Health Information Exchange and Care Coordination for Persons Receiving LTPAC Services ASPE and CMS...

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Health Information Exchange and

Care Coordination for Persons Receiving LTPAC Services

ASPE and CMS Briefing

Jennie HarvellLarry Garber, MD

Terry O’Malley, MDBill Russell, MD

Walter Rosenberg, MSWMarch 28, 2013

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Challenges and ProblemsTransitions in Care and instances of shared care

are common.

Health information is siloed, often not shared (or shared in time) across providers/caregivers, and not shared between health information systems.

The lack of timely health information exchange results in:◦ Poor continuity and coordination care◦ Errors resulting in safety and quality problems◦ Redundancies in tests/other services◦ Avoidable ER admissions and hospital readmissions ◦ Unnecessary costs

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Health Information ExchangeA national priority:Essential for the success of many

health system reform activitiesHHS published an RFI on the

policy and programmatic levers to accelerate HIE, including for persons who receive LTPAC services

https://www.federalregister.gov/articles/2013/03/07/2013-05266/advancing-interoperability-and-health-information-exchange






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AgendaThe need for exchanging information at times

of transitions in care and shared care

Low cost and near term solutions for engaging LTPAC providers in HIE activities

Exchanging information across acute, post-acute, and long-term service and support providers

Advancing standards for the interoperable exchange of information to support transitions of care, shared care, and care planning

Questions and Answers

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)

• Timely information often does not follow from hospital discharge to community-based providers.

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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)

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Problems with Current Standards

• Health IT standards are lacking for needed HIE:

– Lack standardized Care Plan terminology and definitions

– Consolidated CDA (C-CDA) document types (e.g. CCD) fail to meet the needs and responsibilities of physicians, patients, hospitals and LTPAC providers as senders and receivers of information during transitions of care

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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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IMPACT Grant

February 2011 – HHS/ONC awarded $1.7M HIE Challenge Grant to state of Massachusetts (MTC/MeHI):

Improving Massachusetts Post-Acute

Care Transfers (IMPACT)

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14x14 Sender (left column) to Receiver (top) = 196 possibly transition types

Transitions to (Receivers)In Patient ED Outpatient Behavioral LTAC IRF SNF/ECF HHA Hospice Amb Care EMS BH CBOs Patient/

Acute Care Services Health CommunityTransitions From (Senders) Hospitals Inpatient (PCP) Services Family

Inpatient Acute Care Hospital

Emergency Department

Outpatient services

Behavioral Health Inpatient

Long Term Acute Care Hospital

Inpatient Rehab Facility

Skilled Nursing/Extended Care

Home Health Agency

Hospice

Ambulatory Care (PCP, PCMH)

Emergency Medical Services

Behavioral Health Community

Community Based Organizations

Patient/Family

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“Receiver” Data Needs Survey

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

Findings from Survey• Identified for each transition which data

elements are required, optional, or not needed

• Each of the data elements is valuable to at least one type of Receiver

• Many data elements are not valuable in certain care transition

• A single paper form can’t represent this variability in data needs

• Can be grouped into 5 types of transitions14

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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Five Transition Datasets

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5 – Transfer of Care Summary

4 – Consultation Request Clinical Summary3 – Shared Care Encounter Summary

2 – Test/Procedure Request1 – Test/Procedure Report

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


Transitions to (Receivers)

In Patient ED Out patient LTAC IRF SNF/ECF HHA Hospice Amb Care CBOs Patient/Transitions From (Senders) Services (PCP) Family

In patient

ED

Out patient services

LTAC

IRF

SNF?ECF

HHA

Hospice

Ambulatory Care (PCP)

CBOs

Patient/Family17

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3

5

5

5

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Additional Contributor Input•State (Massachusetts)– 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)

•National– 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)/Geisinger MDS HIE– 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

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Longitudinal Care Coordination

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5 – Transfer of Care Summary5 – Transfer of Care Summary5 – Transfer of Care Summary

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2 – Test/Procedure Request1 – Test/Procedure Report

Care Plan

HH POC (CMS-485)• Anticoagulation• CHF




Home Health Plan of Care

Care Plan

How do they compare to CCD?

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175325483

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

•30% have no appropriate templates

ADVANCING HEALTH INFORMATION EXCHANGE TO IMPROVE CARE DELIVERY

AND COORDINATION: EXCHANGING ASSESSMENTS AND CLINICAL SUMMARIES

Bill Russell, MDSeasons Hospice and Palliative Care

ONC Consultant, Theme 2 Challenge Grants21

PAINTING THE PICTURE OF CLINICAL DOCUMENTATION IN LTPAC:

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Moving to Electronic Records• Most providers try to maintain paper records while converting

to EHR’s• Hybrid Charts (Partial paper documents plus electronic data in

multiple systems) create datasets that are even more fragmented.

• There are now multiple additional sources of electronic data• Institutional Pharmacy, Laboratory, Physician EHR data,

Referral source EHR and Health Information Exchange– Providers are responsible for a core of health information

as described in Conditions of Participation, but:• Accessing this data is associated with cost to facilities• IT resources to collect and integrate this information

are constrained or unavailable.23

EHR Technology for LTPAC• LTPAC care delivery depends on a complementary set of clinical

data– Nursing, Rehab and Supportive Care Assessments– Care planning and coordination

• At present, HIT functionality in LTPAC focuses on compliance and financial performance– Clinical assessments are implemented around required tasks (e.g. Fall or

Skin Integrity risk assessments) but the “story of the patient” is often difficult to extract from the LTPAC EHR.

• Health IT standards are available for:– Federally required assessments.

• However, assessments are not generally exchanged using these health IT standards

– Functional and Cognitive status.• Otherwise, there are few standards for document structure,

assessments and terminologies that support clinical services in LTPAC. 24

Moving Forward• Strategic Planning is needed to advance

electronic health information exchange and re-use to support care coordination on behalf of persons who receive LTPAC services. Strategic planning could guide development and use of HIT/EHRs that will support:– caregiving, HIE, and care coordination in this sector,

and – successful implementation of the MU program

• At present, interoperable health information exchange with LTPAC providers is at best “opportunistic ” 25

GETTING IT RIGHT IN LTPAC:

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“Meeting Them Where They Are”

• Singular pocket of complete IT adoption– Federally Required Assessments

Strategy: Make electronic data created for MDS and OASIS submissions available for interoperable exchange in ToC and Shared Care

• While the exchange of assessment data has limits:– It provides some clinically useful information at times of

ToC and shared cared; and– It is a starting point for engaging LTPAC providers in HIE.

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Keystone Beacon Community

Transitions of Care Use Cases:

Acute discharge to nursing homes (NH)

Acute discharge to home health agency (HHA)

NH discharge to HHA

NH transfer to emergency department (ED)

HHA patient with ED visit

Use Case barriers:

• NH/HHA with no EHR

• NH/HHA with EHR, but no HIE interfaces

• HIE interfaces, but no standard CCD (both NH and HHA)

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MDS or OASIS Clinical Summary

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Transform™

Advanced through the Standards and Interoperability (S&I) Initiative.HL7 Balloted. Nationally available Web service.

LTPAC HIE

LTPAC to HIE

Copyright 2013 Keystone Beacon Community Used with Permission

Approach – Easy to Set up

Set up:

1. Enter site information

2. Point to assessment folder

3. Enter e-mail4. Identify recipient

of LTPAC Summary

Visit http://transform.keyhie.org 30

http://transform.keyhie.org/

Operation:

1. Runs automatically2. Self-service tools3. Help Desk support

Approach – Easy to Operate

Visit http://transform.keyhie.org

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Sample LTPAC Summary from MDS

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Principles:

1. No set up or transactions fees

2. One low annual fee3. Sustainable operations4. X-Large group pricing

Annual Pricing

Annual fees:• Small facility $499 ($40/mo.)

• Medium facility $699 ($60/mo.)

• Large facility $899 ($75/mo.)

• XL/Group pricing available

Visit http://transform.keyhie.org

Entity (Metric) Small Medium Large

Nursing Home (# Residents/beds) 0-49 50-199 200-399

Home Health Agency (# Medicare patients) 0-99 100-299 300-499

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“Meeting Them Where They Are”• Widespread adoption of clinical process change to improve care of

patients with Change in Condition:– INTERACT Program

• Widespread adoption of ADL tracking systems because of their affect on payment

Strategy: Leverage LTPAC ADL tracking software, MD EHR adoption, HIE and DIRECT (secure) Messaging to support the creation and exchange of a Change in Condition Document. This allows:

Notification of off site physicians when a NF resident has a change in condition to increase Medical Provider participation in assessments and decision making. Inspired by INTERACT, this workflow is currently specific to NF. Future use cases could include caregivers of homebound patients.

Improved shift to shift and discipline to discipline communication around at risk persons.

Documentation becomes available to ED’s or consultants if a patient requires emergency services or additional assessments to improve care 34

OK Challenge Grant• Extensive Implementation Plan and “Boots on the Ground” with NFs

• Overcome barriers by working with vendors and providers to adapt ADL tracking software to alert and document Change in Condition

• Collaborated with AHRQ to overcome implementation barriers

• Developed a Health IT standardized (CCD format) for SBAR* (nursing note generated with Change in Condition)

• Connected to HIE and exchanging from the NH to physicians and hospitals the electronic Change in Condition/SBAR document.

*SBAR: Situation, Background, Assessment, Recommendation, a technique used for communication in health care organizations, including NHs.

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Preliminary Metrics (October-December 2012)Short Description

Ratio of Completed SBARs and Health Alerts to hospital transfers

2207 (SBARs and Health Alerts grand total) 81 (Transfers) 3.6%

Ratio of Completed SBARs hospital transfers 260 (Completed SBARs) 81 (Transfers) 31%

Ratio of Completed Health Alerts to hospital transfers 1947 (Health Alerts total) 81 (Transfers) 4.1%

% of Patients Surveyed with a Positive Care Transitions Experience

9 (Satisfied residents) 13 (Surveyed Residents) 69.2%

% of transfers from NRHS to NF with completed transfer form NA NA Pending

% of transfers from NF to ED with completed transfer form NA NA Pending

% of transfers from NF to Inpatient Admit with completed transfer form

NA NA Pending

Incomplete measurements pending

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Summary

• Medically complex patients are increasingly cared for in LTPAC settings

• Information flows between hospitals, physicians, and LTPAC providers are fragmented.

• Technology solutions are limited by – Inconsistent adoption– Poorly aligned standards

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Summary• Need a strategic plan to advance widespread

interoperable health information exchange and re-use on behalf of persons who receive LTPAC services.

• Strategies to close the gap include:– Increase use of certified EHR Technology in LTPAC– Develop standards to create and exchange content relevant to

LTPAC– Receiver specified document content– Lightweight and low cost technologies to connect critical

information sets and introduce Health Information Exchange to the LTPAC sector

– Automation of best practices shown to reduce hospital readmissions

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Care Coordination and

Health Information Exchange Bridge Model Perspective

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Social work in transitions

• Bridge model history– Rush University Medical

Center– Aging Care Connections

• Themes emerged– Hospital-community

disconnect– Aging network

underutilization– Systemic barriers– Information transfer

problems

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Illinois Transitional Care Consortium

• Aging Care Connections• Health & Medicine Policy Research Group• Rush University Medical Center• Shawnee Alliance for Seniors• Solutions for Care• University of Illinois, School of Public Health

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The Model

• “How are you now?”• Three phases

– Pre-discharge• Interdisciplinary team• Community services• EMR research

– Post-discharge• Interwoven assessment and intervention• Intensive care coordination• Motivational interviewing• Coordinating post-discharge providers

– 30-day follow-up 44

Aging Resource Centers

• Represents a true hospital-community partnership• CMIS system• Community resource information• Care planning• EMR access for community social workers

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The Bridge Model: Replication Sites

Chicago & Suburbs, IL6 Sites*

Danville, ILCommunity-based organization (CBO), Aging Network

Illinois Hospital Association partnership across the State8 sites

Philadelphia, PA*Area Agency on Aging

Brunswick, GAArea Agency on Aging

San Fernando, CA*Health care organization

North DakotaState Unit on Aging

Brooklyn, NY*CBO

*Community-based Care Transition Program replication sites. Carbondale and Herrin, IL2 sites, CBO, Aging Network

East Lansing, MI* Area Agency on Aging

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De facto teams

Coordinating existing systems to better serve older adults and their caregivers Client

HospitalPrimary

Care Physician

Home Health

Community Based

Agencies

CaregiversSkilled

Nursing Facility

Pharmacy

Non-traditional Resources

Aging Network

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Information interface

• Area Agencies on Aging• Community-based Care Transitions Programs• Home health agencies

– Telehealth

• Patient EMRs• Primary Care Physicians• Pharmacy• SNF

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PERFECT

• Plan of Care• Equipment/Supplies• Reconciliation• Follow-up with physician• Expectations met?• Coordination of care

– Non PCP coordination (community services, DMEs, etc.)

• Therapy49

Advancing Interoperable HIE – development and

adoption of HIT standards

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Advancing Interoperable HIE

Identify need for electronic

HIE

Identify gaps in HIE standards

Fill gaps in standards:

Work with ONC S&I, HL7, other Standards

Development Organizations (SDOs)

Ballot Needed Standards

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Regular/On-going communication with CMS,

ONC, HIT Policy and Standards Committee

regarding need for and status of standards

• Initiated in October 2011 as a community-led initiative with multiple public and private sector partners

• Advances interoperable health information exchange (HIE) on behalf of LTPAC stakeholders and promotes LCC on behalf of medically-complex and/or functionally impaired persons

• Goal: identify standards that support LCC that are aligned with and could be included in the EHR Meaningful Use Programs– Identified content standards that were included in the

EHR Meaningful Stage 2 Programs for Functional and Cognitive Status.

– Influence Meaningful Use Stage 3 standards for HIE for transitions in care and care plans.52

S&I’s Longitudinal Coordination of Care WG

Longitudinal Coordination of Care Workgroup

Patient Assessment Summary Sub-

Workgroup*

LTPAC Care Transition Sub-

Workgroup

Longitudinal Care Plan Sub-

Workgroup

• Providing subject matter expertise and coordination of SWGs

• Developing systems view to identify interoperability gaps and prioritize activities

• Establishing the standards for the exchange of Patient Assessment Summary (PAS) documents

• Providing consultation to transformation tool being developed by Geisinger to transform the non-interoperable MDSv3 and OASIS-C into an interoperable clinical document (CCD+)

• Identifying the key business and technical challenges that inhibit long-term care data exchanges

• Defining data elements for LTPAC information exchange using a single standard for LTPAC transfer summaries

• Identifying and developing key functional requirements and data sets that support exchange of care plan, including home health plan of care.

S&I’s Longitudinal Coordination of Care WG

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*Retired December 2012

Coordinating standards effortsFocused on standards needed for Transitions of Care (ToC)

and Care Plans. Collaborators include:– ONC S&I ToC, esMD and LCC WGs– HL7 Structure Documents and Patient Care Workgroups– IHE Patient Care Coordination Technical Committee– AHIMA– ASPE– MA IMPACT Program

Deliverables include:• HL7 Balloted standards: C-CDA refinements for exchange of: Functional

Status, Cognitive Status, and Pressure Ulcer Content, and LTPAC Assessment Summary Documents. Balloted standards for Questionnaire Assessments.

• IMPACT TOC Data Set• Care Plan Glossary • Recommendations to HITPC RFC Stage 3 MU

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IMPACT Transfer of Care CDA Document

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LCC WG Care Plan Glossary and Use Case

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Care Plan

HH POC (CMS-485)




Home Health Plan of Care(with esMD Digital Signature)

Care Plan

Lantana will work with LCC to make and ballot HL7 CDA IGs

LCC WG Timeline: Mar 2013 – Dec 2013

Mar 13 Apr 13 May 13 Jun 13 Jul 13 Aug 13 Sep 13 Oct 13 Dec 13

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-LiveNY Care Coordination Go-Live

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ContactsLawrence.Garber@reliantmedicalgr

[email protected]@[email protected]@hhs.gov

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mailto:[email protected]






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