACT (Interventions to Reduce Acute Care Transfers)

• Transfer Forms from Ohio, Rhode Island, New York, and New Jersey

MU3 C-CDA Template Gaps

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CCD Data Elements

IMPACT Data Elements for basic Transition of Care

needs

Data Elements for Longitudinal Coordination of Care

•Many “missing” data elements can be mapped to CDA templates with applied constraints

•20% have no appropriate templates

Five Transition Datasets

1. Report from Outpatient testing, treatment, or procedure

2. Referral to Outpatient testing, treatment, or procedure (including for transport)

3. Shared Care Encounter Summary (Office Visit, Consultation Summary, Return from the ED to the referring facility)

4. Consultation Request Clinical Summary (Referral to a consultant or the ED)

5. Permanent or long-term Transfer of Care to a different facility or care team or Home Health Agency

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Shared Care Encounter Summary:•Office Visit to PHR•Consultant to PCP•ED to PCP, SNF, etc…

Consultation Request:•PCP to Consultant•PCP, SNF, etc… to ED

Transfer of Care:•Hospital to SNF, PCP, HHA, etc…•SNF, PCP, etc… to HHA•PCP to new PCP

Five Transition Datasets

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Home Health Plan of Care

Care Plan

Care Plan & Plan of Care

IMPACT Dataset for Testing

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Transfer of Care:•Hospital to SNF, PCP, HHA, etc…•SNF, PCP, etc… to HHA•PCP to new PCP

• 16 Pilot sites in central Massachusetts• Several hundred transitions tested

on paper• 93% found the elements• 92% receivers’ needs

met

IMPACT Transfer of Care CDA Document

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Further Testing of IMPACT Dataset

• Massachusetts ePilot starting in July 2013 with 2 hospitals, 2 large group practices, 2 home health agencies, 8 SNFs, 1 IRF, 1 LTACH

• Electronic exchange of full Transfer of Care dataset

• >1000 document transfers/month

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ONC S&I LCC WG: Advancing Transitions of

Care & Care Planning

Longitudinal Coordination of Care

Workgroup

Longitudinal Coordination of Care

Workgroup

Patient Assessment

Summary (PAS SWG

LTPAC Care Transition SWG

Longitudinal Care Plan SWG

• Engage directly with HL7 to establish the standards for the exchange of patient assessment summary documents

• Inform the development of the Keystone Beacon PAS Document Exchange

• Identify the key business and technical challenges that inhibit LTC data exchanges

• Define data elements for long-term and post-acute care (LTPAC) information exchange using a single standard for LTPAC transfer summaries

• Identify standards for an interoperable, longitudinal care plan* which aligns, supports and informs person-centric care delivery regardless of setting or service provider

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ONC S&I LCC WG Organization

*Care Plan standards will enable providers to create, transmit and incorporate care plans and needed content for the benefit of medically complex and/or functionally impaired individuals, their families and caregivers.

COMMUNITY-LED INITIATIVE

HL7 Tiger Team SWG

• Educate the LCC Community on related HL7 processes, framework and evolving standards relevant to LCC

• Gather and generate comments for HL7 Care Plan related evolving standards (Care Coordination Services & Care Plan Domain Analysis Model (DAM))

LCC WG Coordination with Other National Initiatives

• CMS esMD: advancing standards for Electronic Submission of Medical Documentation (esMD)

• ASPE: sponsoring and collaborating with LCC WG to identify standards for interoperable assessments, assessment summary documents, and care plans

• DoD and VA: working to specify Home Health Plan of Care data

• HL7 Structured Document, Patient Care, and Care Coordination Services Workgroups

• IHE Patient Care Coordination Technical Committee• AHIMA LTPAC HIT Collaborative• HIMSS: Continuity of Care Model

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Lantana C-CDA Revisions Project

• Lantana contracted to work with LCC WG to make and ballot revisions to C-CDA for Aug/Sept 2013 HL7 Ballot Cycle

• One ballot package to address 4 revisions based on IMPACT Dataset:– Update to C-CDA Consult Note

– NEW Referral Note

– NEW Transfer Summary 

– NEW Care Plan document type (will include HHPoC digital signature requirements and will align with HL7 Patient Care WG's Care Plan Domain Analysis Model- DAM)

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LCC WG Care Plan Glossary: Key Terms & Components

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Term/ Component

LCC Proposed Definition

Care Plan The term “care plan” considers the whole person and focuses on a number of health concerns to achieve high level goals related to healthy living. Care Plan and Plan of Care share the SIX components: health concern, goals, instructions, interventions, outcomes, and team member

Health Concern Reflect the issues, current status and 'likely course' identified by the patient or team members that require intervention(s) to achieve the patient's goals of care, any issue of concern to the individual or team member

Goals A defined outcome or condition to be achieved in the process of patient care. Includes patient defined goals (e.g., prioritization of health concerns, interventions, longevity, function, comfort) and clinician specific goals to achieve desired and agreed upon outcomes.

Instructions Information or directions to the patient and other providers including how to care for the individual’s condition, what to do at home, when to call for help, any additional appointments, testing, and changes to the medication list or medication instructions, clinical guidelines and a summary of best practice.Detailed list of actions required to achieve the patient's goals of care.

Interventions Actions taken to maximize the prospects of achieving the patient's or providers' goals of care, including the removal of barriers to success. Instructions are a subset of interventions.

Outcomes Status, at one or more points in time in the future, related to established care plan goals.

Team Member Parties who manage and/or provide care or service as specified and agreed to in the care plan, including: clinicians, other paid and informal caregivers, and the patient.

LCC WG Timeline: Mar 2013 – Dec 2013

Mile

ston

es

Pilot Identification & Engagement

Care Plan IGs Complete

Lantana Contract Awarded

HL7 Project Scope Statement Due

HL7 Intent to Ballot DueHL7 Fall Ballot Open

NY Pilots Monitoring

LCC Care Plan Use Case 2.0 Development & Consensus

IMPACT ToC Pilot Monitoring

IMPACT Care Plan Pilot Monitoring

HL7 Ballot Publication

ToC IGs Development (Transfer Summary, Referral Note, Consult Note)

ToC IGs Complete

HL7 Final Ballot Due

LCC Stakeholder Engagement: Lantana, IMPACT, ASPE, NY, CMS

Care Plan/ Home Health Plan of Care IG Development

HL7 Ballot Package Development

HL7 Ballot & Reconciliation

FACA LCC WG Briefings

LCC & HL7 Care Plan Coordination

IMPACT Go-Live

NY Care Coordination Go-Live

EP, Hospital, and LTPAC EHR vendors want these standards

• Multiple vendors are participating in S&I LCC WG• Multiple vendors are exploring incorporating the standards

into their products• Several intend to pilot the pre-balloted versions in their

products in Massachusetts, New York and Tennessee • Several national LTPAC providers are exploring piloting and

incorporating these standards into their products

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Summary & Next Steps

ONC and CMS have identified requirements for Meaningful Use Stage 3 that require updates to the Consolidated CDA this fall

CMS, ASPE, CDC, VA and DoD have identified the need for a CDA-based Home Health Plan of Care that require updates to the C-CDA this fall

ONC funded IMPACT and S&I Framework to specify the required updates to the C-CDA

NY state HIEs (NYeC, Healthix, CCITY-NY) have hired Lantana to complete these updates to the C-CDA and ballot these revisions with HL7 in advance of MU3 NPRM

ASPE will sponsor development of new Care Plan/HHPoC Document types

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Questions?

LCC Initiative: Resources & Questions

• LCC Leads

– Dr. Larry Garber (Lawrence.Garber@reliantmedicalgroup.org)

– Dr. Terry O’Malley (tomalley@partners.org)

– Dr. Bill Russell (drbruss@gmail.com)

– Sue Mitchell (suemitchell@hotmail.com)

• LCC/HL7 Coordination Lead

– Dr. Russ Leftwich (Russell.Leftwich@tn.gov)

• Federal Partner Lead

– Jennie Harvell (jennie.harvell@hhs.gov)

• Initiative Coordinator

– Evelyn Gallego (evelyn.gallego@siframework.org)

• Project Management

– Becky Angeles (becky.angeles@esacinc.com)

– Lynette Elliott (lynette.elliott@esacinc.com)

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LCC Wiki Site: http://wiki.siframework.org/Longitudinal+Coordination+of+Care

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Supporting Documentation

Communication & Adverse Events

• Poor care coordination increases the chance that a patient will suffer from a medication error or other health care mistake by 140% (Lu, et al., 2011)

• Communication failures between providers contribute to nearly 70% of medical errors and adverse events in health care (Gandhi, et al., 2000)

• 150,000 preventable ADEs ($8 Billion nationwide wasted) each year occur at the time of admission due to inadequate knowledge of outpatient medication history (Stiell, et al., 2003)

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Problems with ED Visits

• Physicians in the Emergency Department (ED) lack important or critical patient information 32% of the time

• 15% of ED admissions could be avoided if the ED had outpatient information (Stiell, et al., 2003)

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Problems After Hospital Discharge

• 1.5 Million preventable adverse events annually nationwide from discharge treatment plans not followed (Forster, et al., 2003)

• When multiple physicians are treating a patient following a hospital discharge, 78% of the time information about the patient’s care is missing (van Walraven, et al., 2008)

• 20% of Medicare patients are readmitted within 30 days. Preventable readmissions waste $26B nationwide annually (McCarthy, et al., 2009)

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Ambulatory Care is just as bad

• 68% of specialists receive no information from the referring PCP prior to referral visits

• 25% of PCPs do not receive timely post-referral information from specialists (Gandhi, et al., 2000)

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Physician Office

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Living at Home

CBSOutpt. Rehab

Home Health

Adult Day Care

PACE

Assist

Living

Nursing

Home

SNF

LTACH

IRF

Acute Care

Hospital

Emergency Department

Urgent

Care

Psych Hospital

Hospice Facility

Home Hospice

Outpt. Behav. Health

Acuity of Illness

Inte

nsi

ty o

f C

are

Adapted from Derr and Wolf, 2012

Low

High

High

The Spectrum of Care

Outpatient Testing/Pharmacy/DME

Where do patients go after hospital?

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Everywhere!

MU’s Impact on LTPAC

• ~40% of Medicare patients are discharged to traditional LTPAC settings (SNF, Home Health, Inpatient Rehab Facility, etc…)

• These patients are the sickest population and account for ~75% of Medicare costs

• Hospitals must be responsible, and given the tools, to convey the information needed by the recipient of a patient during care transitions

Sources: http://aspe.hhs.gov/health/reports/2011/pacexpanded/index.shtml#ch1http://www.medpac.gov/documents/Jun11DataBookEntireReport.pdf

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Testing the IMPACT Transfer of Care Dataset

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Transfer of Care:•Hospital to SNF, PCP, HHA, etc…•SNF, PCP, etc… to HHA•PCP to new PCP

IMPACT Dataset for Testing

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Spring 2012, on paper:

2 hospitals, 2 large group practices, 2 home health agencies, 8 SNFs, 1 IRF, 1 LTACH, and

several hundred patient transfers…

Testing the Transfer of Care Dataset

Senders found the data

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Receivers got most of their needs

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Home Care needed even more!

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LCC WG Key Successes to meet MU3 needs

• (JUNE 12) LCC Use Case 1.0: Expanded from S&I ToC Use Case; identified 360+ additional data elements

• (AUG 12) Care Plan Whitepaper “Meaningful Use Requirements For: Transitions of Care & Care Plans”

• (OCT 12) IMPACT Dataset: Consensus built Transitions of Care and Care Plan/HHPoC dataset (483 data elements). Deep dive of LCC Use Case 1.0

• (MAY- SEPT 12) Balloted 3 standards through HL7: Stage 2MU C-CDA Refinements interoperable exchange of Functional Status, Cognitive Status, & Pressure Ulcer; Questionnaire Assessment; and LTPAC Summary IG

• (OCT 12) Stage 3 MU Care Plan Questions for HITPC MU WG• (DEC 12) Care Plan Glossary• (JAN 13) Community Led submission to HITPC RFC Stage 3 MU• (MAR 13) IMPACT Transfer of Care High-level IG

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