IMPACT - Connecting
Nursing Facilities and Home
Care to the Healthcare
System of the Future
Massachusetts Care Transitions Forum
September 28th, 2012
Drs. Terry O’Malley & Larry Garber
Agenda
 IMPACT – addressing Long Term and PostAcute Care (LTPAC) needs
 ONC’s S&I Framework - Developing national
standards for transitions of care datasets
 LAND & SEE – software to facilitate
integrating LTPAC into electronic health
information exchanges (HIE)
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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)
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IMPACT Objectives & Strategies
• Facilitate developing a national standard
of data elements for transitions across the
continuum of care
• Develop software tools to
acquire/view/edit/send these data
elements (LAND & SEE)
• Integrate and validate tools into
Worcester County using Learning
Collaborative methodology
• Measure outcomes
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IMPACT Core Project Team
• Madeleine Biondolillo, MD - Massachusetts DPH
• Amy Boutwell, MD, MPP - Collaborative Healthcare
Strategies
• Jim Brennan - Massachusetts e-Health Institute
• Larry Garber, MD - Reliant Medical Group/SAFEHealth
• Paula Griswold, MS - MA Coalition for the Prevention of
Medical Errors
• Peggy Preusse, RN - Reliant Medical Group/SAFEHealth
• Susan Sama, PhD - Reliant Medical Group
• Terry O'Malley, MD - Partners HealthCare System
• Craig Schneider, PhD - Massachusetts Health Data
Consortium
• Laurance Stuntz - Massachusetts e-Health Institute
• Michele Visconti - Massachusetts DPH
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IMPACT Advisory Committee
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Leon Barzin - Massachusetts Medical Society
Kate Bones - MA Care Transitions Forum
Ray Campbell, JD, MPA – Mass. Health Data Consortium
Donna Curran - MassPRO
James Fuccione - Home Care Alliance of Massachusetts
Ellen Hafer, MTS, MBA - Massachusetts League of Community
Health Centers
Laurie Herndon, MSN, GNP-BC, ANP-BC – Massachusetts
Senior Care Association
Pat Kelleher - Home Care Alliance of Massachusetts
Amy MacNulty, MBA - Community Care Linkages
Constance Nichols, MD, MS, FACEP - Massachusetts
Emergency Medical Services
Pat Noga, PhD, MBA, RN, NEA-BC - Massachusetts Hospital
Association
John Straus, MD - Mass. Behavioral Health Partnership
Laurance Stuntz - Massachusetts e-Health Institute
Deborah Wachenheim - Health Care For All
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Pilot Site Selection Process
• 9/2011 – Applications sent to 34 organizations
• Selection Criteria:
– High volume of patient transfers with other pilot sites
– Experience with Transitions of Care tools/initiatives
• 16 Winning Pilot Sites:
– 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 VNA)
– 1 Long Term Acute Care Hospital (Kindred Parkview)
– 1 Inpatient Rehab Facility (Fairlawn)
– 8 Skilled Nursing and Extended Care Facilities
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IMPACT Pilot Nursing Facilities
• Beaumont Rehab & Skilled Nursing
Center - Westborough
• Christopher House of Worcester
• Holy Trinity Nursing and Rehab Center
• Jewish Healthcare Center
• Life Care Center of Auburn
• Millbury Healthcare Center
• Notre Dame Long Term Care Center
• Radius Healthcare Center - Worcester
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Developing National
Standards to Support
LTPAC Needs
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The “Data Set” Challenge
• Multiple customers:
– MA UTF
– IMPACT Project Requirements
– State and National stakeholders
• Multiple needs
– The Commonwealth
– IMPACT participants
– Various State and National groups
– Consolidate requirements to facilitate
standardization through ONC and on to HL7
and then to MU3
Stakeholders/Contributors
• State
–
–
–
–
–
UTF work group
IMPACT learning collaborative participants
MCPME
MA Wound Care Committee
Home Care Alliance of MA (HCA)
• National
–
–
–
–
–
–
Substance Abuse, Mental Health Services Agency (SAMSA)
Administration for Community Living (ACL)
Aging Disability Resource Centers (ADRC)
National Council for Community Behavioral Healthcare
National Association for Homecare and Hospice (NAHC)
Longitudinal Coordination of Care Work Group- ONC
Consequences
• 200 element UTF
• 325 element IMPACT
• 450+ LTPAC / LCC
elements
• +?
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
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11x11 Sender (left column) to Receiver (top)
Transitions to (Receivers)
In Patient
ED
Out patient
Transitions From (Senders)
Services
In patient
ED
Out patient services
LTAC
IRF
SNF/ECF
HHA
Hospice
Ambulatory Care (PCP)
CBOs
Patient/Family
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14
LTAC
IRF
SNF/ECF
HHA
Hospice
Amb Care
(PCP)
CBOs
Patient/
Family
Prioritize Transitions by Volume, Clinical
Instability and Time-Value of Information
Transitions to (Receivers)
In Patient
ED
Out patient
Transitions From (Senders)
Services
In patient
ED
Out patient services
LTAC
IRF
SNF/ECF
HHA
Hospice
Ambulatory Care (PCP)
CBOs
V=H
CI = H
TV = H
V=H
CI = H
TV = H
V=H
CI = H
TV = H
V=H
CI = H
TV = H
V=M
CI = H
TV = H
V=H
CI = H
TV = H
V=H
CI = H
TV = H
V=H
CI = M
TV = H
V=H
CI = M
TV = H
IRF
SNF/ECF
HHA
Hospice
V=H
CI = H
TV = H
V=H
CI = H
TV = H
V=H
CI = H
TV = H
V=H
CI = H
TV = H
V=H
CI = H
TV = H
V=H
CI = M
TV = H
V=M
CI = M
TV = H
V=H
CI = M
TV = H
V=H
CI = H
TV = H
V=H
CI = M
TV = H
V=H
CI = M
TV = H
V=H
CI = L
TV = H
V=L
CI = M
TV = M
V=H
CI = M
TV = H
V=H
CI = M
TV = H
V=H
CI = M
TV = H
V=H
CI = M
TV = H
V=H
CI = L
TV = H
V=H
CI = M
TV = H
V=L
CI = L
TV = L
V=L
CI = L
TV = M
V=M
CI = M
TV = M
V=H
CI = L
TV = H
V=M
CI = M
TV = H
V=L
CI = L
TV = H
V=M
CI = M
TV = H
V=L
CI = M
TV = H
V=M
CI = M
TV = M
V=M
CI = L
TV = L
V=L
CI = L
TV = M
V=L
CI = L
TV = H
V=L
CI = H
TV = H
V=M
CI = H
TV = M
V=L
CI = M
TV = M
V=M
CI = M
TV = M
V=L
CI = M
TV = H
Black circles = highest priority
Green circles = high priority
Patient/Family
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V=H
CI = H
TV = H
V=H
CI = H
TV = H
V=H
CI = H
TV = H
V=H
CI = H
TV = H
V=L
CI = H
TV = H
V=M
CI = H
TV = H
LTAC
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Amb Care
(PCP)
V=H
CI = M
TV = H
V=H
CI = L
TV = H
V=H
CI = L
TV = H
V=H
CI = M
TV = H
V=H
CI = L
TV = H
V=H
CI = L
TV = M
V=H
CI = L
TV = L
V=L
CI = M
TV = L
V=L
CI = L
TV = M
CBOs
V=H
CI = L
TV = H
V=M
CI = L
TV = H
V=H
CI = M
TV = H
V=H
CI = L
TV = H
V=H
CI = M
TV = H
V=H
CI = L
TV = L
V=M
CI = L
TV = L
V=M
CI = L
TV = M
Patient/
Family
V=H
CI = M
TV = H
V=H
CI = M
TV = H
V=H
CI = L
TV = L
V=H
CI = M
TV = H
V=H
CI = L
TV = H
V=H
CI = L
TV = H
V=H
CI = L
TV = L
V=L
CI = M
TV = M
V=L
CI = L
TV = L
UTF Data Element Survey
• 46 Organizations completing evaluation
• ~300 Data elements evaluated
• 1135 Transition surveys completed
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12 User Roles
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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
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Five 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)
5. Permanent or long-term Transfer of Care
to a different facility or care team or Home
Health Agency
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Five 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 5 Dataset:
• Hospital to SNF, PCP, HHA, etc…
• SNF, PCP, etc… to HHA
• PCP to new PCP
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5 Transition Datasets
Transitions to (Receivers)
In Patient
ED
Out patient
Transitions From (Senders)
Services
LTAC
IRF
SNF/ECF
HHA
Hospice
Amb Care
(PCP)
5
3
In patient
ED
1
Out patient services
5
LTAC
IRF
5
SNF?ECF
HHA
Hospice
Ambulatory Care (PCP)
CBOs
Patient/Family
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5 4 2
CBOs
Patient/
Family
IMPACT Learning Collaborative:
Testing the Care Transitions
Datasets
16 organization, 40 participants,
6 meetings over 2 months, and
several hundred patient transfers…
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Learning Collaborative Surveys
• Surveys directly on envelopes carrying
IMPACT packet, filled out by sender as
well as receiver.
• Online survey at completion of pilot
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Analyzing data elements helped
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Senders found the data
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Receivers got most of their needs
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Home Care needed even more!
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Comment from Pilot Site Survey
“While we knew what ED's and
hospitals required, we didn't realize
Home Health Agencies needed much
more than what we typically sent.”
-Skilled Nursing Facility
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New World of Standards Development
National Coordinator
for Health IT (ONC)
Office of the Deputy
National Coordinator
for Programs & Policy
Office of the Deputy
National Coordinator
for Operations
Office of Policy &
Planning
HIT Policy
Committee Defines
“Meaningful Use”
of EHRs
Office of Science &
Technology (formerly
known as the Office of
Standards and
Interoperability (S&I))
S&I Framework
convenes public
and private experts,
and proposes
HIT/HIE standards
Office of Provider
Adoption Support
Office of State &
Community Programs
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Office of the Chief
Privacy Officer
IMPACT
Office of Economic
Analysis &
Modeling
HL7 ballots
standards
Office of the Chief
Scientist
Secretary of HHS
makes standards
part of “Meaningful
Use” and EHR
Certification
S&I’s Longitudinal Coordination of Care WG
Longitudinal
Coordination of
Care Workgroup
LTPAC Care
Transition SubWorkgroup
Patient Assessment
Summary SubWorkgroup
•
Identifying the key
business and technical
challenges that inhibit
long-term care data
exchanges
•
Establishing the
standards for the
exchange of Patient
Assessment Summary
(PAS) documents
•
Defining data elements
for LTPAC information
exchange using a single
standard for LTPAC
transfer summaries
•
Providing consultation to
transformation tool being
developed by Geisinger
to transform the noninteroperable MDSv3
and OASIS-C into an
interoperable clinical
document (CCD+)
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• Providing subject matter expertise and
coordination of SWGs
• Developing systems view to identify
interoperability gaps and prioritize activities
Longitudinal Care
Plan SubWorkgroup
•
Near-Term: Developing
an implementation guide
to standardize the
exchange of the Home
Health Plan of Care
(former CMS 485 form)
•
Long-Term: Identify and
develop key functional
requirements and data
sets that would support
a longitudinal care plan
Expanded Transfer of Care Dataset
• Includes Collaborative Care Plan data elements
• Transfer of Care Dataset: ~450 Data Elements
• Timeline for standards development:
October 2012
November 2012
December 2012
March 2013
May 2013
MA HIway go-live in 10 large sites with CCD
Preliminary Implementation Guide completed
Pilot full Transfer of Care Dataset in 16 facilities
Finish Implementation Guide in S&I Framework
HL7 Balloting of Implementation Guide for
inclusion in Consolidated CDA
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Getting Connected:
LAND & SEE
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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” Adaptor for Network
Distribution) acts as a data courier to gather
and securely transfer data if no
support for Direct SMTP/SMIME
or IHE XDR
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LTPAC Communication Today – Paper!
Home Health
Non-standard EHR
OASIS
PCP
Hospital
Billing Program
MDS
Nursing Facility
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LTPAC Communication with LAND & SEE
LAND & SEE
fill in gaps
Home Health
SEE
Non-standard EHR
OASIS
CCD+
OASIS
LAND
CCD+
Hospital
SEE
CCD+
MDS
Nursing Facility
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LAND
Billing Program
MDS
CCD+
PCP
The Future with LTPAC EHR Standards
Home Health
EHR
OASIS
CCD+
CCD+
CCD+
Hospital
EHR
MDS
CCD+
Nursing Facility
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PCP
Next Steps for Pilot Sites
 Update gap analysis using expanded dataset
 Catalog which data elements are captured (and by whom using what
vocabulary) electronically, on paper, or not at all with current standard
process
 Of those captured electronically (including CCD, MDS & OASIS), identify
process (technology & workflow) to make these available to LAND (for
Phase 2).
 Identify workflow to review new documents in SEE
 Notification by email or text message, and to whom?
 View online vs. print? Who does it and where?
 Can any of the data elements received be electronically filed
discretely for re-use using LAND?
 Identify workflow to update and send SEE document with current info
when discharging to Home Health or ED transfer
 How can standard and non-standard data elements be collected and
added online using SEE to the documents being sent?
 How will copies be printed for patient and ambulance?
 Additional computers, printers, or chairs required?
IMPACT Timeline for Next Steps
Dates
9/2012 – 12/2012
Activity
Integrate pilot sites into state HIE using LAND & SEE
12/2012 –
1/2013
Pilot site Go-lives with state HIE using LAND & SEE (Phase 1)
3/2013 –
4/2013
Upgrade SEE to handle multiple CDA reconciliation (Phase 2)
6/2012 –
5/2013
Ballot updated datasets in S&I Framework and HL7
1/2013 –
9/2013
Evaluate hospital (re)admissions & total cost of care
38
Questions?
TOMalley@Partners.org
Lawrence.Garber@ReliantMedicalGroup.org