Using Data to Promote Continuity of Care and Increase Accountability

Transcription

1 Using Data to Promote Continuity of Care and Increase Accountability

2 USING DATA TO PROMOTE CONTINUITY OF CARE AND INCREASE ACCOUNTABILITY KAREN WOLK FEINSTEIN, PHD PRESIDENT AND CHIEF EXECUTIVE OFFICER PITTSBURGH REGIONAL HEALTH INITIATIVE DECEMBER 17, 2013 WASHINGTON, DC

3 THE SYSTEMS VISION: TRANSFORMING THE CARE OF COMPLEX PATIENTS Across Care Settings Collaboration Medication and Reconciliation Integration Informed, Activated, Discerning Consumers, particularly at End-of-Life Screening and Tx Hospice/Palliative Long-Term Care Rehab Hospital Emergency Services Specialty Care Primary Care Data to Treat, Measure, Evaluate Perfect Rewards Patient for Care Collaboration Care Mgt Clinical Pharmacy Patient Engagement Behavioral Health Essential Services Health IT QI Training System Requirements Performance Incentives

4 What is essential to our vision for reducing readmissions? Isn t reimbursed Care Management Clinical Pharmacy Patient Engagement Behavioral Health HIT QI Training Pittsburgh Regional Health Initiative

5 JHF CURRENT PROGRAMS TESTING HOW TO KEEP PEOPLE OUT OF HOSPITALS PRIMARY CARE RESOURCE CENTER QI 2 T Center Where Quality Improvement meets Information Technology Salk Fellowship Closure (End-of-Life and Palliative Care) Patient Safety Fellowship TOMORROW S HEALTHCARE TM MAI Minority AIDS Initiative Health Careers Futures PERFECTING PATIENT CARE SM UNIVERSITY HIV QI in AIDS Service Organizations RAVEN Reduce Avoidable Hospitalizations among Nursing Facility Residents PARTNERS IN INTEGRATED CARE Lean Engagements The Fine Awards Excellence in QI QI 2 T Health Innovators Fellowship Safety Net Medical Home Initiative Long-Term Care Champions REACH Regional Extension Center COMPASS Care Of Mental, Physical, And Substance Use Syndromes

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7 Connecting LTPAC to the Healthcare System of the Future LTQA s 3rd Annual Conference December 17 th, 2013

8 8 The Spectrum of Care is Vast High Intensity of Care Outpt. Behav. Health CBS Outpt. Rehab Adult Day Care Physician Office Living at Home Home Health Outpatient Testing/Pharmacy/DME PACE Psych Hospital Acute Care Hospital Hospice Facility Home Hospice Low Acuity of Illness High Adapted from Derr and Wolf, 2012

9 9 as are the Barriers to Care Coordination High Intensity of Care Outpt. Behav. Health CBS Outpt. Rehab Adult Day Care Physician Office Living at Home Home Health Outpatient Testing/Pharmacy/DME PACE Psych Hospital Acute Care Hospital Hospice Facility Home Hospice Low Acuity of Illness High Adapted from Derr and Wolf, 2012

10 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

11 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 Receiver surveys, along with national and international review 11

12 NYeC, Healthix, CCITINY, ASPE, S&I LCC, HL7, and Lantana update C-CDA for MU3 Consultation Note: Office Visit to PHR Consultant to PCP ED to PCP, SNF, etc Home Health Plan of Care (with esmd Digital Signature) Care Plan 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 12

13 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)

14 Hassle-Free to ED 30 seconds after ED registration, Reliant s CCD Summary Document is automatically loaded into ED s EHR using LAND St. Vincent Hospital ADT for Reliant Patients Reliant Medical Group s Epic EHR CCD with SVH MRN CCD with SVH MRN Outside Record Icon in MedHost Bedboard

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16 Using HIT to Promote Continuity of Care and Increase Accountability LTQA December 2013 Kelly Cronin

17 HIT Efforts Supporting Care Integration 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 12/19/2013

18 HIT Resources for LTPAC Enabling Health Information Exchange Challenge grants and Beacon Communities KeyHIE LAND and SEE LTPAC HIT website; existing Community of Practice; and Issue Brief _IssueBrief pdf 12/19/2013

19 Current and Future HHS Programs and Policies advancing HIT in LTPAC 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 principles_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 patientcentered care delivery. Steps to accelerate HIE will stem from Affordable Care Act delivery reform programs and Medicare and Medicaid payment 12/19/2013

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21 Jim Walker LTPAC and Care-Process Optimization Restricted Siemens AG 2013 All rights reserved. Answers for life.

22 Outline Need What a solution would look like Early Information Services A Developing Solution Restricted Siemens AG 2013 All rights reserved. Page 22

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 23

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: : Restricted Siemens AG 2013 All rights reserved. Page 24

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): Restricted Siemens AG 2013 All rights reserved. Page 25

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 26

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 27

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 28

29 Care-Process Optimization System Evidence-based, Engineered Model Process Contextualization to Patient Needs and Preferences Contextualization to specific Care Setting Instantiated Process for BPM Process monitoring prompts re-contextualization and reporting. Restricted Siemens AG 2013 All rights reserved. Page 29

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31 Using HIT to Promote Continuity of Care and Increase Accountability Karen Collishaw LTQA December

32 CHAP s Purpose 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 32

33 Integrated electronic applications and forms Automated workflow reminders and messaging Innovative reporting functionality to track longterm performance Improved accreditation process Workflow driven Alerts and journal functionality to improve communications

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