Larry Garber, MD PI/Informatics Terry O’Malley, MD Metrics

1. Preliminary Findings From IMPACT(Improving Massachusetts Post Acute Care Transitions)Leveraging IMPACT to Accelerate S&I Framework’s LTPAC WGOctober 12, 2011 Larry Garber, MD PI/Informatics Terry O’Malley, MD Metrics Dawn Heisey-Grove, Project Manager

2. Proposed Modifications to the LTPAC Roadmap • Define LTPAC more broadly • Include in the Relevant Scenarios information exchange to and from Acute Care Hospitals to and from LTPAC sites • Identify high priority transitions • Determine transition-specific data elements • Modify high level process flow

3. Summary • We have implemented a survey process resulting in a draft data set of 300 elements identified as “required” by one or more “receivers” in 39 priority LTPAC transitions. • This same process can be used to further refine the core data set for LTPAC and help leverage the reuse of currently available electronic data in MDS and OASIS

4. Draft LTPAC Data Set • The next eight slides contain the data elements. • Headers are in light blue. • Red elements need further consideration • Elements at the end are duplicates The slides that follow explain our approach to prioritizing transitions and the results of the survey

5. Data Set: Slide 1 of 8

6. Data Set: Slide 2 of 8

7. Data Set: Slide 3 of 8

8. Data Set: Slide 4 of 8

9. Data Set: Slide 5 of 8

10. Data Set: Slide 6 of 8

11. Data Set: Slide 7 of 8

12. Data Set: Slide 8 of 8

13. Traditional LTPAC Sites LTAC IRF SNF ECF Home Health Agency Hospice “Additional” LTPAC Sites Ambulatory Care (PCP) CBO (Community based organizations) Patient/Family Others as needed Expand Purview of LTPAC ToC WG Rationale: traditional sites of care will blur as care is organized more around patient needs and less around the site of care. Information exchange will grow in importance

14. Include the Acute Care Hospital Connection • Most transitions to LTPACs start in the Acute care hospital • Discharges to LTPACs from In-patient units • Discharges or returns to LTPACs from the ED • Return to LTPACs from out-patient testing and treatment sites • Many transitions from LTPACs go to ACH sites • In-patient • ED • Out-patient testing or treatment • This expanded “Scope” results in a grid of eleven “sending sites” and eleven “receiving sites”

15. 11x11 Sender (left column) to Receiver (top) Grid

16. Four Relevant Scenarios from the Expanded Scope • Exchange information between LTPAC providers • Exchange information from LTPAC providers to the patient/family • Exchange information from LTPAC providers to three Acute Care Hospital units: • In-patient floor • ED • Outpatient testing and treatment sites • Exchange information from Acute Care Hospital units to LTPAC providers and patient/family New New

17. 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 New New Four Relevant Scenarios: Transitions by Origin and Destination 4 3 1 2

18. Identifying High Priority Transitions • Three variables determine the priority of each transition: • Volume • Clinical instability of the patient • Time/Value of the clinical information • On the next grid, each transition is represented by a cell • Each cell has three sections, one for each variable • Each variable is either High (red), Medium (yellow) or Low (blue) • Cells with two or more “High” scores indicate priority transitions • Cells in grey or black are either out of scope or rare

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

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

21. Scenario #1: LTPAC TO LTPAC Priority Transitions

22. Scenario #2: LTPAC To Patient/Family Priority Transitions

23. Scenario #3: LTPAC To Acute Care Hospital Units Priority Transitions

24. Scenario #4: Acute Care Hospital Units to LTPAC Sites Priority Transitions

25. Priority Transitions by Relevant Scenario 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 New New

26. Different Transitions Within Each Scenario • Transitions can be one of four different types depending on whether they are • “Permanent” or “Temporary” • “Elective” or ‘Urgent” • The types are: • Permanent and Elective: standard discharge • Temporary and Elective: out-pt testing and treatment or discharge from the ED • Temporary and Urgent: transfer to the ED • Permanent and Urgent: in-pt admission following ED • These transitions also vary by content and receiver types

27. Scenarios, Priorities and Transition Types

28. Transition-Specific Data sets • Transitions can vary by: • Type: permanent or temporary • Urgency: elective or emergent • Origin • Destination • Essential “receivers” (RN, MD, CM, PT, etc): mix of roles varies by site • The essential elements are what the receivers identify as “essential”. • Transition-specific data sets share many common elements but vary in others

29. Process to Develop Transition-specific Data Sets • The purpose of the data sets is to assure safe and efficient transfer of clinical responsibility • Receiving sites identified all essential role groups • Each role group reviewed a draft data set created by merging the S&I ToC Framework document with the Massachusetts Universal Transfer Form (UTF) • They classified elements as “required”, “optional” and “not needed”. • The sum of all “required” data elements constitutes the Transition-specific Data Set (TSDS) for that site.

30. Role-groups by Receiving Site

31. Surveys received for each Priority Transition

32. Survey Responses by Role-group by Site

33. Summary of Survey Results • 48 of 49 high priority transitions have four or more survey responses • Hospice to ED has EMT surveys only • 1135 transition-specific responses • From 12 role groups • Made up of 201 individuals • From 46 facilities

34. Findings • More than 50 changes made to the initial draft data set • The “Current LTPAC Draft Data Set” has 300 data elements that include every required element by every essential role group in all priority transitions • Next step is to vet this more widely with essential receivers.

35. Proposed High Level Process Flow Merged S&I ToC Data elements with UTF elements Created draft data element list for all PAC receivers Surveyed PAC receivers to determine required and optional elements Map MDS 3, OASIS, IRF-PAI, CARE, VNS NY to data list Re-map data elements to S&I ToC CIM. Identify Gaps Establish CIM modifications & extension to support LTPAC HIE Identify, define, and ballot CDA modifications & extensions 10/14/11