Longitudinal Coordination of Care (LCC) Workgroup (WG)

1. Longitudinal Coordination of Care (LCC) Workgroup (WG) LCC Standards Update for the HITPC MU SWG #3 Care Coordination May 8, 2013

2. 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

3. Limitations in Care Coordination & Standards to Support Transitions of Care and Care Plans

4. 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 National care transitions experts overwhelmingly identified “improving information flow and exchange” as the most important tool to improve care transitions. (ONC, 2011)

5. 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

6. 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

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

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

9. 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

10. 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

11. “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 11

12. 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): 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

13. MU3 C-CDA Template Gaps Data Elements for Longitudinal Coordination of Care CCD Data Elements 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

14. 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 to a different facility or care team or Home Health Agency

15. Five Transition Datasets • Shared Care Encounter Summary: • 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: • Hospital to SNF, PCP, HHA, etc… • SNF, PCP, etc… to HHA • PCP to new PCP

16. Care Plan & Plan of Care Home Health Plan of Care Care Plan 5 – Transfer of Care Summary HH POC (CMS-485) Care Plan 4 – Consultation Request Clinical Summary 3 – Shared Care Encounter Summary

17. IMPACT Dataset for Testing • 16 Pilot sites in central Massachusetts • Several hundred transitions tested • on paper • 93% found the elements • 92% receivers’ needs • met 5 – Transfer of Care Summary • Transfer of Care: • Hospital to SNF, PCP, HHA, etc… • SNF, PCP, etc… to HHA • PCP to new PCP

18. IMPACT Transfer of Care CDA Document 18

19. 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

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

21. ONC S&I LCC WG Organization Longitudinal Coordination of Care Workgroup COMMUNITY-LED INITIATIVE NEW! Longitudinal Care Plan SWG LTPAC Care Transition SWG HL7 Tiger Team SWG Patient Assessment Summary (PAS 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)) • 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 • 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 standards for an interoperable, longitudinal care plan* which aligns, supports and informs person-centric care delivery regardless of setting or service provider GOALS *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.

22. 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

23. 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)

24. LCC WG Care Plan Glossary: Key Terms & Components

25. LCC WG Timeline: Mar 2013 – Dec 2013 LCC Stakeholder Engagement: Lantana, IMPACT, ASPE, NY, CMS LCC & HL7 Care Plan Coordination LCC Care Plan Use Case 2.0 Development & Consensus ToC IGs Development (Transfer Summary, Referral Note, Consult Note) HL7 Ballot & Reconciliation Care Plan/ Home Health Plan of Care IG Development HL7 Ballot Package Development Pilot Identification & Engagement IMPACT ToC Pilot Monitoring IMPACT Care Plan Pilot Monitoring NY Pilots Monitoring Care Plan IGs Complete ToC IGs Complete Lantana Contract Awarded IMPACT Go-Live HL7 Fall Ballot Open HL7 Ballot Publication Milestones HL7 Intent to Ballot Due HL7 Project Scope Statement Due NY Care Coordination Go-Live HL7 Final Ballot Due FACA LCC WG Briefings

26. 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

27. 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

28. Questions?

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

30. Supporting Documentation

31. 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)

32. 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)

33. 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)

34. 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)

35. The Spectrum of Care 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

36. Where do patients go after hospital? Everywhere!

37. 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#ch1 http://www.medpac.gov/documents/Jun11DataBookEntireReport.pdf

38. Testing the IMPACT Transfer of Care Dataset

39. IMPACT Dataset for Testing 5 – Transfer of Care Summary • Transfer of Care: • Hospital to SNF, PCP, HHA, etc… • SNF, PCP, etc… to HHA • PCP to new PCP

40. 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

41. Senders found the data

42. Receivers got most of their needs

43. Home Care needed even more!

44. 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