longitudinal coordination of care pilots wg monday, november 25, 2013

Longitudinal Coordination of Care

Pilots WGMonday, November 25, 2013

Meeting Etiquette• Remember: If you are not speaking, please keep your

phone on mute

• Do not put your phone on hold. If you need to take a call, hang up and dial in again when finished with your other call o Hold = Elevator Music = frustrated speakers and

participants

• This meeting is being recordedo Another reason to keep your phone on mute when not

speaking

• Use the “Chat” feature for questions, comments and items you would like the moderator or other participants to know.o Send comments to All Panelists so they can be

addressed publically in the chat, or discussed in the meeting (as appropriate).

From S&I Framework to Participants:Hi everyone: remember to keep your phone on mute

All Panelists

• http://wiki.siframework.org/Longitudinal+CC+WG+Committed+Member+Guidance• http://wiki.siframework.org/LCC+Pilots+WG

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ReminderJoin the LCC WG & Complete Pilot Survey

** If your contact information has recently changed, please send your updated information to Becky Angeles at becky.angeles@esacinc.com

Topic Presenter

Welcome & Announcements Lynette

Presentation: North Shore Integrated Direct (ILHIE) Raul Recarey

Presentation: IMPACT Logic Model Larry

Next Steps Lynette

Agenda

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Meeting Reminders

S&I Framework Hosted Meetings: http://wiki.siframework.org/Longitudinal+Coordination+of+Care • LCC Pilot WG meetings are Mondays from 11:00– 12:00 pm Eastern

– Focus on validation and testing of LCC Standards for Transitions of Care & Care Plan exchange

• LCC All Hands WG meetings are Mondays & Thursdays from 5:00– 6:00 pm Eastern – These meetings are facilitated in partnership with Lantana and will focus on

discussion and review of HL7 C-CDA R2 Ballot Comments

HL7 Structured Documents WG Meetings• Wednesdays from 10:00 – 11:00am Eastern

• WebEx: https://www3.gotomeeting.com/join/216542046• Dial In: +1 770-657-9270; Access Code: 310940• Focus on ballot reconciliation of HL7 C-CDA R2 Ballot comments

• Thursdays from 10:00 – 12:00pm Eastern– WebEx: https://iatric.webex.com/iatric/j.php?ED=211779172&UID=0&RT=MiMxMQ%3D%3D

– Dial In: 770-657-9270; Access Code: 310940– Focus on block voting of HL7 C-CDA R2 Ballot comments

Meeting Reminders

HL7 Patient Care WG Meetings• Care Plan every 2nd Wednesday from 4:00 – 5:00pm ET • Focus on Care Plan DAM Ballot Reconciliation

– Next meeting scheduled for Nov. 27th

– Phone: +1 770-657-9270, Participant Code: 943377

• NEW* Patient Care Health Concern Topic• Meetings every 2nd Thursday from 4:00 – 5:00pm ET

• Next meeting scheduled for Dec. 5th

• Phone: +1 770-657-9270, Participant Code: 943377

• Care Coordination Service• Meetings every Tuesday 4:00 - 5:00 pm ET • CCS ballot reconciliation, new CCS ballot for Jan 2014

FACA Meeting Reminders

HIT Policy Committee• Next meeting scheduled for Dec. 4th from 9:30 – 3:00pm ET• Update from CAW re: Care Planning & voluntary LTPAC certification• http://www.healthit.gov/facas/calendar/2013/12/04/hit-policy-committee

HITPC Meaningful Use WG• Next meeting scheduled for Dec. 2nd from 9:00 – 10:30am ET• Update on MU3 Recommandations• http://www.healthit.gov/facas/calendar/2013/12/02/policy-meaningful-use-workgroup

HIT Standards Committee• Next meeting scheduled for Dec. 18th from 9:00 – 3:00pm ET• http://www.healthit.gov/facas/calendar/2013/12/18/hit-standards-committee

LCC Pilot WG Timeline: Aug 2013 – Sept 2014

Mile

ston

es

Updated HL7 C-CDA IG

Complete

HL7 Fall Ballot Close

LCC Pilot Monitoring & Evaluation

LCC Pilot Proposal Review

HL7 Ballot Publication

LCC Pilots Close

HL7 Ballot & Reconciliation

LCC Pilot WG Launch

IMPACT Go-Live

NY Care Coordination Go-Live

HL7 C-CDA IG Revisions

LCC Pilot Wrap-Up

LCC Pilot Test Spec. Complete

HL7

Bal

lot

LCC

Pilo

t WG

• Purpose– Provide tools and guidance for managing and evaluating

LCC pilot Projects– Create a forum to share lessons learned and best

practices– Provide subject matter expertise– Leverage existing and new partnerships

• Goals– Bring awareness on available national standards for HIE

and care coordination– Real world evaluation of parts of most recent HL7 C-CDA

Revisions Implementation Guide (IG)– Validation of ToC and Care Plan/HHPoC datasets

Pilot Work Group Purpose and Goals

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Illinois Health Information ExchangeNorth Shore Integrated Direct

Raul RecareyRaul.Recarey@illinois.gov

Acute Care to Long Term Care Use Case Using ILHIE Integrated Direct for

“Transition of Care” Summaries

and ILHIE Integrated Direct

• Background:– NorthShore University Health System

• 4 hospitals and 530 physicians (utilizing EPIC)

– Needed interconnectivity with 14 Long Term Care facilities– Use Case: “Transition of Care Summary” for Meaningful

Use and Coordination of Care– Project duration: June 20th (kick-off)

September 23rd (initial “go live” date)

Actual “go live” – 2 weeks early

• Project Organization:– Project Charter w/ Sign-off Agreement– Project Plan– Project Timeline

and ILHIE Direct

• Implementation of Project using ILHIE Integrated Direct– Development of Project Teams:

• Management Team (ILHIE, NorthShore)

• Technical Team (NorthShore, EPIC, ILHIE)

• NorthShore Process/Operational Flow Team

• Long Term Care Process Roll-out Team

– A Success Story:• “Go live” completed 2 weeks early !!!

• Data now flowing smoothly among organizations

• Better coordination of care and communication between hospitals and nursing homes

• Meaningful Use requirements being met

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IMPACT Logic Model Update

Larry GarberLawrence.Garber@ReliantMedicalGroup.org

IMPACT: Adapting to Change

S&I Framework Longitudinal Coordination of Care

Pilots Workgroup Meeting

November 25th, 2013

Larry Garber, MD

Adapting to Change

Changes in scope

Changes in strategies

Changes in metrics

Changes in timeline

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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)

• Develop consumer-oriented translator• Integrate and validate tools into Worcester

County using Learning Collaborative methodology

• Measure outcomes18

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UTF PartnersMA DPH,MA EOHHS,Masshealth,Care Transitions Forum,MA Care Transitions,Strategic Plan, …

Execution PartnersFallon Clinic, SAFE Health,MHDC,MeHI, …

Knowledge and AlignmentHIT and HIEStrategic Plans, IMPACT Project Team, National initiatives and standards, …

Provider Associations MMS, MHA, MLCHC, HCA, MSCA, …

Project AssetsONC and matching funding,Volunteer time,Statewide HIE

Paper version of universal transfer form developed

Providers trained; collaborative learning through ongoing communication with project team

Participating providers in acute care and LTPAC settings

Electronic version of transfer form developed (CCD+)

Software vendors (TBD)Evaluation vendor (TBD) SAFE HealthState HISPConsumers

Transfer Form/CCD+ tested, HL7 balloted, and implemented

Inputs OutputsActivities Participation

OutcomesShort Medium Long

LAND & SEE developed and tested

Gateways to HIEs for non-EHR providers established Policy changes that

incentivize or require providers to implement care transitions paper or electronic forms and processes, including patient-centered care and advance directives

Software fully tested with providers and consumers; modified as appropriate

LAND & SEE Software and consumer-friendly tool developed

Participating providers fully trained and feedback incorporated into model for effective transitions

SEE Host and LAND HIE gateways established

AssumptionsActivities proceed according to the timelines

Improve efficiency measures by streamlining treatment and transitions

Reduce hospital readmissions, ER visits, unnecessary testing/treatments, and preventable admissions

Optimize patient experience, health of defined populations and per capita cost (IHI Triple Aim)

ChallengesSoftware vendor capabilitiesEHR ability to capture additional data elementsCoordination of participantsProvider engagement and trainingIntegration into provider workflows

Project-level Implementation in many and diverse settings in order to inform replication strategy and develop the ROI case for provider organizations

Replicate statewide by leveraging existing care transition initiatives (STAAR, MOLST, etc…) in combination with the ROI case to increase number and diversity of implementation

Inter-state replication based on MA diverse implementation setting experience and ROI case in combination with CCD+ with balloted template extensions.

Learning Collaborative of provider implementation teams tightly coupled with existing transition initiatives (STAAR, MOLST, etc…)

Creating collaborative relationship with existing transition initiatives (STAAR, MOLST, etc…)

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)

• Develop consumer-oriented translator• Integrate and validate tools into Worcester

County using Learning Collaborative methodology

• Measure outcomes20

Disseminating the Seeds

IMPACT Advisory CommitteeMassachusetts Care Transitions Forum

Massachusetts QIO (MassPRO)Massachusetts eHealth Institute

Massachusetts EOHHS

Worcester GalaxyWorcester Galaxy

Pilot Sites

Core IMPACT

Team

Another Galaxy

Pilot Sites

Core ProjectTeam

Another Galaxy

Pilot Sites

Core Project Team

Another Galaxy

Pilot Sites

Core Project Team

Another Galaxy

Pilot Sites

Core Project Team

Another Galaxy

Pilot Sites

Core Project Team

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Grantees & their trading partners by location

32 grantees80 unique trading partners

$2.3M

HIway Implementation Grants

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Measure outcomes

Evaluate pre- and post-implementation:– Efficiency of transfer process

– Adoption of the CCD+ content and process

– Suggested changes to data elements

– Satisfaction with transfer process: Patients, Families, Senders, Receivers

– Utilization of health care services (also c/w cohort)

– Emergency Department (ED) visits, admissions and readmissions

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Measure outcomes

Evaluate pre- and post-implementation:– Efficiency of transfer process

– Adoption of the CCD+ content and process

– Suggested changes to data elements

– Satisfaction with transfer process: Patients, Families, Senders, Receivers

– Utilization of health care services (also c/w cohort)

– Emergency Department (ED) visits, admissions and readmissions

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Measure outcomes• Data sources will include:

– Surveys of Senders, Receivers, Patients and Families

– Utilization data of Fallon Community Health Plan Medicare Advantage, Commercial and Medicaid

– State Hospital Utilization Database• Build evaluation into workflow

– Evaluation as part of the hand-off process– Low intensity, high frequency survey

method25

Measure outcomes• Data sources will include:

– Surveys of Senders, Receivers, Patients and Families

– Utilization data of Fallon Community Health Plan Medicare Advantage, Commercial and Medicaid

– State Hospital Utilization Database• Build evaluation into workflow

– Evaluation as part of the hand-off process– Low intensity, high frequency survey

method26

Timeline

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Be prepared for change

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Summary Even with the best of planning, changes will

take place

Include risk mitigation into your planning

Be willing to adapt to change

TOMalley@Partners.orgLawrence.Garber@ReliantMedicalGroup.org

Questions?

• Homework Assignments:– Complete Pilot Survey– Sign up as an LCC Committed Member– Submit Pilot Documentation Proposals

• Available on the LCC Pilot SWG Wiki: http://wiki.siframework.org/LCC+Pilots+WG

• Email to Lynette Elliott (Lynette.elliott@esacinc.com)

Next Steps

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• LCC Leads– Dr. Larry Garber (Lawrence.Garber@reliantmedicalgroup.org)– Dr. Terry O’Malley (tomalley@partners.org) – Dr. Bill Russell (drbruss@gmail.com) – Sue Mitchell (suemitchell@hotmail.com)

• LCC/HL7 Coordination Lead– Dr. Russ Leftwich (Russell.Leftwich@tn.gov)

• Federal Partner Lead– Jennie Harvell (jennie.harvell@hhs.gov)

• Initiative Coordinator– Evelyn Gallego (evelyn.gallego@siframework.org)

• Project Management– Pilots Lead: Lynette Elliott (lynette.elliott@esacinc.com)– Use Case Lead: Becky Angeles (becky.angeles@esacinc.com)

LCC Initiative: Contact Information

32LCC Wiki Site: http://wiki.siframework.org/Longitudinal+Coordination+of+Care