Health Information Exchange Activities for LTPAC and Behavioral Health Communities

Health Information Exchange Activities for LTPAC and Behavioral Health Communities ASPE Sponsored Webinar December 4, 2012 To ask a question during the live webinar 1) Post a question at any time in the Chat Box 2) Live Q&A will be held at the end of the webinar

Session Overview Health IT and Health Information Exchange are powerful tools supporting transformation in health care This session will Highlight activities that are paving the way for improved communication between providers including LTPAC and BH Provide an overview of meaningful use and its impact on LTPAC and BH communities related to HIE Present examples of the use of technology to transform health care delivery and payment impacting LTPAC and BH communities 2

Speakers: Jennie Harvell, Sr. Policy Analyst, ASPE Travis Broome, CMS/Office of E-Standards & Services Effie R. George, Disabled & Elderly Health Programs Group, CMCS Anita Yuskauskas, Disabled & Elderly Health Programs Group, CMCS Lynda K. Hohmann, PhD, MD, MBA, NY State Department of Health Maria Moen, Healthcare Applications Director, Brookdale Sr. Living 3

Health Information Exchange Involving LTPAC and BH: A Necessary Component for Health System Transformation Jennie Harvell, ASPE December 4, 2012

The Need for Health Information Exchange Persons who receive long-term/post-acute care and behavioral health services are medically fragile, functionally impaired, and/or have serious and complex behavioral health problems. These individuals have frequent contact with the health care delivery system, experience frequent transitions and referrals in care, and are among the most costly patients. Poor health information exchange is believed to be a factor that contributes to: readmissions, duplicative testing treatment, adverse medication events, and poor coordination and integration of care. Improved health information exchange (HIE) on behalf of persons who receive LTPAC and BH services is anticipated to improve quality and reduce unnecessary health care costs. 5

National Quality Strategy Aims NQS Priorities: Making care safer by reducing harm caused in the delivery of care. Ensuring that each person and family are engaged as partners in their care. Better Health for the Population Promoting effective communication and coordination of care. Promoting the most effective prevention and treatment practices for the leading causes of mortality, starting with cardiovascular disease. Better Care for Individuals Lower Cost Through Improvement Working with communities to promote wide use of best practices to enable healthy living. 6

Success requires delivery system and payment transformation Volume Outcomes Driven fragmentation Payment systems support Fragmented payment systems (IPPS, OPPS, RBRVS, SNF PPS, HH PPS, etc.) Fee-for-service payment models Lack of transparency Private Sector + Public Sector + Innovation Center Driven collaboration Payment systems support Value-based purchasing ACOs Episode-based payments Patient-centered Medical Homes Data transparency 7

CMS Innovation Center (CMMI) Charge: Identify, Test, Evaluate, Scale The purpose of the Center is to test innovative payment and service delivery models to reduce program expenditures under Medicare, Medicaid, and CHIP while preserving or enhancing the quality of care furnished. - The Affordable Act Opportunity to scale up : The HHS Secretary has the authority to expand successful models to the national level Measures of Success focus on: Better health care Better health Reducing costs through improvement 8

Innovation Center Portfolio Primary Care Transformation Comprehensive Primary Care Initiative (CPC) Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration Federally Qualified Health Center (FQHC) Advanced Primary Care Practice Demonstration Independence at Home Demonstration Graduate Nurse Education Demonstration Accountable Care Organizations (ACOs) Medicare Shared Savings Program Pioneer ACO Model Advance Payment ACO Model PGP Transition Demonstration Bundled Payment for Care Improvement Model 1: Retrospective Acute Care Model 2: Retrospective Acute Care Episode & Post Acute Model 3: Retrospective Post Acute Care Model 4: Prospective Acute Care Capacity to Spread Innovation Partnership for Patients Community-Based Care Transitions Million Hearts Innovation Advisors Program Health Care Innovation Awards State Innovation Models Initiative Initiatives Focused on the Medicaid Population Medicaid Emergency Psychiatric Demonstration Medicaid Incentives for Prevention of Chronic Diseases Strong Start Initiative Medicare-Medicaid Enrollees Financial Alignment Initiative Initiative to Reduce Avoidable Hospitalizations of Nursing Facility Residents http://innovations.cms.gov/ 9

ACO Vision An ACO promotes seamless coordinated care Puts the beneficiary and family at the center Remembers patients over time and place Attends carefully to care transitions Manages resources carefully and respectfully Proactively manages the beneficiary s care Evaluates data to improve care and patient outcomes Innovates around better health, better care and lower growth in costs through improvement Invests in team-based care and workforce 10

Accountable Care Organizations Medicare Shared Savings Program (Center for Medicare and CMMI): Facilitates coordination of care and shared savings on behalf of Medicare FFS beneficiaries by creating of participating in ACOs. Pioneer ACO Model: Organizations including several integrated delivery systems that include LT/PAC and/or BH services, and use health IT to support care coordination. Advance Payment Model: Physician-based and rural providers that work to coordinate care for Medicare beneficiaries. 11

Bundled Payments for Care Improvement GOAL: Drive care redesign by aligning incentives that improve coordination across services and reduce the cost of care. Four patient-centered approaches Focus on bundling payment for episodes of care: 1. Acute care hospital stay only 2. Acute care hospital stay plus post-acute care: episode bundles the inpatient hospital and PAC stay for either 30 or 90 days posthospital discharge. 3. Post-acute care only: episode begins with the initiation of PAC services within 30 days of hospital discharge and ends after 30 days of PAC service delivery. PAC services are: SNF, HHA, LTCH, IRF. Bundle includes: physician, PAC, lab, DME, and Part B meds. 4. Prospective payment of all services during inpatient stay 12

Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents GOAL: Reduce preventable inpatient hospitalizations among residents of nursing facilities. Providing preventive care and treatment without hospital visits. 40 percent of hospital admissions among Medicare-Medicaid enrollees who were nursing facility residents were preventable in 2005. That s 314,000 potentially avoidable hospitalizations. This cost $2.6 billion in unnecessary Medicare expenditures. Initiative supports the goal of reducing avoidable hospitalizations by 20% by end of 2013. 09/27 - Announced 7 participating organizations 13

Medicaid Health Home State Plan Option GOAL: Allowing Medicaid beneficiaries with at least two chronic conditions to designate a single provider as their health home. Open to all states. Participating states receive enhanced financial resources from the federal government to support health homes. Innovation Center will assist with learning, technical assistance, and evaluation activities. 14

Community-based Care Transitions Program (CCTP) Focus on partnerships between community-based organizations and hospitals to reduce 30-day hospital readmissions. GOALS of CCTP: Improve transitions of beneficiaries from inpatient hospitals to home or other care settings. Reduce readmissions for high risk beneficiaries. Document measurable savings to the Medicare program. Applications now being accepted and awarded on a rolling basis. 30 program participants to date. 15

Medicaid Emergency Psychiatric Demonstration GOAL: Test whether Medicaid Beneficiaries aged 21 to 64 who are experiencing a psychiatric emergency (suicidal or homicidal thoughts or gestures) get more immediate, appropriate care when institutions for mental diseases (IMDs) receive Medicaid reimbursement Demonstration provides federal matching funds over 3 years Demonstration pays for inpatient services necessary to stabilize the psychiatric emergency 11 States Alabama, California, Connecticut, Illinois, Maine, Maryland, Missouri, North Carolina, Rhode Island, Washington, and West Virginia and the District of Columbia were selected to participate 16

Health Care Innovation Awards GOAL: Identify and support a broad range of innovative service delivery and payment models that achieve better care, better health and lower costs in communities across the nation. Innovation Awardees will: Improve care and lower costs for Medicare, Medicaid, and CHIP beneficiaries. Reach diverse populations in underserved and geographically remote communities Rapidly implement the proposed model. Develop, train, and deploy workforce in innovative payment and delivery models. Status: 107 Projects Awarded for a three-year period in all 50 states 17

Meaningful Use: Advancing Health Information Exchange and Improving Quality Use technology Access information Patient informed Structured data capture Care coordination Patient engagement Clinical Decision Support Transformation Performance and population management CQM data enables outcome improvements Case management & longitudinal view Patient centered, team based care Robust CDS (evidence based medicine & practice goals) Enhanced access and continuity Improved population health Stage 1 MU Stage 2 MU Stage 3 MU Future National Quality Strategy. Better Care. Healthy People/Health Communities. Affordable care. 18

Meaningful Use Opportunities December 04, 2012 Travis Broome, CMS

Eligibility Professionals Medicare-only Eligible Professionals Medicaid-only Eligible Professionals Doctors of Optometry Doctors of Podiatric Medicine Chiropractor Doctors of Medicine Doctors of Osteopathy Doctors of Dental Medicine or Surgery Nurse Practitioners Certified Nurse-Midwives Physician Assistants (PAs) when working at an FQHC or RHC that is so led by a PA Could be eligible for both Medicare & Medicaid 20

Eligibility - Hospitals Hospitals only eligible for Medicare incentive Hospitals only eligible for Medicaid incentive Subsection (d) hospitals in 50 U.S. states and the District of Columbia* Critical Access Hospitals (CAHs) Most subsection (d) hospitals/ acute care hospitals Most CAHs Children s hospitals Acute care hospitals in the territories Cancer hospitals *without 10% Medicaid Could be eligible for both Medicare & Medicaid 21

Closer Look at Stage 2: Electronic Exchange Stage 2 focuses on actual use cases of electronic information exchange: Stage 2 requires that a provider send a summary of care record for more than 50% of transitions of care and referrals. The rule also requires that a provider electronically transmit a summary of care for more than 10% of transitions of care and referrals. At least one summary of care document sent electronically to recipient with different EHR vendor or to CMS test EHR. 22

Describing Transition of Care and Referrals Transition of Care: the movement of a patient from one setting of care to another Referral: one provider refers a patient to another, but the referring provider maintains their care of the patient as well 23

Counting Transition of Care and Referrals Eligible Professionals The transition or referral is ordered by the EP For example, the EP is the admitting physician for the patient to a hospital or LTPAC facility Eligible Hospitals All discharges from the inpatient department Emergency department visits when follow-up care is ordered by an authorized provider of the hospital 24

Enabling Standards Consolidated Clinical Document Architecture (C-CDA) HL7 Implementation Guide for CDA Release 2: IHE Health Story Consolidation DIRECT Project Applicability Statement for Secure Health Transport http://healthit.hhs.gov/portal/server.pt/community/healthit_hhs_gov direct_project/3338 XDR and XDM for Direct Messaging Specification http://wiki.directproject.org/xdr+and+xdm+for+direct+messaging Simple Object Access Protocol (SOAP) http://modularspecs.siframework.org/soap+based+secure+transport+artifacts 25

MU Required Data in the C-CDA? Data Standard Data Standard Patient Name Care plan field(s) Demographics Multiple Procedures SNOMED CT ICD-10 PCS Smoking Status SNOMED CT Care Team Members Problems SNOMED CT Encounter diagnosis ICD -10 CM Medication RxNorm Immunizations HL7 CVX Medication Allergies Laboratory tests and results Vital Signs LOINC Cognitive and functional status Reasons for referral Referring provider s name and contact SNOMED CT and LOINC 26

Further Info Explanation of MU Required Data in the C-CDA Functional status, including activities of daily living, cognitive and disability status Care plan field, including goals and instructions Care team including the primary care provider of record and any additional known care team members beyond the referring or transitioning provider and the receiving provider 27

Certification for Other Settings Nothing prohibits anyone from getting a technology certified to as many criteria as they wish even if the technology is not designed for or marketed to eligible providers Certification ensures that the technology is capable of sharing a C-CDA with other certified technologies and that it can both create and consume information in C-CDA ONC Final Rule: HIT: Standards, Implementation Specifications, and Certification Criteria for EHR Technology, 2014 Edition; Revisions to the Permanent Certification Program for HIT We encourage EHR technology developers to certify EHR Modules to the transitions of care certification criteria ( 170.314(b)(1) and (2)) as well as any other certification criteria that may make it more effective and efficient for EPs, EHs, and CAHs to electronically exchange health information with health care providers in other health care settings. 28

Balancing Incentive Program Section 10202 of the Affordable Care Act Effie R. George, Ph.D. Disabled & Elderly Health Programs Group, CMCS

Balancing Incentive Program Goal increase access to non-institutionally based Medicaid Services and implement key structural reforms States must reach benchmarks of either 2 or 5% by the end of the program CMS is accepting applications from States immediately through August 1, 2014 Enhanced FMAP available until September 30, 2015 or until total program funding of $3 billion dollars is expended State Medicaid Agencies must apply 30

Balancing Incentive Program Eligibility States who submit an application and spend less than 50 % on HCBS States may submit expenditure data on total Medicaid expenditures on LTSS as of FY 2009 to be reviewed on case by case basis States may not apply based on expenditures by target population(s) Funding available for community-based LTSS 31

Balancing Incentive Program Financial Incentives 2 or 5 % on eligible HCBS provided under the following Medicaid program authorities: HCBS under 1915 (c) or (d) or under an 1115 Waiver; State plan home health; State plan personal care services; The Program of All-Inclusive Care for the Elderly (PACE); Home and community care services defined under Section 1929(a); and Self-directed personal assistance services in 1915 (j), services provided under 1915(i), private duty nursing authorized under Section 1905 (a)(8) (provided in home and community-based settings only) Affordable Care Act, Section 2703, State Option to Provide Health Homes for Enrollees with Chronic Conditions Affordable Care Act, Section 2401, 1915(k) - Community First Choice (CFC) Option. 32

Balancing Incentive Program Structural Changes: No Wrong Door/Single Entry Point system, Conflict-free case management, and Core assessment instruments And data reporting requirements A User Manual and technical assistance will be available 33

Balancing Incentive Program Opportunities for collaboration and coordination Community First Choice (CFC), Health Home, Money Follows the Person (MFP), and Aging and Disability Resource Centers (ADRCs) 34

Resources Balancing Incentive Program Guidance: http://www.medicaid.gov/medicaid-chip- Program-Information/By-Topics/Long-Term- Services-and-Support/Balancing/Balancing- Incentive-Program.html Questions or comments: Balancing-Incentive-Program@cms.hhs.gov 35

Information Follows the Person: Advancing LTSS Measures & Integrated Electronic Records TEFT GRANT INITIATIVE Anita Yuskauskas 36

Demonstration Grant for Testing Experience and Functional Tools (TEFT) in Medicaid Long Term Services and Supports 37

Four Components of TEFT Test and Experience of Care Survey Test a set of CARE Functional Assessment Measures Develop Standards for e-ltss Records Demonstrate Personal health Records 38

TEFT Initiative Description: $64 million Initiative Ten + Grants Four Contracts EoC Testing CARE Testing Technical Assistance Evaluation Two Federal Interagency Agreements ONC Standards Development DoD PHR/EHR 39

Why TEFT? The Three-Part Aim Better Health for the Population 40 Better Care for Individuals Lower Cost Through Improvement

Adult Quality Measures: The Affordable Care Act of 2010 Development of a Core Set of Health Care Quality Measures for Adults Eligible for Benefits Under Medicaid Includes Individuals with LTSS Needs 5% Using 55% Resources Lack of National Measures 41

5% Drive 55% of Medicaid Expenditures 0% 0% Top 5% 45% 55% Remaining 95% 42

Meaningful Use: The American Recovery & Reinvestment Act of 2009 Provides Incentives to targeted eligible professionals for using Electronic Health Technology Targeted Professionals in Medicaid include: Physicians, certified nurse midwife, nurse practitioner, physician assistant practicing in a FQHC or RHC led by a Physician Assistant May not be based in an inpatient hospital or emergency room of a hospital 43

WHAT S MISSING IN THIS PICTURE?? 44

WHERE IS LONG TERM CARE??? 45

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Complicating Factors in LTSS Wide Range Of Settings Wide Range Of Service Provider Types And Qualifications Wide Range of Measurement Sets: No Standardization Wide Variety Of Diagnostic Categories in LTC No Standard Treatment Intervention, i.e., service definitions & service delivery models Personal & social outcomes versus illness or disease outcomes 47

MESSY! 48

System of LTSS Needs to Participate in MU 1. Personal Health Records 2. Trained Providers 3. Standards 4. Measures 49

PHR and an E-LTSS Record: Two Goals of TEFT Demonstrate personal health records with beneficiaries of CB-LTSS; and Curate an electronic Long Term Services and Supports (e-ltss) standard coordinated through the Office of National Coordinator s (ONC) Standards and Interoperability Framework. 50

Demonstrate personal health records with beneficiaries of CB-LTSS Individuals will have access to their own PHR States will have the option to include additional components of interest in the PHRs Applicable providers are equipped to train and support individuals to access and use their PHRs through an outreach and training strategy. 51

Curate an electronic Long Term Services and Supports (e-ltss) standard States can develop a strategy in their initial operational protocol to integrate health related information through the use of HIT (Health Information Technology). This strategy is intended to engage and integrate information from EHRs into a beneficiary s PHR. 52

Curate an electronic Long Term Services and Supports (e-ltss) standard More on the process States will be able to identify a HIE strategy that aligns with the State s HIE protocol. CB-LTSS providers will be required to enter information in the e-ltss record based on standards developed through the S&I Framework. At least two iterations of the e-ltss record will be rolled out to States and their providers for testing. State s will need to develop a crosswalk with their standards for service plan development and reporting. 53

NYS Medicaid Health Homes Office of Health Insurance Programs (OHIP) Division of Program Development and Management Lynda K. Hohmann, PhD, MD, MBA

New York State Health Homes : Health Home Framework Health Home Roll-out in NYS Integrating HIE into Health Homes 55

What is a Health Home? It s not a PCMH.. A health home is an approach to how health care is delivered. A health home is a provider or a team of health care professionals that provide integrated health care. This means that if a person is participating in a health home, that person s health care, from primary care doctor to dentist to behavioral health professional, all share the same information and coordinate treatment based on that information. Health homes operate under a whole-person philosophy caring not just for an individual s physical condition, but providing linkages to long-term community care services and supports, social services and family services. The integration of primary care and behavioral health services is critical to achievement of enhanced outcomes. (SAMHSA) 56

What is the central theme of Health Homes? A care manager who knows the member, organizes care, ensures communication with other care providers and assures that the member s circumstances does not affect his/her progress to better health Complex health conditions with complex treatment regimens Literacy and health literacy issues Homelessness and unreliable food Safety concerns Familial disruption 57

How Eligible Members are Being Identified and Assigned New York State Health Home Analytical Products CRG Based Attribution For Cohort Selection CRG Based Acuity For Payment Tiers Predictive Model Predicts future negative events (Inpatient, Nursing Home, Death) using claims and encounters For Assignment Priority Ambulatory Connectivity Measure For Assignment Priority Provider Loyalty Model Establishes Patient Connectivity to Existing Care Management, Ambulatory (including BH), ED and Inpatient For Matching to Appropriate HH and to Guide Outreach activity. 58

Populations Total Complex N=976,356 $2,338 PMPM 32% Dual 51% MMC Developmental Disabilities 52,118 Recipients $10,429 PMPM Mental Health and/or Substance Abuse 408,529 Recipients $1,370 PMPM $6.5 Billion 50% Dual 10% MMC $6.3 Billion 16% Dual 61% MMC $25.9 Billion $10.7 Billion 77% Dual 18% MMC $2.4 Billion 20% Dual 69% MMC Long Term Care 209,622 Recipients $4509 PMPM All Other Chronic Conditions 306,087 Recipients $698 PMPM 59

Status of NYS Health Homes New York currently has 51 designated Health Homes in 57 counties. Phase 1 Health Homes are in active outreach and engagement and active care management. Phase 2 and 3 Health Homes are pending approval of their SPA. Quality process and outcome measures are close to completion. 60

Required Health Home Services: Comprehensive care management An individualized patient centered care plan based on a comprehensive health risk assessment must meet physical, mental health, chemical dependency and social service needs. Care coordination and health promotion One care manager will ensure that the care plan is followed by coordinating and arranging for the provision of services, supporting adherence to treatment recommendations, and monitoring and evaluating the enrollee s needs. The health home provider will promote evidence based wellness and prevention by linking patient enrollees with resources for smoking cessation, diabetes, asthma, hypertension, self-help recovery resources, and other services based on need and patient preference. Comprehensive transitional care Prevention of avoidable readmissions to inpatient facilities and oversight of proper and timely follow-up care. Patient and family support Individualized care plan must be shared with patient enrollee and family members or other caregivers. Patient and family preferences are considered. Referral to community and social support services Provider will identify and coordinate community and social supports Use of health information technology (HIT) when feasible Health home providers will be encouraged to utilize RHIOs or a qualified entity to access patient data and to develop partnerships that maximize the use of HIT across providers. Health home provider applicants must submit a plan with their application for achieving compliance with the final health home HIT requirements within 18 months of program implementation 61

PCP Member Care Manager Care Management Record Health Information Exchange/RHIO 62

HIE Health Home Challenges: NYS has developed a strong state HIE infrastructure with the SHIN-NY and local RHIOs. Most development has been focused on hospital and physicians. Very little funding has been available for behavioral health providers aside from HEAL 17. RHIOs use different platforms and have different consenting processes for HIE access. MU incentives apply to a limited number of providers. 63

HIE Health Home Challenges: EHR for medical practices are common, there are some EHRs for behavioral health, but there are few electronic care management tools. There is wide disparity in HIT sophistication among the Health Homes. There is wide disparity in HIT financing among the Health Homes. 64

HIE Health Home Challenges: In 18 months from the date of the SPA, Health Homes need to meet HIT Health Home standards: Health home providers will be encouraged to utilize RHIOs or a qualified entity to access patient data and to develop partnerships that maximize the use of HIT across providers. Health home provider applicants must submit a plan with their application for achieving compliance with the final health home HIT requirements within 18 months of program implementation 65

Solutions: Several HHs are participating in CMMI grants. NYS has released HEAL 22 which is providing HIT technical support to behavioral health providers particularly related to HH. NYS OMH has released funding for certain programs for connectivity to RHIOs. 66

Solutions: NYS DOH has requested budget funding to support HIT development for under resourced HH. NYS has submitted a waiver to CMS with funding to support the IT infrastructure for Health Homes. NYS is spec ing a DOH Health Home portal that includes a Care Management Lite tool that meets minimal care management record needs. 67

Reducing Avoidable Resident Re-Hospitalizations: A Quality Improvement Project for Skilled Nursing Facilities, Assisted Living and Home Health Maria D. Moen, Healthcare Applications Director November 30, 2012 Brookdale Senior Living

The Changing Landscape.. Patient Protection & Affordable Care Act (PPACA) Accountable Care Organization (ACO): A term that signifies a very specific CMS program initiative that is outlined in a 696-page Final Rule released in October 2011 On March 23, 2010, the President signed into law the Patient Protection and Affordable Care Act PPACA, and a subsequent amendment to it, form the Affordable Care Act (ACA) ACA encourages the development of new patient care models for payment and service delivery to reduce costs and enhance quality Accountable Care Organization (ACO) is one major program initiative under ACA Proposed Rule for ACO was released March 31, 2011 and it required ACO implementation no later than Jan 1, 2012 69

The Changing Landscape & Goals of ACO s ACOs are designed to contain Medicare Fee-for-Service costs ACOs target the 73% of Medicare beneficiaries who steadfastly remain in the Medicare Fee-for-Service system ACOs that meet established quality standards, and achieve savings beyond a minimum threshold... will share CMS monetary rewards ACO legislation allows certain groups of providers to come together in a specific way (see Appendix) to manage/coordinate care of Medicare beneficiaries across a continuum of service settings 70

What Does it Mean for Long Term and Post Acute Care? Emphasis on prevention of illness and effective management of chronic medical conditions Reduction in hospitalization & care costs Emphasis on Advanced Care Planning/End of Life Care Quality Improvement through data exchanges, benchmarking, and quality metrics Growing of horizontal relationships across the continuum of care Seamless transitions for residents (not discharges) 71

CMS Innovations Challenge Grant Brookdale Senior Living owns / operates 647 senior living communities in 36 states A successful Transitions of Care program was implemented in select skilled nursing centers CMS Innovations Grant awarded for 3 years (July 2012-July 2015) Partnerships in the Grant Brookdale Senior Living University of North Texas Health Sciences Center (UNTHSC) Florida Atlantic University (FAU) Loopback Analytics University of South Florida (USF) American Association of Colleges of Nursing (AACN) Florida Medical Quality Assurance Inc. ( FMQAI) 72

Innovations Grant Components Goals INTERACT Clinical Nurse Leaders Education Outcomes Clinical Cost Savings Improve the quality of care for the resident, NOT prevent hospitalization when warranted. 1 out of 4 resident admitted to a nursing home will be readmitted to the hospital within 30days INTERACT can result in a more rapid transfer for residents who need acute care. Implement INTERACT in 67 Brookdale communities over 3 years that provide Skilled Nursing, Assisted Living, Independent Living and Home Health services and demonstrate success metrics Increase care coordination across continuum Integrate care cost data Create strong collaborative relationships/partnerships with hospital systems 73

What is INTERACT? INTERventions to reduce Acute Care Transfers Developed by a project supported by the Centers for Medicare and Medicaid Services (CMS) INTERACT is a Quality Improvement Program designed to identify situations around residents with acute changes in condition that commonly result in transfers to the hospital. INTERACT consists of processes and tools One study found that 65% of all transfers to the hospital could be prevented 74

Clinical Nurse Leaders to Facilitate a LTPAC Case Management Model Nurses with specialized training to have an effect on care transitions and quality of care Teach and train in our communities Evaluate data for trends and identify opportunities for improvement Report outcomes 75

Alignment with the Advancing Excellence Campaign Reporting, Analysis and Tracking tools support Quality Improvement and Root Cause Analysis Monthly Summaries produced can be entered on the AE website for trend graphing http://www.nhqualitycampaign.org Admission logs from Acute Care Hospitals Transfer logs for Acute Care Transfers Communication Tool logs and graphs Transfer Related process logs and graphs Admissions by Day of Week graph template Admissions by Hospital graph template Transfers by Doctor graph template Transfers by Time of Day graph template Transfers by Outcome graph template Transfers by Primary Reason for Transfer graph template 76

Data Targeted for Exchange Between LTPAC and the Acute Care Partner is Key 77

Opportunities and Barriers for Technology and Health Information Exchange State Initiatives to use as Models for Transfer of Information include Florida and Massachusetts S&I Framework work groups related to Assessment and Care Plan exchange of information are also models to evaluate Acute Care partners to facilitate information exchange to meet thresholds for Meaningful Use Stage 2 criteria Finding that facilitating data exchange is not always high on their development radar 78

WRAP UP 79

Request for Comment Weigh In! Possible MU Stage 3 Requirements HIT Policy Committee Requests Your Comments on Stage 3 MU Definitions Comments due January 14, 2013 Areas under consideration include: care plan, transitions of care, advanced directives, enhanced patient engagement, and others Participate in S&I Sponsored Webinars on the RFC http://wiki.siframework.org/longitudinal+coordination+of+care For more information go to: http://www.healthit.gov/sites/default/files/hitpc_stage3_rfc_final.pdf To Submit a Comment: http://www.regulations.gov 80

Upcoming ASPE-Sponsored Webinars All Audiences Information Exchange Activities for LTPAC and BH Communities December 4 12:30 1:45 p.m. ET Providers and Affiliated Organizations Implementing HIE in the BH Community December 4 2:30 3:45 p.m. ET Implementing HIE in the LTPAC Community December 12 1 2:15 p.m. ET State and HIE Organizations Implementing HIE in the BH Community December 5 12 Noon 1:15 p.m. ET Implementing HIE in the LTPAC Community December 14 11:30 12:45 p.m. ET All sessions are recorded & will be available Web replay To Register: https://www.ahimastore.org/productlist.aspx?categoryid=1324 81

Resources: Assistant Secretary for Planning and Evaluation Health Information and Technology Reports (http://tinyurl.com/aspe-hit) CMS EHR Incentive Program https://www.cms.gov/regulations-and- Guidance/Legislation/EHRIncentivePrograms/ index.html?redirect=/ehrincentiveprograms/ Center for Medicare & Medicaid Innovation http://www.innovations.cms.gov/ Office of the National Coordinator http://healthit.hhs.gov Substance Abuse & Mental Health Services Administration www.samhsa.gov SAMHSA.HIT@SAMHSA.HHS.gov Join the bi-monthly calls federal behavioral health HIT initiative Standards and Interoperability Framework: Data Segmentation for Privacy http://wiki.siframework.org/dat a+segmentation+for+privacy Longitudinal Coordination of Care http://wiki.siframework.org/longitu dinal+coordination+of+care Transition of Care http://wiki.siframework.org/transitio ns+of+care+%28toc%29+initiative 82

Thank you for attending. QUESTIONS 83