1 / 13

LCC Use Case 2.0 Paragraph

LCC Use Case 2.0 Paragraph.

tambre
Download Presentation

LCC Use Case 2.0 Paragraph

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. LCC Use Case 2.0 Paragraph As the number of Health Concerns increases, the health care of that individual becomes more complex. Often this complexity is manifested by acute and chronic issues that intertwine and create management dilemmas, care in multiple sites by multiple care team members and an increased risk of care plan failure resulting in admissions and readmissions. Each additional problem, team member and site of care increases the complexity of care. Recent Medicare data (2012 Chartbook) showed that of individuals with six or more chronic conditions, two thirds were hospitalized and 16% were hospitalized 3 or more times in 2010. Of the 1.9 million readmissions in 2010, 98% occurred in individuals with two or more chronic conditions, and 14% of Medicare beneficiaries with six or more chronic conditions accounted for 70% of all readmissions. Only 1% of beneficiaries with 0-1 chronic conditions received care in PAC settings (SNF, LTAC, IRF and Home Care), while 41% of those with six or more chronic conditions received PAC care. Nearly half of these individuals had 13 or more PCP office visits in 2010; and 70% had at least one ER visit and 27% had three or more visits. In order to avoid gaps in care, conflicting interventions and duplicate services, these individuals with complex medical, behavioral and functional issues require a care plan that can be shared across sites and teams. This use case examines the requirements for two high volume exchanges: the transfer of a care plan between a Hospital-based Team to a Home Health Agency based team and the individual’s Primary Care Team (PCMH), between the Primary Care Team and the full Community Based Care Team.

  2. Assumptions: • Although there may be some overlap in the Home Health-Based and Community-Based Teams, these are treated as separate teams • 1A and 1B could occur at the same time • Discussion: • A patient can be discharged from the hospital to home health, primary care, community based, meals on wheels, transportation, etc. Discharge orders and referrals may or may not go from the hospital to the receiving care provider. The only certainty is that it goes to the physician and patient. The community based team members may not even be recognized by the hospital or physician. • We will not focus on the technology (Direct, fax, e-fax, etc) for the exchange of information between teams. We will only focus on the information flow, functional requirements, and content. • This diagram does not reflect our previous discussion of 2 types of exchanges. 1). medically complex patient (high risk) 2). general patient • Open Question: Is there any form of electronic exchange between Hospital and Community-based Non-Medical Team? • Need to include a statement in the Background section of the Use Case stating that several of the information exchanges between teams is not / may not be electronic

  3. Scenario 1A • Exchange of care plan from hospital team to PCP/Primary Care team. The team members listed are a subset of the potential team members.

  4. Scenario 1B • The exchange of a care plan from the Hospital Team to the Home Health Agency-based Team.

  5. Scenario 2 • Exchange of a care plan between the Primary Care Team and the Community-based team.

  6. Patient Stories • Two patient stories, same patient with different degrees of complicating issues.

  7. Patient 1 Community-Based Care Non-Medical Team Community-based care Medical Team 1 Primary Care Team Meals on Wheels 2AA Home Health Care Team 2 Housing Services Nursing Home Hospital-Based Care Team Transportation DME provider Other Hospice Out-patient therapy DME provider • Lines1: Current state. Note: This obfuscates (and thus allows for variation in) the current state of HIE between the hospital and the community based medical team. E.g.: • Do hospital exchange info with: • only the CB doc? • The HHA? • The OPT provider? • Do CB doc exchange info w/ other members of the CB medical team? • Can we for purposes of this UC state that the current state of affairs is diverse and varies. • Lines2: Use Case Scenarios Pharmacy Labs Other

  8. Hospital-based Care Team Community-based Care Team (Medical) Patient Primary Care Team Home Health Care Team Community-based Care Team (Non-Medical) Nursing Home DME Provider Meals on Wheels Housing Services Hospice Out-Patient Therapy Transportation DME Provider Other Pharmacy Labs

  9. DME Provider Hospital-based Care Team Nursing Home Home Health Care Team Hospice DME Provider Out-Patient Therapy Pharmacy Community-based Care Team (Non-Medical) Labs Community-based Care Team (Medical) Primary Care Team Patient Home w/ No Services Primary Care Team Meals on Wheels Housing Services Home w/ Services Transportation Home Health Agency Other Home w/ Services Other Certifying Physician

  10. Priority/Frequency of Exchange of Care Plans

  11. Hospital-based Care Team to PCMH only PCMH Team HHA Team Specialist CBO Team

  12. Hospital-based Care Team to HHA PCMH Team HHA Team Specialist CBO Team

  13. Hospital-based Care Team to PCMH and Specialist PCMH Team Specialist HHA Team CBO Team Communication on discharge to PCMH and Specialist Then: PCMH to HHA and CBO Then HHA to CBO

More Related