Using Data to Promote Continuity of Care and Increase Accountability

D E C E M B E R 1 7 , 2 0 1 3 W A S H I N G T O N , D C

KAREN WOLK FEINSTEIN, PHD PRESIDENT AND CHIEF EXECUTIVE OFFICER PITTSBURGH REGIONAL HEALTH INITIATIVE

USING DATA TO PROMOTE CONTINUITY OF CARE AND

INCREASE ACCOUNTABILITY

THE SYSTEMS VISION: TRANSFORMING THE CARE OF COMPLEX PATIENTS

Acr

oss

Car

e Se

tting

s

Essential Services System Requirements

Care Mgt

Clinical Pharmacy

Patient Engagement

Health IT

QI Training

Performance Incentives

Collaboration and

Integration

Medication Reconciliation

Informed, Activated, Discerning

Consumers, particularly at End-of-Life

Data to Treat,

Measure, Evaluate

Perfect Patient Care

Rewards for

Collaboration

Hospice/Palliative Long-Term Care

Rehab

Hospital

Emergency Services

Specialty Care

Primary Care

Screening and Tx

Behavioral Health

© Pittsburgh Regional Health Initiative 2013 4

What is essential to our vision for reducing

readmissions?

Care Management

Clinical Pharmacy

Patient Engagement

Behavioral Health

HIT QI Training

Isn’t reimbursed

JHF CURRENT PROGRAMS TESTING HOW TO KEEP PEOPLE OUT OF HOSPITALS

REACH Regional Extension

Center

PRIMARY CARE RESOURCE

CENTER

TOMORROW’S HEALTHCARETM

Salk Fellowship

PARTNERS IN INTEGRATED

CARE

Long-Term Care Champions

Health Careers Futures

Lean Engagements

PERFECTING PATIENT CARESM

UNIVERSITY

RAVEN Reduce Avoidable

Hospitalizations among Nursing Facility Residents

MAI Minority AIDS Initiative

Patient Safety

Fellowship

QI2T Center Where Quality

Improvement meets Information Technology

COMPASS Care Of Mental, Physical,

And Substance Use Syndromes

Safety Net Medical Home

Initiative

HIV QI in AIDS Service Organizations

The Fine Awards

Excellence in QI

Closure (End-of-Life and Palliative Care)

QI2T Health Innovators Fellowship

Connecting LTPAC to the

Healthcare System of the Future

LTQA’s 3rd Annual Conference December 17th, 2013

Physician Office

Living at Home

CBS Outpt. Rehab

Home Health

Adult Day Care

PACE

Acute Care

Hospital Psych Hospital

Hospice Facility

Home Hospice

Outpt. Behav. Health

Acuity of Illness

Inte

nsity

of C

are

Adapted from Derr and Wolf, 2012

Low

High

High

Outpatient Testing/Pharmacy/DME

8

The Spectrum of Care is Vast…

Physician Office

Living at Home

CBS Outpt. Rehab

Home Health

Adult Day Care

PACE

Acute Care

Hospital Psych Hospital

Hospice Facility

Home Hospice

Outpt. Behav. Health

Acuity of Illness

Inte

nsity

of C

are

Adapted from Derr and Wolf, 2012

Low

High

High

Outpatient Testing/Pharmacy/DME

9

…as are the Barriers to Care Coordination

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)

10

Datasets for Coordinated Care

• Traditionally – What the sender thinks is important to the receiver

• Future – Also take into account what the receiver says they need

• 1000+ Receiver surveys, along with national and international review

11

12

Consultation Note: • Office Visit to PHR • Consultant to PCP • ED to PCP, SNF, etc…

Referral Note: • PCP to Consultant • PCP, SNF, etc… to ED

Transfer Summary: • Hospital to SNF, PCP, HHA, etc… • SNF, PCP, etc… to HHA • PCP to new PCP

Home Health Plan of Care (with esMD Digital Signature)

Care Plan

NYeC, Healthix, CCITINY, ASPE, S&I LCC, HL7, and Lantana update C-CDA for MU3

LAND & 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, transform, and securely transfer data if no support for Direct SMTP/SMIME or IHE XDR (live since 10/2012)

• Non-EHR users complete all of the data fields and routing using a web browser to access their “Surrogate EHR Environment” (SEE) (go-live 1/7/2014)

Hassle-Free to ED

St. Vincent Hospital

Reliant Medical Group’s Epic EHR

Outside Record Icon in MedHost Bedboard

CCD with SVH MRN

ADT for Reliant

Patients

CCD with SVH MRN

30 seconds after ED registration, Reliant’s CCD Summary Document is automatically loaded into ED’s EHR using LAND

Using HIT to Promote Continuity of Care and Increase

Accountability

LTQA December 2013 Kelly Cronin

HIT Efforts Supporting Care Integration

12/19/2013

EHR Incentives and HIT Certification Programs Stage 2 – Transitions of Care Measures; include sharing

summary records with LTPAC Stage 3 – TBD but care plans and advanced directives

are being considered by advisory committees HIT certification for LTPAC under consideration with

the goal of enabling interoperability across the care continuum

ACO spread, priorities and their HIT/HIE infrastructure can support continuity of care across acute, post-acute and long-term care settings Recent ACO survey showed reducing SNF utilization

and increasing community/home based care to be a priority

HIT Resources for LTPAC

12/19/2013

Enabling Health Information Exchange – Challenge grants and Beacon Communities KeyHIE http://transform.keyhie.org/

LAND and SEE http://mehi.masstech.org/what-we-do/hie/impact/land-and-see

LTPAC HIT website; existing Community of Practice; and Issue Brief http://www.healthit.gov/policy-researchers-

implementers/long-term-post-acute-care http://www.healthit.gov/sites/default/files/pdf/HIT_LTPAC

_IssueBrief031513.pdf

Current and Future HHS Programs and Policies advancing HIT in LTPAC

12/19/2013

State Innovation Models – many testing states are prioritizing LTPAC and LTSS to be part of multi-payer accountable care communities and primary care integration models

Value based Purchasing for SNFs and HH has the potential to drive adoption of interoperable HIT and exchange

HHS HIE Acceleration Strategy http://www.healthit.gov/sites/default/files/acceleratinghieprinciples_strategy.pdf HHS will seek to ensure that all new regulations and guidance

on existing programs enable a patient’s health information to follow them wherever they access care to support patient-centered care delivery.

Steps to accelerate HIE will stem from Affordable Care Act delivery reform programs and Medicare and Medicaid payment

Answers for life. Restricted © Siemens AG 2013 All rights reserved.

LTPAC and Care-Process Optimization Jim Walker 2013.12.03

Restricted © Siemens AG 2013 All rights reserved. Page 22

Outline

• Need

• What a solution would look like

• Early Information Services

• A Developing Solution

Restricted © Siemens AG 2013 All rights reserved. Page 23

Need

• Strategic Need

• High-reliability, high-efficiency provision to every patient of every relevant grade-A recommendation

Restricted © Siemens AG 2013 All rights reserved. Page 24

Need

• Strategic Need

• High-reliability, high-efficiency provision to every patient of every relevant grade-A recommendation

• Current State

• 2003: 55% received evidence-based interventions. McGlynn (2003) "The Quality of Health Care Delivered to Adults in the United States." NEJM 348: 2635-45.

• 2011:

Restricted © Siemens AG 2013 All rights reserved. Page 25

Need

• Strategic Need • High-reliability, high-efficiency provision to every patient of

every relevant grade-A recommendation

• Current State

• 2003: 55% received evidence-based interventions.

• 2011: 44% got evidence-based medication before PCI.

Borden (2011) Patterns and intensity of medical therapy in patients undergoing PCI. JAMA 305(18): 1882-89.

Restricted © Siemens AG 2013 All rights reserved. Page 26

Need

• Strategic Need

• High-reliability, high-efficiency provision to every patient of every relevant grade-A recommendation

• Salient Need

• High-reliability, high-efficiency care processes for the BCPI 48 (aka 90-day bundles)

Restricted © Siemens AG 2013 All rights reserved. Page 27

What a Solution Would Look Like

• Shared Care Processes

• Hospital

• LTPAC

• Patient

• Home Health

• Lay Caregiver

• Clinic

Restricted © Siemens AG 2013 All rights reserved. Page 28

Early Information Services

• ADT-based Alerts

• Auto-extracts of MDS and OASIS

• Regional, networked PHR (portal)

• Process-Management Reports

Restricted © Siemens AG 2013 All rights reserved. Page 29

Care-Process Optimization System

Process monitoring prompts re-contextualization and reporting.

Evidence-based, Engineered Model Process

Contextualization to Patient Needs and Preferences

Contextualization to specific Care Setting

Instantiated Process for BPM

Using HIT to Promote Continuity of Care and Increase Accountability

Karen Collishaw LTQA

December 2013 www.chapinc.org

To define and advance the highest quality of community-based care by:

• Objectively validating the excellence of community health care practice through consistent measurement of the delivery of quality service

• Motivating providers to achieve continuous improvement by adhering to standards of excellence

• Assisting the public in the selection of community health services and providers with demonstrated excellence

• Leading by example through organizational excellence and quality performance

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CHAP’s Purpose

Integrated electronic applications and forms Automated workflow reminders and email

messaging Innovative reporting functionality to track long-

term performance Improved accreditation process Workflow driven Alerts and journal functionality to improve

communications