IMPACT Improving Massachusetts Post-Acute Care Transfers

IMPACT Improving Massachusetts Post-Acute Care Transfers New England Home Care Conference May 31 st, 2012 Larry Garber, MD Medical Director for Informatics Reliant Medical Group Agenda IMPACT project overview Developing national standards for transitions of care datasets LAND & SEE software to facilitate integrating LTPAC into electronic health information exchanges Improving Massachusetts Post-Acute Care Transfers (IMPACT) Project Overview/Update 3 1

IMPACT Grant February 2011 HHS/ONC awarded $1.7M grant to State (MTC/MeHI) to: Improve Long-Term and Post-Acute Care Transitions using electronic Health Information Exchange 4 IMPACT Goals Enable nursing and rehab facilities, and home health agencies to participate in regional and statewide Health Information Exchange Improve the speed, efficiency, and satisfaction of processes to provide essential clinical data during transitions of care Decrease avoidable ER visits, hospital admissions, and hospital readmissions Reduce the total cost of care Replicate this model in other communities IMPACT Objectives Facilitate developing a national standard of data elements for transitions across the continuum of care Develop applications to acquire/view/edit/send these data elements (LAND & SEE) Develop consumer-oriented translator Integrate tools into Worcester County: 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) 8 SNFs/ECFs 1 Inpatient Rehab Facility (Fairlawn) 1 Long Term Acute Care Hospital (Kindred Parkview) Measure outcomes 6 2

Developing National Standards to Support LTPAC Needs 7 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 8 Massachusetts Paper UTF Pilot 9 3

UTF Data Element Survey 46 Organizations completing evaluation ~300 Data elements evaluated 113 Transition surveys completed 10 11 Types of Organizations 11 12 User Roles 12 4

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 13 11x11 Sender (left column) to Receiver (top) In patient ED Out patient services LTAC IRF SNF/ECF HHA Hospice Ambulatory Care (PCP) 14 14 Prioritize Transitions by Volume, Clinical Instability and Time-Value of Information V = H V = H V = H V = H V = H V = H V = H V = H In patient CI = H CI = H CI = M CI = M CI = L CI = M CI = L CI = M V = H V = H V = H V = H V = M V = H V = M V = H ED CI = H CI = H CI = H CI = M CI = M CI = L CI = L CI = M V = H V = H V = H V = H V = L V = H V = H Out patient services CI = H CI = M CI = M CI = M CI = L CI = L CI = L TV = H TV = H TV = H TV = H TV = H TV = H TV = L V = H V = H V = H V = M V = H V = H V = M V = H V = H V = H LTAC CI = H CI = H CI = H CI = M CI = M CI = M CI = M CI = M CI = M CI = M TV = H TV = H V = H V = H V = H V = L V = H V = H V = L V = H V = H V = H IRF CI = H CI = H CI = M CI = H CI = L CI = L CI = M CI = L CI = L CI = L TV = H TV = H V = H V = H V = H V = M V = L V = L V = H V = M V = H V = H V = H SNF/ECF CI = H CI = H CI = M CI = H CI = M CI = M CI = M CI = M CI = L CI = M CI = L TV = H TV = H TV = H TV = M TV = M TV = M TV = H TV = M TV = M TV = H TV = H V = H V = H V = L V = M V = H V = H V = H HHA CI = H CI = H CI = L CI = L CI = L CI = L CI = L TV = H TV = H TV = L TV = L TV = L TV = L TV = L V = L V = M V = M V = L V = L V = L V = M V = L Hospice CI = H CI = H CI = M CI = L CI = L CI = M CI = L CI = M TV = H TV = H TV = M TV = M TV = M TV = L TV = L TV = M V = M V = H V = L V = M V = L V = L V = M V = L Ambulatory Care (PCP) CI = H CI = H CI = M CI = M CI = L CI = L CI = L CI = L TV = H TV = H TV = H TV = M TV = H TV = M TV = M TV = L 1 1 Black circles = highest priority Green circles = high priority

Home Health and Hospice as Receivers V = H V = H V = H V = H V = H V = H V = H V = H In patient CI = H CI = H CI = M CI = M CI = L CI = M CI = L CI = M V = H V = H V = H V = H V = M V = H V = M V = H ED CI = H CI = H CI = H CI = M CI = M CI = L CI = L CI = M V = H V = H V = H V = H V = L V = H V = H Out patient services CI = H CI = M CI = M CI = M CI = L CI = L CI = L TV = H TV = H TV = H TV = H TV = H TV = H TV = L V = H V = H V = H V = M V = H V = H V = M V = H V = H V = H LTAC CI = H CI = H CI = H CI = M CI = M CI = M CI = M CI = M CI = M CI = M TV = H TV = H V = H V = H V = H V = L V = H V = H V = L V = H V = H V = H IRF CI = H CI = H CI = M CI = H CI = L CI = L CI = M CI = L CI = L CI = L TV = H TV = H V = H V = H V = H V = M V = L V = L V = H V = M V = H V = H V = H SNF/ECF CI = H CI = H CI = M CI = H CI = M CI = M CI = M CI = M CI = L CI = M CI = L TV = H TV = H TV = H TV = M TV = M TV = M TV = H TV = M TV = M TV = H TV = H V = H V = H V = L V = M V = H V = H V = H HHA CI = H CI = H CI = L CI = L CI = L CI = L CI = L TV = H TV = H TV = L TV = L TV = L TV = L TV = L V = L V = M V = M V = L V = L V = L V = M V = L Hospice CI = H CI = H CI = M CI = L CI = L CI = M CI = L CI = M TV = H TV = H TV = M TV = M TV = M TV = L TV = L TV = M V = M V = H V = L V = M V = L V = L V = M V = L Ambulatory Care (PCP) CI = H CI = H CI = M CI = M CI = L CI = L CI = L CI = L TV = H TV = H TV = H TV = M TV = H TV = M TV = M TV = L 16 16 Black circles = highest priority Green circles = high priority Home Health and Hospice as Senders V = H V = H V = H V = H V = H V = H V = H V = H In patient CI = H CI = H CI = M CI = M CI = L CI = M CI = L CI = M V = H V = H V = H V = H V = M V = H V = M V = H ED CI = H CI = H CI = H CI = M CI = M CI = L CI = L CI = M V = H V = H V = H V = H V = L V = H V = H Out patient services CI = H CI = M CI = M CI = M CI = L CI = L CI = L TV = H TV = H TV = H TV = H TV = H TV = H TV = L V = H V = H V = H V = M V = H V = H V = M V = H V = H V = H LTAC CI = H CI = H CI = H CI = M CI = M CI = M CI = M CI = M CI = M CI = M TV = H TV = H V = H V = H V = H V = L V = H V = H V = L V = H V = H V = H IRF CI = H CI = H CI = M CI = H CI = L CI = L CI = M CI = L CI = L CI = L TV = H TV = H V = H V = H V = H V = M V = L V = L V = H V = M V = H V = H V = H SNF/ECF CI = H CI = H CI = M CI = H CI = M CI = M CI = M CI = M CI = L CI = M CI = L TV = H TV = H TV = H TV = M TV = M TV = M TV = H TV = M TV = M TV = H TV = H V = H V = H V = L V = M V = H V = H V = H HHA CI = H CI = H CI = L CI = L CI = L CI = L CI = L TV = H TV = H TV = L TV = L TV = L TV = L TV = L V = L V = M V = M V = L V = L V = L V = M V = L Hospice CI = H CI = H CI = M CI = L CI = L CI = M CI = L CI = M TV = H TV = H TV = M TV = M TV = M TV = L TV = L TV = M V = M V = H V = L V = M V = L V = L V = M V = L Ambulatory Care (PCP) CI = H CI = H CI = M CI = M CI = L CI = L CI = L CI = L TV = H TV = H TV = H TV = M TV = H TV = M TV = M TV = L 17 17 Black circles = highest priority Green circles = high priority Prioritize Transitions by Volume, Clinical Instability and Time-Value of Information In patient ED Out patient services LTAC IRF SNF?ECF HHA Hospice Ambulatory Care (PCP) 18 18 Black circles = highest priority Green circles = high priority 6

High-priority Transition Datasets 1. Report from Outpatient testing, treatment, or procedure 2. Referral to Outpatient testing, treatment, or procedure 3. Shared Care Encounter Summary (Office Visit, Consultation Summary, Return from the ED to the referring facility) 4. Consultation Request Clinical Summary (Referral to a consultant or the ED). Permanent or long-term transfer to a different facility or care team or Home Health Agency 19 High-priority Transition Datasets In patient ED Out patient services LTAC 3 1 IRF SNF?ECF HHA Hospice Ambulatory Care (PCP) 4 2 20 High-priority Transition Datasets Type 3 Dataset: Office Visit to PHR Consultant to PCP ED to PCP, SNF, etc Type 4 Dataset: PCP to Consultant PCP, SNF, etc to ED Type Dataset: Hospital to SNF, PCP, HHA, etc Hospital, SNF, etc to HHA PCP to new PCP 21 7

Relationship to Assessment Tools 22 Relationship to Plan of Care 23 Home Health Certification & Plan of Care is a subset of # Relationship to CMS-48 Unique to HHA/H: Face-to-Face Site of Care 24 8

Join the work! ONC is supporting an open platform to address the issues of: Longitudinal coordination of care Data elements required for all PAC transitions Re-use of standardized assessment tools (MDS 3, OASIS S C, IRF-PEI) Standardization and intra-operability of data S&I Framework: http://wiki.siframework.org/longitudinal+coordination+of +Care+WG 2 Marc h26 Getting Connected: LAND & SEE 26 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 Application for Network Distribution) acts as a data courier to gather and securely transfer data if no support for Direct or IHE XDR 27 9

Local Application for Network Distribution (LAND) Documents with destination Direct address, local patient ID, and patient demographics Interface Engine + Mapper Consistent Time (CT) LAND Assemble/Extract XDR + Metadata ATNA (Audit Trail Assemble & Node XDM Zip Authentication) File/ Unzip Sign/Verify Private w/ Private Key Key Store Statewide Services XDR/SOAP/TLS XDR Gateway Send/Receive via SMTP + Encrypt/Decrypt w/ Destination Certificate PKI (Public Key Infrastructure) SMTP/SMIME NwHIN & Internet other HISPs Supports both IHE XDR and SMTP/SMIME Direct Virtual Gateway Direct Gateway Statewide HISP HISP Direct Gateway/Mailbox and SEE SEE Fixture CCD+ Viewer / Documents Local Master Medical Editor (Long Term) Patient Index Vocabulary HTTP + TLS (HTTPS) Web Browser API Gateway/Mailbox Document Viewer Private Key Store Fixture Audit Log Documents (Short Term) Locate Destination Address/ Services Locate/Verify Destination Certificate (Public Key) Assemble XDR + Metadata Assemble XDM Zip file/ Unzip Sign/Verify w/ Private Key Encrypt/Decrypt w/ Destination Cert Send/Receive via SMTP + Data Translation Services Deidentification Services Fax Server Statewide MPI/Consent Provider Directory/ Certs MA Data Rules HISP Pipe SMTP + 29 Imagine the Future Hospital Home Health PCP 2013 HH Referral (CCD+) SEE CCD+ EHR OASIS CMS-48 CMS-48 ER Referral (CCD+) OASIS & CMS-48 LAND HH Discharge (CCD+) 201 HH Referral (CCD+) EHR OASIS CMS-48 CMS-48 ER Referral (CCD+) CCD+ HH Discharge (CCD+) 30 10

IMPACT Timeline Dates Activity 3/2012 6/2012 Data Element Pilot using paper 6/2012 12/2012 Submit updated datasets to S&I Framework and HL7 12/2012 2/2013 LAND & SEE Go-lives 31 Summary IMPACT is helping ONC s S&I Framework to develop national standards for transitions of care datasets LAND & SEE software will facilitate integrating LTPAC organization and into electronic health information exchanges and enable reusing data Questions? 11