Meeting Name
Location:
Meeting Date and Time:
Next Meeting Scheduled:
LCC Pilots WG Meeting
Web / Conference Call
Monday, July 21, 2014 @ 11:00am ET
Monday, August 4, 2014 @ 11:00am ET
Agenda
 Welcome and Announcements
 Discussion: National Quality Forum Measure Gaps Care Coordination Report
 Next Steps
Attendance
Name/Affiliation
Abhishek Khowala
Alex Baker
Amy Koizim
Andrey Ostrovsky
Annalisa Wilde
Atia Amin
Barbara Gage
Becky Angeles
Becky McClaren
Benjamin Flessner
Beth Halley
Bonnie Kohr
Brett Marquard
Catherine Payne
Cathy Walsh
Cheryl Irmiter
Chris Clark
Christol Green
Cindy Levy
Curtis Trimble
Daniel Lopez
David Foster
David Nessim
David Tao
Dawn Foster
Deb Castellanos
Diane Evans
Donna Doneski
Elaine Ayers
Elizabeth Amato
Ernest Grove
Elizabeth Serraino
Enrique Meneses
Evelyn Gallego
Gay Dolin
Gayathri Jayawardena
George Hur
Gordon Raup
Harrison Fox
Holly Miller
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Attended
Yes
Yes
Yes
Yes
Yes
Name/Affiliation
Holly Urban
Iona Thraen
Jack Kemery
Janel Welch
Jeffrey Levy
Jen Schiller
Jennie Harvell
Jennifer VanWinkle
Jim Younkin
Joanne Lynn
John King
Julia Chan
Karen Beach
Karen Green
Kari Ballou
Kate Wetherby
Kathleen McGrow
Kathy Applin
Kelly Cronin
Kelton Swartz
Kerrie Petrin
Kris Cyr
Kunal Agarwal
Larry Atkins
Larry Garber
Larry Seltzer
Laura Heerman Langford
Lauralei Dorian
Laurene Vamprine
Lee Jones
Lee Unangst
Leigh Sterling
Lenel James
Les Morgan
Lester Keepper
Liora Alschuler
Lisa Peters-Beumer
Lori O’Connor
Lorie Smith
Lynette Elliott
Marie Chesley
Mark Pilley
Mark Roche
Marlene Maheu
Matt Peeling
Matthew Arnheiter
Michael Carbery
Michael Lardieri
Mina Rasis
Nora Kershaw
Okaey Ukachukwu
Pam Russell
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Attended
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Name/Affiliation
Parag More
Pat Rioux
Paul Burnstein
Paul Lomayesva
Rachel Rusnik
Renee Tolliver
Rich Brennan
Rita Torkzadeh
Robert Dieterle
Robert Drake
Robin Bronson
Rodolfo Alvarez del Castillo
Russ Leftwich
Sandra Raup
Scott Zacks
Sean Kelly
Stacy Mandl
Steve Stasiak
Su-Hsiu Wu
Sue Mitchell
Susan Campbell
Susan McKeever
Sweta Ladwa
Tara McMullen
Teresa Mota
Terry O’Malley
Tom Moore
Troy Seagondollar
Vincent Lewis
Wan Li
Wen Dombrowski
Zabrina Gonzaga
Zachary May
Attended
Yes
Yes
Yes
Yes
Discussion
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The meeting was introduced with a reminder for participants to join the LCC Work Group via the “Join the
Initiative” tab in the wiki and to complete the Pilot Survey on the LCC Pilots WG wiki page.
Meeting reminders were presented and included LCC WG, relevant HL7 WG meetings and meeting dates
and times. Special dates/events included the following:
o HIMSS Health Story Round Table
 Meets monthly on the 1st Monday from 4pm-5pm ET. Next meeting is scheduled for August
4th.
 Web URL: Click here to view agenda and download calendar invitation (this link will also
work to join the meeting when it starts)
 Meeting Number: 927 311 214
 Meeting Password: meeting
 To receive a call back, join the meeting and then provide your phone number where
indicated. The system will call and when you answer you will be added to the
teleconference. To call directly, use the number below and enter the meeting number when
prompted:
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 Call in toll free number (US/Canada) 1(866) 469-3239
 Call in local toll number (US/Canada) 1(650) 429-3300
Timelines and milestones were presented and Pilot Work Group Purpose and Goals were restated.
Upcoming presentations:
o August 4th: Lantana HIMSS Health Story Presentation & SEE Tool Demo and IMPACT Updates
(tentative)
o August 18th: GSI Health Pilots Follow-up
o September 15th: VHA Care Plan FHIR Introduction
Presentation: Community-based Care Coordination Quality Framework (Dr. Andrey Ostrovsky, Care at
Hand)
 An overview was provided highlighting the intersection between Quality Measures and Care Plan, and
ultimately the business case for shifting care delivery into the community.
o PPACA is forcing a shift in the epicenter of care delivery
 Part of this shift is recognizing where care delivery can be lower cost, higher delivery and
with better incentives (“Triple Aim”)
o The Care Transitions Program (Section 3026) created a stimulus for community organizations to
create transition programs they can offer to hospitals and, in some cases, payers.
o The challenge in the business model is moving beyond grant funding mentality and toward market
driven business cases.
 The disconnect having the capacity to relay a value proposition to the payers and hospitals.
 To get paid, providers need to prove impact. To prove impact, they need to be able to measure impact.
Current quality measures do not respect the impact community organizations can have.
o HEDIS
o NQF
o AHRQ
o ACO 33 Measures
o Measures for VBP
 Among these, there is no language around care coordination and no language around the
role of community organizations.
 Some of these measures (an example of NQF’s proposed measures was provided) actually
hinder rather than help the shift in care delivery.
 Care at Hand proposes a new way to measure the quality of ER workflow from a perspective other than
that of the hospital and payer. They are approaching it from a community perspective using real-time data
to actually measure how care coordination is being carried out.
 Patient-facing source data for the Community-based Care Coordination Quality Framework (C3QF) is
completely independent of claims or ICD-9 codes and comes from the following:
o Alerts triggered by CAH technology
o Nurse documented responses to the alerts received
o mHealth Transitions model (loosely based on the Coleman model using mobile technology)
 This is based on the following process:
 Patient is enrolled while still in the hospital and a coach completes the discharge
survey
 High risk patients receive an in-person visit in the home within 24 hours and
moderate risk patients receive a visit within 48 hours
 Algorithms (loosely based on the Coleman model) determine the timing of follow up
visits based on existing documentation (survey plus 3 Pillars and/or ADLs)
 The coach completes a survey which triggers alerts to the Nurse Coordinator, who
triages to VNA, PCP or other community resources
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The Nurse Coordinator proactively reviews dashboards to determine which patients
may be at the highest risk and take action accordingly
A “before technology” scenario was depicted:
o A Health Coach interacting with the patient
o A supervising Nurse Care Coordinator interacting with the patient
o No connection between the coach and the Nurse Care Coordinator, no guidance from the Nurse
Care Coordinator to a non-clinical coach, which generally resulted in patients unnecessarily ending
up in the emergency department
A “with technology” scenario was depicted:
o There is a guided survey regarding the issues for the patient on that particular day. Questions are
answered by the health coach in layman’s terms.
o About 1 in 5 surveys will trigger an alert. When that alert goes to a Nurse Care Coordinator, they
can follow up with a phone call to the coach.
o One Nurse Care Coordinator supervises about 20 coaches and on average with this ratio, they can
enroll about 800-1,000 patients a month into a care transitions program.
o This allows for concerning issues to be triaged at the lowest cost level of care.
Care at Hand technology currently provides four pathways:
o Population Health Management
o Alerts (this pathway is what is being discussed in this presentation)
o Care Coordination Measurement
o Provider Measurement and Training
Question posed: Are the surveys developed using standards?
o Response: These are proprietary questions that have been developed over the past several years
and they’re stored in our database. They’re written in layman’s terms and the answers can be
provided in layman’s terms—about 40% of our questions are not clinical. They address
transportation, environmental issues, care coordination issues, etc. We’re proposing a paradigm
shift to get away from the questionnaires being used for Medicare. We need to measure care and
speak the language of community illness, not necessarily medicine. This could be a topic for a
much larger discussion, which is whether our standards are biasing us to remain in the 1990s
health care mentality or is there, perhaps, a role for redefining how we collect data, measure it and
evaluate programs.
Evelyn suggested that Care at Hand should participate in the upcoming eLTSS initiative to present lessons
learned to the states and to provide feedback on what kinds of data need to be captured to create the most
impact.
Evidence-based or evidence-informed practice has been inspired by the following:
o AHRQ-funded Stanford Atlas
o Commonwealth Fund-funded Antonelli et al. Care Coordination Framework
o Coleman’s CTI
o Bridge Model
o ONC-funded project IMPACT and HL7 architecture
Care at Hand put together an initial set of nurse documentation for response to alerts and used some of
the above as guidance. They are reviewing 1,400 documentation episodes via a blind review by 2 of 4
nursing students using Cochran Handbook for Systematic Reviews
o These are purely coach answer surveys triggering an alert, a nurse responding to the alert and the
nurse documenting her response. They are totally independent of ICD-9 codes, claims or
hospital/clinical data.
All this data has been collected from the Care Transitions program deployed in Lawrence, MA at Elder
Services of Merrimack Valley, who just won the number award at the AAA conference.
o The patient population is Medicare Fee for Service (FFS) within a 30 day program. Only about ¼
of this population is dual.
o
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243 documentation episodes were of significance.
The results were 24 domains of C3QF (24 reasons a nurse was concerned that the patient is at risk
for going to the hospital):
 Intrinsic to the Patient (3)
 Medical or surgical condition
 Mental or behavioral problem
 Functional decline
 Extrinsic (21)
 Environmental (7 domains)
 Care coordination breakdowns (14 domains)
A chart was displayed depicting the above causes for nurse concern about readmission risk. Medical or
surgical concerns were the most frequent concerns for patient risk. However, there were many nonmedical reasons for concern of patient readmission risk.
o Medical risks are traditionally handled where the nurse is the transition coach. The gap is where
the reasons for readmission are non-medical.
o Nurse-driven care transition models are not financially sustainable based on the current payer
model. Current standards of care transition include the following:
 Guided Care: $1,732 per consumer per year
 Geriatric Resources for Assessment and Care of Elders (GRACE): $1,432 per consumer
per year
 Transitional Care Model (Naylor Model): $982 per consumer per year
 Care Transitions Intervention (Coleman Model): $196+ per consumer per year
o If the health coach is a nurse, 32 nurses ($45-70K per year) are needed for 800 patients per month
o If the health coach is separated out from the nurse role—meaning a community health provider is
the health coach and is supervised by a Nurse Care Coordinator—the same 800 patients enrolled
per month could be managed by 20 health coaches ($30K per year) and 1 nurse
o If the coach is introduced as the Community Health Worker, the extrinsic environmental factors of
the survey concerns are more covered. However, there is still a gap between the Nurse Care
Coordinator and the health coach because the nurse may not be able to adequately supervise the
community health care worker.
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Care at Hand technology fills the gaps between the Nurse Care Coordinator and the coach as a
Community Health Care Worker in this scenario because most of the reasons for readmission can now be
addressed through the communication between the nurse and the coach.
o
At Merrimack Valley the new average for the initial patient in-home visit is within 28 hours.
A list of the most frequent interventions was displayed as a chart, which the most frequent interventions
being the following:
o See PCP or specialist for next scheduled visit
o Call PCP or specialist if further questions arise
o Take medicine as instructed by PCP or specialist
o See PCP or specialist if symptoms worsen
o Schedule appointment with PCP or specialist
o Call Skilled home care/VNA if further questions arise
o Other – please be sure option is not on list above
o Notify patient that their PCP or specialist appointment has been rescheduled to an earlier date
o Call PCP or specialist to send prescriptions to the pharmacy
o Call pharmacy to check on prescription availability
The data suggests this duplication of communication reinforces the relationship with the patient.
The assumption was that most of the care coordination work was being done by the Nurse Care
Coordinator, but the data shows it is actually being done by the coach after the initial nurse triage. Coach
tasks in the data results include but are not limited to the following:
o Confirm patient is receiving/eligible for skilled home care/VNA services
o Educate patient on red flags
o Refer to skilled home care/VNA
o Follow up phone call within next two days
o Follow up phone call in three or more days
o Follow up phone call after next doctor visit or diagnostic test
o Assess for or refer to other services
o Confirm patient is going to scheduled PCP or specialist appointment
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o Refer for behavioral health management
o (see slide 58 of the presentation for all)
In this model, the Skilled Nursing role mostly reinforces the need for assessing the patient: sick vs. not
sick and triage to other care team members. The coach does most of the care coordination.
The data showed that physicians were only engaged in about 1 in 20 episodes.
Only 3% of these events required urgent or emergent care that resulted in a hospital visit.
The data showed that there was an average of 1.5 concurrent problems at any given time. Future work
will expand to include duals in these results, which may increase the average.
Owners of this community based care model who can help push it forward were identified as the following:
o NQF
o ACL
o n4a
o AHRQ
o ONC
o Commonwealth Foundation
o Hartford Fund
o AARP
o SCAN Foundation
Discussion
 Does the nurse have access ot the ambulatory EHR or the hospital EHR for conditions or trends?
o When this data was collected the nurse did not have access to that data. At Merrimack they are
currently receiving data from one hospital through the HIE and will be receiving from two more
shortly. Our technology does offer a concise and somewhat comprehensive care plan. Based on
all this data we identified trends that would set a context for this patient—problems, interventions,
goals, all the basic building blocks of a care plan. A limitation is that the nurses don’t have access
to the hospital data, but the strength is that they have access to a dynamic picture of how the
patient has evolved over time.
 When you refer to care plan, what is the content of that?
o You’re right on track. We’ve taken the traditional thinking of care plan and de-medicalized it to
some extent. The nurses are managing it so they’re fully capable of looking through the clinical
lens, but all the data is through a non-medical lens, such as lack of transportation, that have no
ICD-9 code but have an immediate effect on the well being of the patient. It has the identical
blocks of a care plan but it’s adapted in a way that’s more comprehensive and reflects what’s being
done in the community and not in the hospital.
 Since there’s less of an ICD-9 focus on that, is it created by the nurse or by an ambulatory appointment?
Is there a referral sent to Care at Hand to start tracking this patient?
o Just like any other interaction with our system, it’s through the eyes of a coach with a survey. In
any pre-transition setting, the coach will identify active issues in a survey. It’s just like when we
interact with patients out in the community. We’ll probably be submitting the onboarding risk
assessment tool for publication around September. It predicts 30-day readmissions. I have not yet
seen anything as predictive as that.
 Do you develop a business agreement with the hospital or a medical group to come in and do the
preliminary survey which stratifies patients into risk levels, and then the nurse intervenes based on the
content and patient needs?
o The business case is different. We leave all the contracting and relationship building to the
community organizations. We don’t sell to hospitals or health agencies. Our goal is to have health
community organizations make money. That’s secondary, but it may be a driver for community
organizations to achieve a larger impact. We also have payer and managed care organization
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clients and they use the technology in a similar way, but ultimately it’s the payers and the hospitals
that are the target consumers of care transition programs.
When the patient is directed to go to the ER, if they’re not admitted, what is the client’s responsibility in
paying for any transportation or support services?
o I don’t have an exact answer. There is a theme that reflects the importance of a community
transitions program, which is time. The community health worker has the time to sit with the patient
and can speak their language so there’s an opportunity to create a care team and a dialogue with
the patient’s community that helps weigh the risks and benefits of any possible intervention (such
as the cost of transportation to the ER).
This work group did work on the standards for care plan. You had worked with Terry on implementing the
pre-balloted C-CDA R2, which is very clinically driven. Can you highlight on that point how you
implemented the standard and updated to meet your needs?
It’s very difficult to actually implement customer development. We instituted a series of design thinking
exercises to reconcile what we experts think and what the customers actually needed. In the middle is the
business case, and that’s how our technology was created. To whatever extent this workgroup evolves
into the eLTSS discussion, the more we can boil down this technical S&I language into digestible morsels
so the end users and consumers can advise the process, the better.
Proposed Next Steps
 Homework Assignments:
o Complete Pilot Survey
o Sign up as and LCC Committed Member
o Submit Pilot Documentation Proposals
 Available on the LCC Pilot WG wiki: http://wiki.siframework.org/LCC+Pilots+WG
 Email to Lynette Elliott (lynette.elliott@esacinc.com)
 The next meeting will be held Monday, August 4th at 11am ET.
Action Items
Name
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Task
Due Date