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Data Sets for Transitions and Longitudinal Coordination of Care

Data Sets for Transitions and Longitudinal Coordination of Care. HL7’s 27 th Annual Plenary Meeting September 23 rd , 2013 Terrence A. O’Malley, MD Medical Director Non-Acute Care Services Partners HealthCare System, Inc. 2. ToC and LCC Data Sets. Part 1. 3. Part 1. Sites of Care.

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Data Sets for Transitions and Longitudinal Coordination of Care

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  1. Data Sets for Transitions and Longitudinal Coordination of Care HL7’s 27th Annual Plenary Meeting September 23rd, 2013 Terrence A. O’Malley, MD Medical Director Non-Acute Care Services Partners HealthCare System, Inc

  2. 2

  3. ToC and LCC Data Sets Part 1 3

  4. Part 1 Sites of Care Longitudinal Care Plan Prioritized Transitions ToC and LCC Data Sets Receiver Specific Information Types of Transitions ToC- Transitions of Care LCC-Longitudinal Coordination of Care Receivers at each Site

  5. The Spectrum of Care is Vast… High Acute Care Hospital Psych Hospital Emergency Department PACE LTACH Home Health Outpt. Rehab Adult Day Care Outpt. Behav. Health CBS Intensity of Care IRF SNF Hospice Facility Urgent Care Physician Office Nursing Home Outpatient Testing/Pharmacy/DME Home Hospice Assist Living Living at Home Low Acuity of Illness High Adapted from Derr and Wolf, 2012 5

  6. Where do patients go after hospital? Everywhere! 7

  7. 14x14 Sender (left column) to Receiver (top) = 196 possibly transition types 8

  8. Reduced Grid 11x11 (no Behavioral Health)

  9. Low volume/Out of Scope

  10. Low: Volume, Clinical Instability, Time-Value

  11. Low and Medium: Volume, Clinical Instability, Time Value

  12. High, Medium, Low: Volume, Clinical Instability, Time Value

  13. Prioritizing Transitions by Volume, Clinical Instability and Time-Value of Information Black circles = highest priority Green circles = high priority

  14. Factors Influencing ToC Data • Origin of transfer • Destination of transfer • Reason for transfer • Consultation • Permanent transfer • Urgency of transfer • Elective • Urgent/Emergent

  15. Priority Transitions by Relevant Scenario: Transfer LTPAC to LTPAC 1 Scenario 1: Exchange between LTPAC sites

  16. Priority Transitions by Relevant Scenario: LTPAC to Discharge Home 1 2 Scenario 1: Exchange between LTPAC sites Scenario 2: Exchange from LTPAC sites to patient

  17. Priority Transitions by Relevant Scenario: Transfer LTPAC to Hospital 3 1 2 Scenario 1: Exchange between LTPAC sites Scenario 2: Exchange from LTPAC sites to patient Scenario 3: Exchange from LTPAC sites to ACH sites

  18. Priority Transitions by Relevant Scenario: Discharge Hospital to LTPAC 4 3 1 2 Scenario 1: Exchange between LTPAC sites Scenario 2: Exchange from LTPAC sites to patient Scenario 3: Exchange from LTPAC sites to ACH sites Scenario 4: Exchange from ACH sites to LTPAC sites

  19. Temporary Transitions: Emergent (Orange) Elective (Yellow) Permanent Transition: Open 4 3 1 2 Scenario 1: Exchange between LTPAC sites Scenario 2: Exchange from LTPAC sites to patient Scenario 3: Exchange from LTPAC sites to ACH sites Scenario 4: Exchange from ACH sites to LTPAC sites

  20. IMPACT “Receiver” Survey • Largest survey of Receiver data needs • 46 Organizations completed evaluation • 11 Types of healthcare organizations • 12 Different types of user roles • 1135 Transition surveys completed 21

  21. Findings from Survey • Each role group selected different data elements • Within role group the data sets were similar regardless of sending or receiving site • The composite data set contains every data element required by any receiver • Five generic transitions account for all LTPAC hand-offs 22

  22. Additional Contributor Input National • American College of Physicians • 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) • Longitudinal Coordination of Care Work Group (ONC S&I Framework) • Transfer of Care & CCD/CDA Consolidation Initiatives (ONC’s S&I) • Electronic Submission of Medical Documentation (esMD) (ONC S&I) • ONC Beacon Communities and LTPAC Workgroups • Assistant Secretary for Planning and Evaluation (ASPE) and Geisinger: Standardizing MDS and OASIS • Centers for Medicare & Medicaid Services (CMS)(MDS/OASIS/IRF-PAI/CARE) • DoD and VA: working to specify Home Health Plan of Care dataset • AHIMA LTPAC HIT Collaborative • HIMSS: Continuity of Care Model • INTERACT (Interventions to Reduce Acute Care Transfers) • Transfer Forms from Ohio, Rhode Island, New York, and New Jersey

  23. Five Transition Datasets • Report from Outpatient testing, treatment, or procedure • Referral to Outpatient testing, treatment, or procedure (including for transport) • Shared Care Encounter Summary (Office Visit, Consultation Summary, Return from the ED to the referring facility) • Consultation Request Clinical Summary (Referral to a consultant or the ED) • Permanent or long-term Transfer of Care Summary to a different facility or care team or Home Health Agency 24

  24. Five Transition Datasets • Shared Care Encounter Summary (AKA Consult Note): • Office Visit to PHR • Consultant to PCP • ED to PCP, SNF, etc… 5 – Transfer of Care Summary 1 – Test/Procedure Report 2 – Test/Procedure Request 4 – Consultation Request Clinical Summary 3 – Shared Care Encounter Summary • Consultation Request: • PCP to Consultant • PCP, SNF, etc… to ED • Transfer of Care Summary: • Hospital to SNF, PCP, HHA, etc… • SNF, PCP, etc… to HHA • PCP to new PCP 25

  25. Five Transition Datasets 5 3 1 5 5 2 4 5 26

  26. Role Groups by Transition

  27. Home Health Plan of Care Care Plan • Shared Care Encounter Summary (AKA Consult Note): • Office Visit to PHR • Consultant to PCP • ED to PCP, SNF, etc… 5 – Transfer of Care Summary 5 – Transfer of Care Summary 5 – Transfer of Care Summary 5 – Transfer of Care Summary Datasets include Care Plan • Anticoagulation • CHF 1 – Test/Procedure Report 2 – Test/Procedure Request 4 – Consultation Request Clinical Summary 3 – Shared Care Encounter Summary • Transfer of Care Summary: • Hospital to SNF, PCP, HHA, etc… • SNF, PCP, etc… to HHA • PCP to new PCP • Consultation Request: • PCP to Consultant • PCP, SNF, etc… to ED 28

  28. Transition of Care vs Care Plan • ToC • Simple, flat, one transition Site A to Site B • Conveys essential clinical data as required by receivers • One point in time • Care Plan • Complex, multidimensional, iterative • All ToC data elements • Plus relationships among • Team members, Health concerns, Interventions and Goals • Patient priorities • Master blueprint for care across sites and providers

  29. Patient Status • Functional • Cognitive • Physical • Environmental Assessments Patients are evaluated with assessments (history, symptoms, physical exam, testing, etc…) to determine their status 30

  30. Health Conditions/ Concerns Active Problems Disease Progression • Risks/Concerns: • Wellness • Barriers • Injury (e.g. falls) • Illness (e.g. ulcers, cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc…) • Patient Status • Functional • Cognitive • Physical • Environmental Assessments Disabilities/ Concerns Barriers Treatment Side effects • Risk Factors • Age, gender • Significant Past Medical/Surgical Hx • Family Hx, Race/Ethnicity, Genetics • Historical exposures/lifestyle (e.g. alcohol, smoke, radiation, diet, exercise, workplace, sexual…) Risks Patient Status helps define the patient’s current conditions, concerns, and risks for conditions Risks/concerns come from many sources 31

  31. Care Plan Decision Modifiers • Patient/family preferences (values, priorities, wishes, adv directives, expectations, etc…) • Patient situation (access to care, support, resources, setting, transportation, etc…) • Goals • Desired outcomes and milestones • Readiness • Prognosis • Related Conditions • Related Interventions • Progress Health Conditions/ Concerns Active Problems Disease Progression Prioritize • Risks/Concerns: • Wellness • Barriers • Injury (e.g. falls) • Illness (e.g. ulcers, cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc…) • Patient Status • Functional • Cognitive • Physical • Environmental Assessments Disabilities/ Concerns Barriers Treatment Side effects • Risk Factors • Age, gender • Significant Past Medical/Surgical Hx • Family Hx, Race/Ethnicity, Genetics • Historical exposures/lifestyle (e.g. alcohol, smoke, radiation, diet, exercise, workplace, sexual…) Risks Goals for treatment of health conditions and prevention of concerns are created collaboratively with patient taking into account their statuses and Care Plan Decision Modifiers 32

  32. Care Plan Decision Modifiers • Patient/family preferences (values, priorities, wishes, adv directives, expectations, etc…) • Patient situation (access to care, support, resources, setting, transportation, etc…) • Goals • Desired outcomes and milestones • Readiness • Prognosis • Related Conditions • Related Interventions • Progress Health Conditions/ Concerns Active Problems Disease Progression Prioritize • Risks/Concerns: • Wellness • Barriers • Injury (e.g. falls) • Illness (e.g. ulcers, cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc…) Decision Support • Patient Status • Functional • Cognitive • Physical • Environmental Assessments Disabilities/ Concerns Barriers Treatment Side effects • Risk Factors • Age, gender • Significant Past Medical/Surgical Hx • Family Hx, Race/Ethnicity, Genetics • Historical exposures/lifestyle (e.g. alcohol, smoke, radiation, diet, exercise, workplace, sexual…) Risks Decision making is enhanced with evidence based medicine, clinical practice guidelines, and other medical knowledge 33

  33. Care Plan Decision Modifiers • Patient/family preferences (values, priorities, wishes, adv directives, expectations, etc…) • Patient situation (access to care, support, resources, setting, transportation, etc…) • Patient allergies/intolerances • Interventions/Actions • (e.g. medications, wound care, procedures, tests, diet, behavior changes, exercise, consults, rehab, calling MD for symptoms, education, anticipatory guidance, services, support, etc…) • Start/stop date, interval • Authorizing/responsible parties/roles/contact info • Setting of care • Instructions/parameters • Supplies/Vendors • Planned assessments • Expected outcomes • Related Conditions • Status of intervention • Goals • Desired outcomes and milestones • Readiness • Prognosis • Related Conditions • Related Interventions • Progress Health Conditions/ Concerns Active Problems Disease Progression Orders, etc.. Prioritize • Risks/Concerns: • Wellness • Barriers • Injury (e.g. falls) • Illness (e.g. ulcers, cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc…) Decision Support Decision Support • Patient Status • Functional • Cognitive • Physical • Environmental Assessments Disabilities/ Concerns Barriers Treatment Side effects • Risk Factors • Age, gender • Significant Past Medical/Surgical Hx • Family Hx, Race/Ethnicity, Genetics • Historical exposures/lifestyle (e.g. alcohol, smoke, radiation, diet, exercise, workplace, sexual…) Risks Interventions and actions to achieve goals are identified collaboratively with patient taking into account their values, situation, statuses, risks & benefits, etc… 34

  34. Care Plan Decision Modifiers • Patient/family preferences (values, priorities, wishes, adv directives, expectations, etc…) • Patient situation (access to care, support, resources, setting, transportation, etc…) • Patient allergies/intolerances • Interventions/Actions • (e.g. medications, wound care, procedures, tests, diet, behavior changes, exercise, consults, rehab, calling MD for symptoms, education, anticipatory guidance, services, support, etc…) • Start/stop date, interval • Authorizing/responsible parties/roles/contact info • Setting of care • Instructions/parameters • Supplies/Vendors • Planned assessments • Expected outcomes • Related Conditions • Status of intervention • Goals • Desired outcomes and milestones • Readiness • Prognosis • Related Conditions • Related Interventions • Progress Health Conditions/ Concerns Care Plan Active Problems Disease Progression Orders, etc.. Prioritize • Risks/Concerns: • Wellness • Barriers • Injury (e.g. falls) • Illness (e.g. ulcers, cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc…) Decision Support Decision Support • Patient Status • Functional • Cognitive • Physical • Environmental Assessments Disabilities/ Concerns Barriers Side effects • Risk Factors • Age, gender • Significant Past Medical/Surgical Hx • Family Hx, Race/Ethnicity, Genetics • Historical exposures/lifestyle (e.g. alcohol, smoke, radiation, diet, exercise, workplace, sexual…) Risks The Care Plan is comprised of Modifiers, Conditions/Concerns, their Goals, Interventions/Actions/Instructions, Assessments and the Care Team members that actualize it 35

  35. Care Plan Decision Modifiers • Patient/family preferences (values, priorities, wishes, adv directives, expectations, etc…) • Patient situation (access to care, support, resources, setting, transportation, etc…) • Patient allergies/intolerances • Interventions/Actions • (e.g. medications, wound care, procedures, tests, diet, behavior changes, exercise, consults, rehab, calling MD for symptoms, education, anticipatory guidance, services, support, etc…) • Start/stop date, interval • Authorizing/responsible parties/roles/contact info • Setting of care • Instructions/parameters • Supplies/Vendors • Planned assessments • Expected outcomes • Related Conditions • Status of intervention • Goals • Desired outcomes and milestones • Readiness • Prognosis • Related Conditions • Related Interventions • Progress Health Conditions/ Concerns Care Plan Active Problems Disease Progression Orders, etc.. Prioritize • Risks/Concerns: • Wellness • Barriers • Injury (e.g. falls) • Illness (e.g. ulcers, cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc…) Decision Support Decision Support Outcomes • Patient Status • Functional • Cognitive • Physical • Environmental Assessments Disabilities/ Concerns Barriers Outcomes Side effects • Risk Factors • Age, gender • Significant Past Medical/Surgical Hx • Family Hx, Race/Ethnicity, Genetics • Historical exposures/lifestyle (e.g. alcohol, smoke, radiation, diet, exercise, workplace, sexual…) Risks Interventions and actions achieve outcomes that make progress towards goals, cause interventions to be modified, and change health conditions 36

  36. Care Plan Decision Modifiers • Patient/family preferences (values, priorities, wishes, adv directives, expectations, etc…) • Patient situation (access to care, support, resources, setting, transportation, etc…) • Patient allergies/intolerances • Interventions/Actions • (e.g. medications, wound care, procedures, tests, diet, behavior changes, exercise, consults, rehab, calling MD for symptoms, education, anticipatory guidance, services, support, etc…) • Start/stop date, interval • Authorizing/responsible parties/roles/contact info • Setting of care • Instructions/parameters • Supplies/Vendors • Planned assessments • Expected outcomes • Related Conditions • Status of intervention • Goals • Desired outcomes and milestones • Readiness • Prognosis • Related Conditions • Related Interventions • Progress Health Conditions/ Concerns Care Plan Active Problems Disease Progression Orders, etc.. Prioritize • Risks/Concerns: • Wellness • Barriers • Injury (e.g. falls) • Illness (e.g. ulcers, cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc…) Decision Support Decision Support Outcomes • Patient Status • Functional • Cognitive • Physical • Environmental Assessments Disabilities/ Concerns Barriers Outcomes Side effects • Risk Factors • Age, gender • Significant Past Medical/Surgical Hx • Family Hx, Race/Ethnicity, Genetics • Historical exposures/lifestyle (e.g. alcohol, smoke, radiation, diet, exercise, workplace, sexual…) Risks The Care Plan (Concerns, Goals, Interventions , and Care Team), along with Risk Factors and Decision Modifiers, iteratively evolve over time 37

  37. Care Plan Decision Modifiers • Patient/family preferences (values, priorities, wishes, adv directives, expectations, etc…) • Patient situation (access to care, support, resources, setting, transportation, etc…) • Patient allergies/intolerances • Interventions/Actions • (e.g. medications, wound care, procedures, tests, diet, behavior changes, exercise, consults, rehab, calling MD for symptoms, education, anticipatory guidance, services, support, etc…) • Start/stop date, interval • Authorizing/responsible parties/roles/contact info • Setting of care • Instructions/parameters • Supplies/Vendors • Planned assessments • Expected outcomes • Related Conditions • Status of intervention • Goals • Desired outcomes and milestones • Readiness • Prognosis • Related Conditions • Related Interventions • Progress Health Conditions/ Concerns Care Plan Active Problems • Risks/Concerns: • Wellness • Barriers • Injury (e.g. falls) • Illness (e.g. ulcers, cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc…) 0…∞ 0…∞ 0…∞ 0…∞ A many-to-many-to-many relationship exists between Health Conditions/Concerns, Goals and Interventions/Actions 38

  38. Care Team Members each have their own responsibilities • Care Plan Decision Modifiers • Patient/family preferences (values, priorities, wishes, adv directives, expectations, etc…) • Patient situation (access to care, support, resources, setting, transportation, etc…) • Patient allergies/intolerances • Interventions/Actions • (e.g. medications, wound care, procedures, tests, diet, behavior changes, exercise, consults, rehab, calling MD for symptoms, education, anticipatory guidance, services, support, etc…) • Start/stop date, interval • Authorizing/responsible parties/roles/contact info • Setting of care • Instructions/parameters • Supplies/Vendors • Planned assessments • Expected outcomes • Related Conditions • Status of intervention • Goals • Desired outcomes and milestones • Readiness • Prognosis • Related Conditions • Related Interventions • Progress Health Conditions/ Concerns Care Plan Active Problems • Risks/Concerns: • Wellness • Barriers • Injury (e.g. falls) • Illness (e.g. ulcers, cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc…) • Patient Status • Functional • Cognitive • Physical • Environmental 39

  39. Data Elements for Longitudinal Coordination of Care CCD Data Elements C-CDA Data Element Gaps 483 325 175 • Many “missing” data elements can be mapped to CDA templates with applied constraints • 20% have no appropriate templates IMPACT Data Elements for basic Transition of Care needs 40

  40. Sites of Care Longitudinal Care Plan Prioritized Transitions ToC and LCC Data Sets Receiver Specific Information Types of Transitions Receivers at each Site

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