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IMPACT - Connecting Nursing Facilities and Home Care to the Healthcare System of the Future

IMPACT - Connecting Nursing Facilities and Home Care to the Healthcare System of the Future. Massachusetts Care Transitions Forum September 28 th , 2012 Drs. Terry O’Malley & Larry Garber. Agenda. IMPACT – addressing Long Term and Post-Acute Care (LTPAC) needs

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IMPACT - Connecting Nursing Facilities and Home Care to the Healthcare System of the Future

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  1. IMPACT - Connecting Nursing Facilities and Home Care to the Healthcare System of the Future Massachusetts Care Transitions Forum September 28th, 2012 Drs. Terry O’Malley & Larry Garber

  2. Agenda • IMPACT – addressing Long Term and Post-Acute Care (LTPAC) needs • ONC’s S&I Framework - Developing national standards for transitions of care datasets • LAND & SEE – software to facilitate integrating LTPAC into electronic health information exchanges (HIE)

  3. IMPACT Grant February 2011 – HHS/ONC awarded $1.7M HIE Challenge Grant to state of Massachusetts (MTC/MeHI): Improving Massachusetts Post-Acute Care Transfers (IMPACT)

  4. IMPACT Objectives & Strategies • Facilitate developing a national standard of data elements for transitions across the continuum of care • Develop software tools to acquire/view/edit/send these data elements (LAND & SEE) • Integrate and validate tools into Worcester County using Learning Collaborative methodology • Measure outcomes

  5. IMPACT Core Project Team • Madeleine Biondolillo, MD - Massachusetts DPH • Amy Boutwell, MD, MPP- Collaborative Healthcare Strategies • Jim Brennan- Massachusetts e-Health Institute • Larry Garber, MD- Reliant Medical Group/SAFEHealth • Paula Griswold, MS - MA Coalition for the Prevention of Medical Errors • Peggy Preusse, RN - Reliant Medical Group/SAFEHealth • Susan Sama, PhD - Reliant Medical Group • Terry O'Malley, MD- Partners HealthCare System • Craig Schneider, PhD- Massachusetts Health Data Consortium • Laurance Stuntz - Massachusetts e-Health Institute • Michele Visconti- Massachusetts DPH

  6. IMPACT Advisory Committee • Leon Barzin - Massachusetts Medical Society • Kate Bones - MA Care Transitions Forum • Ray Campbell, JD, MPA – Mass. Health Data Consortium • Donna Curran - MassPRO • James Fuccione - Home Care Alliance of Massachusetts • Ellen Hafer, MTS, MBA - Massachusetts League of Community Health Centers • Laurie Herndon, MSN, GNP-BC, ANP-BC – Massachusetts Senior Care Association • Pat Kelleher - Home Care Alliance of Massachusetts • Amy MacNulty, MBA - Community Care Linkages • Constance Nichols, MD, MS, FACEP - Massachusetts Emergency Medical Services • Pat Noga, PhD, MBA, RN, NEA-BC - Massachusetts Hospital Association • John Straus, MD - Mass. Behavioral Health Partnership • Laurance Stuntz - Massachusetts e-Health Institute • Deborah Wachenheim - Health Care For All

  7. Pilot Site Selection Process • 9/2011 – Applications sent to 34 organizations • Selection Criteria: • High volume of patient transfers with other pilot sites • Experience with Transitions of Care tools/initiatives • 16 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

  8. IMPACT Pilot Nursing Facilities • Beaumont Rehab & Skilled Nursing Center- Westborough • Christopher House of Worcester • Holy Trinity Nursing and Rehab Center • Jewish Healthcare Center • Life Care Center of Auburn • Millbury Healthcare Center • Notre Dame Long Term Care Center • Radius Healthcare Center - Worcester

  9. Developing National Standards to Support LTPAC Needs

  10. The “Data Set” Challenge • Multiple customers: • MA UTF • IMPACT Project Requirements • State and National stakeholders • Multiple needs • The Commonwealth • IMPACT participants • Various State and National groups • Consolidate requirements to facilitate standardization through ONC and on to HL7 and then to MU3

  11. Stakeholders/Contributors • State • UTF work group • IMPACT learning collaborative participants • MCPME • MA Wound Care Committee • Home Care Alliance of MA (HCA) • National • Substance Abuse, Mental Health Services Agency (SAMSA) • 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

  12. Consequences • 200 element UTF • 325 element IMPACT • 450+ LTPAC / LCC elements • +?

  13. MA DPH Universal Transfer Form • Started with DPH’s 3-pg Discharge Form • Sought input from LTPAC “receivers” • Reviewed existing forms and datasets: • MDS • OASIS • IRF-PAI • INTERACT • Sought expert opinions • Resulted in 7-page UTF

  14. 11x11 Sender (left column) to Receiver (top) 14

  15. Prioritize Transitions by Volume, Clinical Instability and Time-Value of Information Black circles = highest priority Green circles = high priority 15

  16. UTF Data Element Survey • 46 Organizations completing evaluation • ~300 Data elements evaluated • 1135 Transition surveys completed

  17. 12 User Roles

  18. Findings from UTF Survey • Largest survey of Receivers’ needs • Identified for each transitions which data elements are required, optional, or not needed • Each of the ~300 data elements is valuable to at least one type of Receiver • Many data elements are not valuable in certain care transition • Paper form can’t represent these needs

  19. Five Transition Datasets • Report from Outpatient testing, treatment, or procedure • Referral to Outpatient testing, treatment, or procedure • 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

  20. Five Transition Datasets • Type 3 Dataset: • 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 • Type 4 Dataset: • PCP to Consultant • PCP, SNF, etc… to ED • Type 5 Dataset: • Hospital to SNF, PCP, HHA, etc… • SNF, PCP, etc… to HHA • PCP to new PCP

  21. 5 Transition Datasets 5 3 1 5 5 2 4 5

  22. IMPACT Learning Collaborative:Testing the Care Transitions Datasets16 organization, 40 participants, 6 meetings over 2 months, and several hundred patient transfers…

  23. Learning Collaborative Surveys • Surveys directly on envelopes carrying IMPACT packet, filled out by sender as well as receiver. • Online survey at completion of pilot

  24. Analyzing data elements helped

  25. Senders found the data

  26. Receivers got most of their needs

  27. Home Care needed even more!

  28. Comment from Pilot Site Survey “While we knew what ED's and hospitals required, we didn't realize Home Health Agencies needed much more than what we typically sent.” -Skilled Nursing Facility

  29. New World of Standards Development National Coordinator for Health IT (ONC) Office of the Deputy National Coordinator for Programs & Policy Office of the Deputy National Coordinator for Operations Office of the Chief Privacy Officer Office of Economic Analysis & Modeling Office of the Chief Scientist HIT Policy Committee Defines “Meaningful Use” of EHRs Office of Policy & Planning Office of Science & Technology (formerly known as the Office of Standards and Interoperability (S&I)) S&I Framework convenes public and private experts, and proposes HIT/HIE standards HL7 ballots standards Secretary of HHS makes standards part of “Meaningful Use” and EHR Certification Office of Provider Adoption Support Office of State & Community Programs IMPACT

  30. S&I’s Longitudinal Coordination of Care WG Longitudinal Coordination of Care Workgroup • Providing subject matter expertise and coordination of SWGs • Developing systems view to identify interoperability gaps and prioritize activities LTPAC Care Transition Sub-Workgroup Patient Assessment Summary Sub-Workgroup Longitudinal Care Plan Sub-Workgroup • Establishing the standards for the exchange of Patient Assessment Summary (PAS) documents • Providing consultation to transformation tool being developed by Geisinger to transform the non-interoperable MDSv3 and OASIS-C into an interoperable clinical document (CCD+) • Identifying the key business and technical challenges that inhibit long-term care data exchanges • Defining data elements for LTPAC information exchange using a single standard for LTPAC transfer summaries • Near-Term: Developing an implementation guide to standardize the exchange of the Home Health Plan of Care (former CMS 485 form) • Long-Term: Identify and develop key functional requirements and data sets that would support a longitudinal care plan

  31. Expanded Transfer of Care Dataset • Includes Collaborative Care Plan data elements • Transfer of Care Dataset: ~450 Data Elements • Timeline for standards development: October 2012 MA HIway go-live in 10 large sites with CCD November 2012 Preliminary Implementation Guide completed December 2012 Pilot full Transfer of Care Dataset in 16 facilities March 2013 Finish Implementation Guide in S&I Framework May 2013 HL7 Balloting of Implementation Guide for inclusion in Consolidated CDA

  32. Getting Connected:LAND & SEE

  33. LAND & SEE • Non-EHR users complete all of the data fields and routing using a web browser to access their “Surrogate EHR Environment” (SEE) • 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 and securely transfer data if no support for Direct SMTP/SMIME or IHE XDR

  34. LTPAC Communication Today – Paper! Home Health Non-standard EHR OASIS PCP Hospital Billing Program MDS Nursing Facility

  35. LTPAC Communication with LAND & SEE LAND & SEE fill in gaps Home Health SEE CCD+ OASIS Non-standard EHR OASIS CCD+ CCD+ LAND PCP Hospital LAND SEE CCD+ MDS Billing Program MDS Nursing Facility

  36. The Future with LTPAC EHR Standards Home Health EHR OASIS CCD+ CCD+ CCD+ PCP Hospital EHR MDS CCD+ Nursing Facility

  37. Next Steps for Pilot Sites • Update gap analysis using expanded dataset • Catalog which data elements are captured (and by whom using what vocabulary) electronically, on paper, or not at all with current standard process • Of those captured electronically (including CCD, MDS & OASIS), identify process (technology & workflow) to make these available to LAND (for Phase 2). • Identify workflow to review new documents in SEE • Notification by email or text message, and to whom? • View online vs. print? Who does it and where? • Can any of the data elements received be electronically filed discretely for re-use using LAND? • Identify workflow to update and send SEE document with current info when discharging to Home Health or ED transfer • How can standard and non-standard data elements be collected and added online using SEE to the documents being sent? • How will copies be printed for patient and ambulance? • Additional computers, printers, or chairs required?

  38. IMPACT Timeline for Next Steps

  39. Questions? TOMalley@Partners.org Lawrence.Garber@ReliantMedicalGroup.org

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