February 2013 Drs. Larry Garber and Terry O’Malley

1. IMPACT - Connecting Long Term and Post-Acute Care Organizations to the Healthcare System of the Future February 2013 Drs. Larry Garber and Terry O’Malley

2. Agenda • Problems with care transitions • What is Long Term and Post-Acute Care (LTPAC)? • IMPACT – addressing 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. 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)

4. 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)

5. 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)

6. 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)

7. Is Massachusetts Different? • Preventable readmissions waste $577 Million in Massachusetts annually • MA ranks 35th in the nation on measures of quality relating to coordination of care, such as preventable hospitalizations for chronic conditions and hospital readmissions (McCarthy, et al., 2009)

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

9. An Odd Twist of Fate • 2008 – Economy crashed • 2009 – ARRA passes, including the Health Information Technology for Economic and Clinical Health • $27 Billion for hospital and MD practice EHRs • Must use the EHR in a “Meaningful” way, including improved communication with others that have EHRs • But Long Term and Post-Acute Care was left out!

10. Yet Post-acute Care Costs are Rising faster than acute care costs Source: MedPAC, 2011

11. What is LTPAC?

12. 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

13. Traditional Long-Term and Post-Acute Care (LTPAC) High PACE LTACH Home Health Intensity of Care IRF SNF Hospice Facility Nursing Home Home Hospice Assist Living Living at Home Low Acuity of Illness High Adapted from Derr and Wolf, 2012

14. IMPACT’s View of LTPAC High 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

15. 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

16. How is LTPAC Different Than Acute Care or Typical Office-Base Care?

17. Type of LTPAC Patient • Closer to end of life • Greater number of health concerns, meds, healthcare providers, and care settings • Reduced cognitive capabilities • Increased risk of adverse events • Reduced mobility; increased risk of falls • Increased transportation issues/costs • Less financial and social support • More legal issues

18. Type of LTPAC Organization • Limited financial and human resources • Fewer incentives for EHRs or HIE participation • Less likely to have risk-sharing contracts • Not part of HITECH/Meaningful Use • Limited technological infrastructure: • LAN/WIFI • IT Security/Policies/Backup/Redundancy • EHR, if present, likely to be ASP model • Being asked to care for increasingly more complex patients

19. MU’s Impact on LTPAC • Meaningful Use defines the datasets that Hospitals send when patients are discharged • ~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 ~80% of Medicare costs Sources: http://aspe.hhs.gov/health/reports/2011/pacexpanded/index.shtml#ch1 http://www.medpac.gov/documents/Jun11DataBookEntireReport.pdf

20. 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)

21. 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

22. Developing National Standards to Support LTPAC Needs

23. 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

24. 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

25. Massachusetts Paper UTF Pilot Too Long!

26. 14x14 Sender (left column) to Receiver (top) = 196 possibly transition types 26

27. Prioritize Transitions by Volume, Clinical Instability and Time-Value of Information Black circles = highest priority Green circles = high priority 27

28. “Receiver” Data Element Survey • 1135 Transition surveys completed • Largest survey of Receivers’ needs • 46 Organizations completing evaluation • 12 Different types of user roles

29. 11 Types of Organizations

30. 12 User Roles

31. Findings from Survey • Identified for each transition which data elements are required, optional, or not needed • Each of the data elements is valuable to at least one type of Receiver • Many data elements are not valuable in certain care transition

32. A single paper form can’t represent this variability in data needs 49 Documents Is Too Many! Black circles = highest priority Green circles = high priority 32

33. 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

34. 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

35. Five Transition Datasets 5 3 1 5 5 2 4 5

36. Additional Contributor Input • State (Massachusetts) • MA Universal Transfer Form workgroup • Boston’s Hebrew Senior Life eTransferForm • 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)/Geisinger MDS HIE • 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

37. Two Care Plan Datasets Transfer of Care Consultation Request Care Plan Shared Care Encounter Summary Home Health Plan of Care (CMS-485)

38. Situation-specific Data Elements Variable Base on Situations: Setting Diagnoses Medications Treatments Procedures 5 – Transfer of Care Summary 5 – Transfer of Care Summary 5 – Transfer of Care Summary 5 – Transfer of Care Summary 5 – Transfer of Care Summary 5 – Transfer of Care Summary 5 – Transfer of Care Summary 5 – Transfer of Care Summary 5 – Transfer of Care Summary 5 – Transfer of Care Summary 5 – Transfer of Care Summary 5 – Transfer of Care Summary 5 – Transfer of Care Summary 5 – Transfer of Care Summary 5 – Transfer of Care Summary 5 – Transfer of Care Summary Care Plan 1 – Test/Procedure Report 2 – Test/Procedure Request 4 – Consultation Request Clinical Summary 3 – Shared Care Encounter Summary

39. Care Plan Permeates Datasets 5 – Transfer of Care Summary Care Plan 1 – Test/Procedure Report 2 – Test/Procedure Request 4 – Consultation Request Clinical Summary 3 – Shared Care Encounter Summary

40. How do they compare to CCD? • 175 element CCD • 325 element IMPACT for basic LTPAC needs • 480+ elements for Longitudinal Coordination of Care

41. Testing the IMPACT Dataset

42. Pilot Sites to Test the Datasets • 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

43. Nursing Facility Pilot Sites • Beaumont Rehabilitation of Westborough • Christopher House of Worcester • Holy Trinity Nursing & Rehab • Jewish Healthcare Center • LifeCare Center of Auburn (+EMR) • Millbury Healthcare Center • Notre Dame LTC • Radius Healthcare Center Worcester

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

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

46. Analyzing data elements helped

47. Senders found the data

48. Receivers got most of their needs

49. Home Care needed even more!

50. 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