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Improving Financial & Clinical Performance Through

Health Information Exchange & Enhanced Transitions

LeadingAge NY 2017 Financial Professionals Conference

August 30, 2017

• Al Kinel: President Strategic Interests

• Travis Masonis: CIO Jewish Senior Life

• Cesar Perez: Sr. Account Manager Healthix (NYC RHIO)

• Jeff Norton: VP of Sales, SNF & ALF PointClickCare

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Agenda

▪ Measures Positively Impacted by HIE & ToCs

▪ Industry Actions to Utilize HIE to Enhance ToCs

▪ Perspectives of Jewish Senior Life

▪ Capabilities, Perspectives & Example from a RHIO

▪ Capabilities, Perspectives & Example from PCC

▪ Discussion: Barriers & Actions to Make a Difference

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CMS 5-Star Short-Stay Quality Measures

Source: Nursing Home Compare

Claims Based Measures

Measures:

• % Short-Stay Residents with 30 day Readmissions

• Hospital readmissions from SNF rehab

• Includes hospitalizations following SNF stay

• % Short-Stay Residents ED visit within 30 days

• Pop Health, Care Management, provider access

• Collaboration and use of telehealth

• % Short-Stay Residents Successfully Discharged to

Community

• MDS to identify patients discharged & claims

• Success: 30 days no hospital, SNF readmit death

Mechanics:

• Claims, in conjunction with MDS used to build stays

• Medicare FFS, soon to include Medicare Advantage

• Short stay residents following hospital stay

• Risk adjusted, based on claims, MDS & enrollment

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Hospital(s) Home Care / PGHD

Non-PCP Specialist

Urgent Care

CBOs / Social

Services

Labs, Rads, Geneticists

Behavioral Health

Disabilities

PT/OT

Community - PCMH

Transitions of CareWhere Information Gaps Appear & Compromise Care

SNF

Assisted Living

Inpatient Rehab

LTPAC

Health Home

PCP / FQHC

• Use Case 1:

– HOSPITAL to HOME

• Use Case 2:

– HOSPITAL to LTPAC

• Use Case 3:

– LTPAC to HOME

• Use Case 4:

– PCMH – PCP to Other

• Use Case 5:

– HOME to HOSPITAL

• Use Case 6:

– LTPAC to HOSPITAL

• Use Case 7:

– HOSPITAL to HOSPITAL

• Use Case 8:

– HOME to LTPAC

• Use Case 9:

– PROVIDER to BH/CBOs

• Use Case 10:

– Specialist to Specialist

Key Transitions

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Impact of Problems Associated with ToC

• 2001 Institute of Medicine (IOM) report, Crossing the Quality Chasm, described US

healthcare as decentralized, complicated, and poorly organized, noting “layers of processes

and handoffs that patients and families find bewildering and clinicians view as wasteful.”

• Health Affairs 2012: Inadequate care coordination, including inadequate management of

care transitions, estimated to cause $25 to $45 billion in wasteful spending in 2011 through

avoidable complications and unnecessary hospital readmissions.

• Commonwealth Fund 2013: Substantial proportion of readmissions caused in part by poor

discharge and transition planning and execution:

▪ ~ 20% hospitalized Medicare beneficiaries are readmitted within 30 days

▪ > 33% readmitted within 90 days

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Causes of Problems Associated with ToC

Source: Joint Commission Hot Topic in Health – Transition Planning 2012

• Communication: Providers do not effectively or completely communicate important information to each

other, the patient, or caregivers

Different Style / CultureNo Time for

Successful Handoff

• Patient Education: Patients or caregivers receive conflicting direction, confusing medications, and unclear

instructions about follow-up care. Patients may lack a understanding of medical condition or the plan

• Accountability breakdowns: In many cases, there is no physician or clinical entity that takes responsibility to

assure that the patient’s health care is coordinated across various settings and among different

Lack Standard

ToC ProcedureGap in Expectations

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Keys for Successful ToCs – More than HIE

• Right information, right time, right format…without extra noise

• Comprehensive Care Coordination, Health Coaching and PCMH Model

• Medication Management

• Effective Hand-offs to Providers and Social Workers

• Timely Post Discharge Follow-up

• Self-Management Care Plans with Patient Education and Clear Follow-up

• Identify and Provide Resources for Social Determinants of Care

• High Patient Satisfaction (correlated with lower 30 day readmit rates)

Sources:• Project BOOST (Better Outcomes by Optimizing Safe Transitions) – www.hospitalmedicine.org• Care Transitions Interventions (CTI) –www.caretransitions.org• CMS Community-Based Care Transitions Program (CCTP) – www.innovations.cms.gov/initiatives/CCTP/• Guided Care Comprehensive Primary Care for Complex Patients – www.guidedcare.org• Project RED (Re-Engineered Discharge) – www.bu.edu• State Action on Avoidable Rehospitalizations (STAAR) – www.ihi.org

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Partnering to Improve Transitions of Care (ToC)

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Hospitals & LTC/Home Health partners can jointly improve ToC effectiveness by

reviewing areas on both sides to change discharge planning, admit process & HIE:

• Improve Hospital-LTC ToC: discharge/admit▪ Screening and discharge efficiently getting patients to right facility

▪ Process & tools to provide LTC data needed to receive patient

• Collaborate After ToC: address patients & risks together▪ Process, tools, and alignment to identify patients at risk, gaps in care, actions to address

them, & means for team to communicate

• Improve LTC-Home ToC: discharge/admit▪ Discharge efficiently to home health agency, PCP, or both

▪ Process & tools to provide data and alert hospital

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Using IT & HIE to Improve Transitions of Care

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Process Technologies

Hospital Discharge Planning Care Management Tool - Creation of Care Plan

Risk Profile Scoring Tool

Referral Admin Process Discharge-Referral Process

LTC Admit Process

Metrics Reporting

Healthcare Information

Exchange (HIE)

Key Data from Hospital EMR in C-CDA

Transport Data (RHIO, DIRECT, Other)

Ability to Load Key Data in LTC EMR

Manage Patients at Risk Population Health – by payer, risk & other criteria

Dashboards & Rounding Tool with Alerts & Gaps

Telehealth: Surgeon, Care Team, Behavioral Health

LTC Discharge Process & HIE Key Data from LTC EMR in C-CDA

Transport Data (RHIO, DIRECT, Other)

Ability to Load Key Data in Home Health/PCP EMR

Transition

Of

Care

Transition

Of

Care

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LTPAC Attempting to Improve ToCs

S&I Framework - 2011

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Care Coordination Tool for ToC to LTC DataData Proposed to be Provided by Hospital Discharge

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DSRIP: Hospital Data that Facilitates LTPAC Care

Data Desired by LTPACRecipient Priority

Source Availability

Ease of Extraction

CDA Compatibility

Referrer Contact for Questions High High High Mod

02Sat High High High Mod

Detailed Pain Information High Mod Low Low

Detailed Functional and Cognitive Status High Mod Low Low

Pre-hospital admission meds High High High Mod

PT/OT care, abilities and willingness Mod High High Mod

Pressure ulcers / skin / wounds High High High Mod

Detailed Nursing Care: nutrition, hydration, devices, therapies

High High Mod Low

Advance Directives/MOLST High High Mod Low

Relative Notified of Transiton of Care? Mod Mod Mod Low

Vendor Supply / Info Mod Mod Mod Low

Notification regarding ToCs High High High N/A

FLPPS compared data requested by LTPAC to enable successful

transitions vs. ability to enable ToC to include additional data

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What do we have to do in our communities

to utilize HIE and other tools to improve

ToCs and enhance performance of SNFs and

Home Health agencies?