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Electronic-Person-Centered Care/Service Planning for Persons Receiving Medicaid Covered
Home and Community-based Services
Jennie Harvell, HHS/ASPE
Terrence A. O’Malley, MD
June Simmons, CEO Partners in Care foundation
Alex Bartolic, Continuing Care Administration, Minnesota Department of Human Services
John Martin, Ohio Department of Development Disabilities
Lee Mendoza, Office of Aging and Adult Services, Louisiana Department of Health and Hospitals
Eric WeiskopfNew York State Office of Health Information Technology
November 5. 2014
Agenda E-Care/Service Planning and Medicaid
• Introductions– Presentations on E-care/service planning:
• Terry O’Malley, MD Partners HealthCare • June Simmons, CEO Partners in Care Foundation • Alex Bartolic, MN Department of Human Services, Continuing Care
Administration, Aging and Adult Services • John Martin, OH Department of Developmental Disabilities • Lee Mendoza, LA Department of Health and Hospitals, Office of Aging and Adult
Services • Eric Weiskopf, NY Department of Health
• Defining LTPAC and LTSS
• Discussion
What is LTPAC?
• Often defined to include:– Skilled nursing facilities– Nursing facilities– Home health agencies– LTC Hospitals– IRFs: In-patient rehabilitation facilities
What are Long-Term Services and Supports?
• Medicaid covers institutional and home and community-based (HCBS) Long Term Care Services (LTSS) through several vehicles and over a continuum of settings1, 2.
• Community-based LTSS services include: assistance with activities of daily living and instrumental activities of daily living provided to beneficiaries who cannot perform these activities on their own due to a physical, cognitive, or chronic health condition3.
• Populations receiving LTSS include: older adults and persons with physical disabilities, people with intellectual/development disabilities, persons with serious mental illness/emotional distrubance2.
• 1. “MEDICAID EXPENDITURES FOR LONG-TERM SERVICES AND SUPPORTS IN FFY 2012” (April 28, 2014). http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Long-Term-Services-and-Supports/Long-Term-Services-and-Supports.html
• 2. “How Many Medicaid Beneficiaries Receive Long-Term Services and Supports?” (October 17, 2014). http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Long-Term-Services-and-Supports/Long-Term-Services-and-Supports.html
• 3. Draft Standards and Interoperability Electronic LTSS project Charter.
Institutional LTSS includes: HCBS includes:
Nursing homes, ICF/IID, Mental health facilities, Mental health facilities DSH
1915(c) waivers, personal care, home health, community first choice, PACE, private duty nursing, health home, case management, rehabilitative services, targeted case management, adult day care, Money Follows the Person Demonstration, and HCBS under: Section 1115 demonstrations, Section 1915(a), Section 1932(a), Section 1915(i), Section 1915(j)
Merging Two Worlds:Health Care and LTSS
Terrence A. O’Malley, MDNovember 5,2014
Patient-Centered vs Person-Centered
Time spent as a Patient
Time spent as a Person
Long Term Services and Supports
Home Function Community Environment
Personal PrioritiesTeam Collaboration
Health Care Services
HealthDiseaseTreatmentManagement
Team PrioritiesPatient Preferences
Area of Convergence
Convergence is the Promise
• High risk, high complexity, high cost individuals use both LTSS and Healthcare services: those with– Chronic severe mental illness– Multiple chronic illnesses– TBI– Dual eligibility– Homelessness– Substance abuse
Four Challenges
• Agreeing on what’s important• Measuring whether services address what’s
important• Developing a common vocabulary across all
service providers• Connecting all service providers on a common
IT platform
Connecting Home and Community Based Organizations and Healthcare
IT Integration for TruePerson-Centered Planning:
A business and clinical imperative
June Simmons, CEOPartners in Care foundation
Person Centered Planning Briefing: 11/5/14
Services for Diverse PopulationsModerate Risk – Chronic Diseases
w/o disability
Evidence-Based Self-
Management
HomeMeds
Complex – Eyes & Ears in the Home
HomeMeds+ Risk Assessment
& Services
Care Transitions
Frail – Long term services & supports
Ongoing care management
Purchase of services
Transforming the Health Care System
• Social services represent a new specialty practice in the evolving healthcare world– Essential to reduce ER/hospital/SNF utilization
• Opportunities to enhance health and prevent avoidable crises and costs:– Preventing and managing chronic conditions– Managing transitions from hospital and SNF to home
• Prototype development sponsored by John A. Hartford Foundation, Archstone Foundation, The US Administration for Community Living
Bold new partnerships require integrating two very different worlds
• Home and community services must prove their expertise PLUS adapt to the sophisticated and highly regulated culture and landscape of medicine– Integrated data required to accomplish this
• IT used by Community Based Organizations (CBOs) must – Facilitate true shared practice– Create new CBO infrastructure– Meet HIPAA & other regulations
• New IT market for a new CBO world - must be: – interoperable , flexible, comprehensive and affordable
Missing Data = Lost Clinical Opportunities• Typical in-home assessment includes:
– Medications inventory – Rx from all sources, OTC, borrowed, etc.– Patient understanding of meds & adherence issues– Physical & cognitive functioning– Depression screening– Nutrition – special diets, shopping, affordability, ability to prepare– Incidents – like falls, dizziness, confusion– Financial info: ability to afford care– Transportation for access to care– Caregiver information– Housing condition & home safety– Advance directive– Alcohol, tobacco, other hazards
• Most physicians have no access to this vital information in their practice and their EHR
Example: HomeMedsSM: Uncovering Problems at Home
• Across all programs 40%+ aged 65+ have at least 1 medication problem targeted by HomeMedsSM
– Unnecessary therapeutic duplication– High-risk use of pain medications related to gastric bleeding– Psychoactive medications w/falls, dizziness or confusion, – Cardiac med issues (low pulse, orthostasis, low SBP)
• Meals on Wheels – Ft. Worth – 1,500 patients– 70% had potential medication-related problems. – 45% had at least one fall in last 3 months.
• 250 post-acute medical group patients– 66% had med issues pharmacist referred to prescriber– 77% had home safety or other issues/needs
Numerous Basic CBO Challenges• History of fragmented funding & related IT• Unique formats, data requirements and services for each
contract• Lack of IT products specific to new CBO requirements in the
context of an interdisciplinary healthcare team• Impact of timing to develop and costs of building for a new
very technical/regulated market • Lack of standards, certification and support
• E.g., meaningful use and funding to support development &/or adoption
• Unpredictable and often duplicative expense to build new systems for new services
Key Components• Interoperability for electronic screening/
referral, report-back, analytics/ QI• Workflow tracking/productivity monitoring• Billing capability across multiple payers• Portable; enables real-time in-home data entry• Full security of protected information
– Phones and portable field devices• Output of data, not just PDF reports
Delivery and Payment Reform Policy Levers to Promote Integration of PCP, LTSS and Health Care Information through Technology
Alex Bartolic, Continuing Care Administration, Minnesota Department of Human Services
Rolf Hage, Continuing Care Administration, Minnesota Department of Human Services
November 5, 2014
Vision Better outcomes and quality of life for people
Better transitions for people and caregivers moving through health care and long term supports and services
Earlier intervention with meaningful information so consumers and caregivers can make good decisions
Sustainability of long term services and support funding
Minnesota Service Strategies Integrated health care
Help connecting home supports with primary health care—MLTSS (Medicaid Managed Long Term Services and Supports)
Know strengths and desired outcomes through person-centered planning
Person centered assessment and support planning (MnCHOICES) Person-Centered Thinking and Planning training
Information on community service choices and advocate to help
Aging and Disability Resource Center Return to Community Program DB 101 counseling Pre Admission Screening Report Card
Minnesota Strategies in Ehealth
State Health Care Home Initiative—need to know about all care plans
State and federal Ehealth Initiative—coordinates with Meaningful Use for hospitals and clinics
State Ehealth requires by 2015 the exchange of waiver services information and home care
Next Steps with Personal Health Records
Access to personal health records including LTSS is a building block for person centered planning
Through the TEFT grant and stakeholders: Develop the services and supports data set Use Data set including assessment, clinical care
plans and service plans in PHR Display it for understanding and best use Leverage the Health Information Exchange
infrastructure
Contact Information
651-431-2563
651-431-2381
651-431-2594
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The Imagine ProjectOhio’s Effort to Create an Electronic,
Interactive Platform to Support Person Center Practices
October 16, 2014John L. Martin, Director
Bryant Young, IT DirectorMatt Curren, Product Developer
Debra Albert, Project Owner
Imagine Overview• Imagine is an Ohio effort drive from the bottom up by 18 small rural
counties, their families, consumers, providers, service coordinators with full support of county leadership and a consultant. – A community effort
• The Challenge – to develop an information technology platform that creates fidelity to the person center planning process by:
• Increasing individual/guardian input and control in the planning and implementation process;
• Making the plan an organic rather than static process;• Increasing participation in the individuals life by those the individual
chooses;• Standardizing processes to create efficiencies;• Increasing transparency so everyone is aware of costs and services;• Provides a holistic picture by connecting to other applications (13) with
a long term vision to incorporate EHR.• Security (HIPPA, PHI)• Training
• Current Status24
What People Like and Admire About MeJoshua has a great sense of humor and enjoys joking around. He is very devoted to his family and passionate about things he loves such as football and wrestling. I am loving this.
Best Way to Communicate with MeTalk to Joshua. He also likes to talk on the phone and use Facebook.
Important People in My LifeMom, Dad, Aunt Pam, Christopher, Kelly, Ed, Mary Kay, Grandma Julie, Grandma Jan, Grandma Kay, Grandpa Bob. His friends: Nancy, Brett, Scott. His support team: Josh, Gina, Dianna, Emily, Tracy, Mamie, Merit, Bunkie, Natashia, Matt & Lorraine.
What I’m Interested in DoingJoshua loves sports, particularly football & wrestling. He loves watching them on TV. He likes going to the movies, playing video games (sports only), going out to eat (McDonalds or any place that has chicken), talking to his friends and spending time with his mom.
Imagine – Front Page Screen Shot Example
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Person Centered Plan Components
-Discovery (what is important to/for and risk )
-Outcomes Identified-Planning Occurs to Develop Support Considerations-Action Plan-Resource ManagementLocal Medicaid Community Resources
-Agreement occurs
-Notification-Learning Log-Alerts (Need for immediate attention)
-Documents (Categorized)Confidential
Non Confidential
-Pictures
Supporting Components
-Accessed through either the Individual/Provider/SSA Portal, Clickable from the Front Page
Imagine Components
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Outcome: INFORMATIONNew Outcome: Individual Projected Start* Projected Completion*
Joshua Ross 11/3/2014 2/27/2015
Josh and his team would then discuss what outcomes he would like to work on based on the discovery results
Outcomes
Current As of -- Status Working Draft – InternalOutcome Name* Time alone Discovered In* Day to Day LifeDesired Outcome* Joshua takes his medication on his ownProjected Start Date* 11/3/2014 So that/In order to* He can have time without staffProjected Completion Date* 2/27/2015Priority* 5
Emergency Request NoHow will we balance* It is important to Joshua to have time to himself, therefore it is important for him to learn to Important to and identify his medication and to learn what they are for rather than have staff give them to him.Important for?
How and how often will progress towards this Outcome be reviewed? -What does the person say progress will look like? Josh will be able to identify the medication, know the schedule he takes them and what they are for. To be reviewed monthly.
*Mandatory Fields
Outcomes – Screen Shot Example
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-- Adaptive devices e.g. chair, walker, etc
-- Do not resuscitate
-- Medications including medication assessment and list of medications
Essential Health
-- Diagnosis information used for DD eligibility and current active diagnosis
-- Allergies and allergy protocol for interaction
-- Special diet e.g. drinks with low sugar content
-- Health related e.g. take vitals 2x/day
Imagine Front Page – Health Related Information
For More Information:
(1) Bryant Young, IT Director, (614) 466-2809, [email protected]
(2) Matt Curren, Product Development, (614) 466-0145, [email protected]
(3) Debra Albert, Interface between IT and Program folks, Trainer & Implementer, (614) 387-1166, [email protected]
Handouts:Technology Information
29
OFFICE OF AGING AND ADULT SERVICES
Lee Mendoza
Alicia Smith
Louisiana Department of Health and Hospitals
LTSS in Louisiana
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• Nursing home residents ~ 20,000
• State Plan LTSS ~ 16,000
• 1915(c) ~ 6,000
Current process and systems (simplified)
32
Future processes and systems
33
Health Information Exchange
in New York State
November 5, 2014
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Broad Goals for NY’s Health IT Strategy
Build health information infrastructure to support state health reform goals:Support clinicians and consumers with information at point
of careAdvance care coordinationStrengthen public health surveillance and responseEnhance quality and outcome measures
OVERALL STRATEGY IS NOT JUST ABOUT HEALTH.IT’S ABOUT SYSTEMS CHANGE
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Major Elements of NY HIT:Strategic & Operations Plans
• Promote broad adoption of HIT & HIE usage
• Develop statewide HIE services, and consolidate infrastructure to lower overall costs and reduce technical variability of commodity components
• Formalize Health Information Exchanges within the state by designating “Qualified HIT Entities”
• Build upon the state’s investment in “collaborative care organizations” through further development of technical services to support new care models
• Incorporate the expansion of public health and population health data services into the HIE infrastructure
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Vision for New York’s Health Information Infrastructure
Costly, High Risk and
Non-Interoperable EHRs
Interoperable EHRs
Clinician
EHR
SHIN-NY
Consumers
Payers
Government/
Medicaid
LabsHospitals
Pharmacies Radiology
NYS Office of Health Information Technology Transformation
38
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Elements Critical to Successful Reform
Health Homes in New York State:
• 4 Initial (Policies & Procedures) and 5 Final HIT standards to facilitate the use of HIE
• Final standards must be met within 18 months of Health Home program initiation
40
Discussion
