Longitudinal Coordination of Care Pilots WG

1. Longitudinal Coordination of Care Pilots WG Monday, September 16, 2013

2. Meeting Etiquette Remember: If you are not speaking, please keep your phone on mute Do not put your phone on hold. If you need to take a call, hang up and dial in again when finished with your other call • Hold = Elevator Music = frustrated speakers and participants This meeting is being recorded • Another reason to keep your phone on mute when not speaking Use the “Chat” feature for questions, comments and items you would like the moderator or other participants to know. • Send comments to All Participants so they can be addressed publically in the chat, or discussed in the meeting (as appropriate). From S&I Framework to Participants: Hi everyone: remember to keep your phone on mute  All Participants

3. Agenda

4. Why are we here today? • Let’s discuss… • Why you should pilot LCC standards • Who should consider being a pilot • What standards you can pilot • How we can help you pilot these standards • How you can learn for those already committed to piloting LCC standards

5. Background of LCC WG • Initiated in October 2011 as a community-led initiative with multiple public and private sector partners, each committed to overcoming interoperability challenges in long-term, post-acute care (LTPAC) transitions • Supports and 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 is to identify standards that support LCC of medically-complex and/or functionally impaired persons that are aligned with and could be included in the EHR Meaningful Use Programs (focus on MU3) • Activities supported via 4 sub-workgroups (SWGs): • Longitudinal Care Plan (LCP) * • LTPAC Care Transition (LTPAC) * • HL7 Tiger Team* • Patient Assessment Summary (PAS)* * The work of the LCP and LTPAC completed in SEP2013, HL7 Tiger Team completed in AUG13 and PAS SWG completed in JAN13

6. 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 • 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 • 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)

7. S&I Framework: The Value of Community Participation ENABLING FACAs • HIT Standards Committee • HIT Policy Committee • Tiger Team Community S&I Framework SDOs (LCC WG) • Technology Vendors • System Integrators • Government Agencies • Industry Associations • Other Experts • HL7 • OASIS • Other SDOs ONC Programs & Grantees • State HIE Program & CoPs • REC Program & CoPs • Beacon Program

8. LCC WG Partnerships • Strong collaboration and engagement with broad stakeholder groups to address gaps in standards for ToC and Care Plan exchange • Other ONC S&I Initiatives: Transitions of Care (ToC) and esMD • HL7 WGs: Structured Documents, Patient Care • IHE Patient Care Coordination Technical Committee • AHIMA LTPAC HIT Collaborative • FACAs: MU3 Recommendations • Contracts with Lantana to make and ballot revisions to C-CDA for HL7 August 2013 Ballot Cycle • One ballot package to address C-CDA revisions based on IMPACT dataset

9. S&I Framework Phases

10. Aim for the LCC Pilot SWG • Bring awareness on available national standards for HIE and care coordination • Provide tools and guidance for managing and evaluating LCC Pilot Projects • Create a forum to share lessons learned and best practices • Real world evaluation of parts of most recent HL7 C-CDA Revisions Implementation Guide (IG) • Is this implementable? Useable? • Validation of ToC and Care Plan/HHPoC datasets • Do these data elements address your organization’s information needs for effective care coordination??

11. Why Pilot LCC Standards? • Demonstrate compliance with MU2 requirements and proposed standards for MU3 • Increase efficiency of development and maintenance of these standards • LCC C-CDA IG caninform changes to existing HIT systems and the process by which ToC & Care Plan information is exchanged • These specifications are being harmonized with a broad consortium of Standards Development Organizations (SDOs) including HL7 and IHE • Meet CMS Quality Reporting Requirements • i.e. Reduce Readmission Rates • Enable LTPAC (non-eligible) providers to participate in HIE • Increase access to LTPAC data to support caregiving (including access by other members of clinical care team) • Contribute to the community • Be recognized as an early HIE adopter

12. Who Should Pilot LCC Standards? • HIE capability exists • High proportion of dual eligibles • Integrated Delivery Networks including Managed Care Organizations (MCO), ACOs and other at-risk provider groups • Other organizations participating in various CMS/CMMI Demonstrations • Providers with high readmission rates • Those interested in addressing transition of care issues • Those interested in exchanging care plans

13. 3 5 4 2 1 6 Transition Datasets 5 – Transfer of Care Summary 5 – Transfer of Care Summary 5 – Transfer of Care Summary 5 – Transfer of Care Summary • Test/Procedure Report & Request • i.e SNF to IRA HH POC (CMS-485) Care Plan 1 – Test/Procedure Report 2 – Test/Procedure Request 4 – Consultation Request Clinical Summary 3 – Shared Care Encounter Summary • Consultation Request & Response • i.e. SNF to ED • Transfer Summary/ Care Plan/HHPoC • i.e. Hospital to Home Health Agency; HHA  PCP 13 13

14. What Standards Can You Pilot? • New exchange standards for: • MU2 Patient Care Summary and proposed MU3 updates for: • Care Plan • Home Health Plan of Care • 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 • Exchange standards that easily enable low cost interoperable HIE by LTPAC providers • New software for HIE access

15. Sample Pilot Options

16. How Can You Participate in the LCC Pilot SWG? • http://wiki.siframework.org/LCC+Pilots+WG

17. LCC Pilot WG Timeline: Aug 2013 – Sept 2014 LCC Pilot Proposal Review LCC Pilot Monitoring & Evaluation LCC Pilot WG LCC Pilot Wrap-Up HL7 Ballot & Reconciliation HL7 Ballot HL7 C-CDA IG Revisions LCC Pilot WG Launch Updated HL7 C-CDA IG Complete HL7 Ballot Publication HL7 Fall Ballot Close LCC Pilots Close LCC Pilot Test Spec. Complete Milestones IMPACT Go-Live NY Care Coordination Go-Live

18. LCC Pilot WG Tasks

19. Summary of Documentation Templates & Reference Materials (Pilot Materials)

20. Improving Massachusetts Post-Acute Care Transfers

21. IMPACT Grant • February 2011 – HHS/ONC awarded $1.7M HIE Challenge Grant to state of Massachusetts (MTC/MeHI) • Sites with EHR or electronic assessment tool use these applications to enter data elements • LAND (“Local”Adaptor for Network Distribution) acts as a data courier to gather, transform, and securely transfer data if no support for Direct SMTP/SMIME or IHE XDR • Non-EHR users complete all of the data fields and routing using a web browser to access SEE, their • “Surrogate EHR Environment”

22. Sharing LAND & SEE LAND • Orion Health’s Rhapsody Integration Engine http://www.orionhealth.com/solutions/packages/rhapsody • Currently Modular EHR certified for MU1. MU2 (2014) pending • We’re trying to make some standard configurations available SEE • Written in JAVA • Baseline functionality software and source code that can connect to Orion’s HISP mailbox via API available for free starting ~December 2013 (Apache Version 2.0 vs. MIT open source license) • Innovators can develop and charge for enhancements, for example: • Integration with other vendors’ HISP mailboxes • Automated CDA document reconciliation

23. Pilot Sites to Test the IMPACT Datasets • Selection Criteria: • High volume of patient transfers with other pilot sites • Experience with Transitions of Care tools/initiatives • Winning Pilot Sites: • St Vincent Hospital and UMass Memorial Healthcare • Reliant Medical Group (formerly known as Fallon Clinic) and Family Health Center of Worcester (FQHC) • 2 Home Health agencies (VNA Care Network & Overlook VNA) • 1 Long Term Acute Care Hospital (Kindred Parkview) • 1 Inpatient Rehab Facility (Fairlawn) • 8 Skilled Nursing and Extended Care Facilities

24. IMPACT Pilot Participants

25. IMPACT Pilot Go-Live • November 2013 • 10 SEE sites (full Transfer of Care dataset) • 6 LAND sites (initially send CCD but receive any CDA document) • 4/week starting with trading pairs (e.g. Hospital  SNF)

26. Downstate New York Care Coordination ProjectSeptember 16, 2013

27. Context • NYS Medicaid Health Homes have implemented (or are implementing) care coordination solutions to meet their near term requirements • Each Health Home currently uses a separate care management system or EHR • In the Downstate NY region, there are many providers who are in multiple Health Homes and multiple RHIOs and their patients will cross borders • If various care management tools do not support interoperability, providers may have to use 2 or 3 different systems and this is not sustainable • Current state leaves untenable situation of no care plan interoperability

28. Goals and Objectives Develop consensus around functionality that would enable enhanced care coordination, care plan management and interoperability across Health Homes and RHIOs through the SHIN-NY Align activity with developments at the national level Develop Requirements to support the interoperability and joint management of Care Coordination Plans across organizations Phase I implementation - Demonstrate the ability for two sites with two different care management tools to exchange Care Coordination Plans

29. Requirements The DCC Workgroup agreed upon the following seven functions: Enrollment of Health Home patients Linking of patients and providers: care teams Exchange of interoperable care plans Clinical Event Notifications Secure Messaging Access to medical records for clinicians Access to care plans for non-clinicians

30. NY Downstate Pilot Participants

31. Care Coordination Plan (CCP) CollaborationWhat is a CCP? Care Coordination Plan (CCP) refers to a shared document that is used to track problems, goals, interventions and outcomes related to both clinical and social issues CCPs are a focus of collaboration for diverse care teams across organizations

32. Care Coordination Plan (CCP) CollaborationUse Case • 2. Editor will view the CCP in their local care management tool, and suggest edits to the Author for review and approval. The Author retains editorial control of the CCP • 1. Author will create and edit the CCP in a care management tool that uses a national agreed upon structure for interoperable CCPs Iterative process based on interoperability standards • 3. Reader can view the most recent CCP in the RHIO, and provide comments to the Author through secure messaging

33. Healthix HEAL 17 – Project Highlights • Identified two sites with two different vendors to participate in Phase 1 implementation, both part of Continuum Health Partners • Addiction Institute of New York • Methodone Treatment Program (Netsmart) • Outpatient Treatment Program (Caradigm) • Held kick off meeting with stakeholders in early June • Agreed on Requirements and Phase 1/2 development • June – July: Design phase; engaged Lantana to align the data model with proposed standard as closely as possible • July - August: Development, finalize draft data model for the standard Care Coordination Plan with the LCC Standards Workgroup • September: Testing, Acceptance • October: Phase 1 Implementation, Evaluation

34. Next Steps • Homework Assignment: • Complete Pilot Survey • Sign up as an LCC Committed Member • Submit Pilot Documentation Templates • Available on the LCC Pilot SWG Wiki: http://wiki.siframework.org/LCC+Pilots+WG • Email to Lynette Elliott (Lynette.elliott@esacinc.com) • NO Meeting next week due to HL7 WGM in Boston, MA

35. LCC Initiative: Contact Information • 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 • Pilots Lead: Lynette Elliott (lynette.elliott@esacinc.com) • Use Case Lead: Becky Angeles (becky.angeles@esacinc.com) LCC Wiki Site: http://wiki.siframework.org/Longitudinal+Coordination+of+Care