Longitudinal Coordination of Care (LCC)

Pilots Proposal

CCITI NY

01/27/2014

Pilot Team

2

Name Role Email

Harrison Fox, MPH Project Director hfox@ccitiny.org

Kunal Agarwal Technical Director kagarwal@ccitiny.org

Jeffrey Paul Project Manager jpaul@ccitiny.org

Full Disclosure?

• CCITI NY is a partner organization working on the New York Reducing Avoidable Hospitalizations (NY-RAH) The initiative, sponsored by CMS, is focused on reducing hospitalizations of long-stay nursing facility residents.

NY-RAH Project Overview

• CCITI NY is working on a CMS funded initiative to reduce avoidable hospitalizations among long-stay nursing home residents

• Consists of multiple interventions:

• Electronic tools including a transfer application

• Onsite RN Care Coordinators (RNCCs)

• Clinical practices toolkit

• Palliative care support and training

• Collaborate with EMR vendors in order to integrate the electronic tools into their systems in order to streamline the clinician workflow

4

Project Participants

• The project consists of the following participants:

• 30 Nursing Facilities in New York State including Schervier and Silvercrest

• 10+ Hospitals in New York State including New York Hospital Queens

• Electronic Medical Record Vendors for both acute and post-acute care settings

Goal of the Pilot

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The goal of Continuum of Care Improvement through Information New York (CCITI NY) is to improve the quality, patient safety, cost and satisfaction aspects of transferring patients between acute, post-acute, and ambulatory care organizations.

Project Specific Goals:•Improve quality of patient care during transitions•Develop standardized workflows to break down communication barriers•Create connectivity between disparate clinical systems to improve care coordination•Improve clinician satisfaction with the care transition process•Reduce avoidable hospitalizations within 30 days of a transfer

Problems:

• Avoidable hospitalizations caused in part by a lack of timely, accurate and comprehensive information for patients transitioning between the acute and post-acute care settings

• Harmful events stemming from changes in patient medications during care transfers

Solution:

• Reduce avoidable hospitalizations through the use of a standardized electronic transfer form

• Implement a clinical decision support (CDS) tool to prevent any adverse drug-drug and drug-allergy interactions

Common Problems and Our Solution

Benefits of Our System

• Improve medical decision making by providing the most critical and pertinent patient information to clinicians during patient transfers

• Reduce avoidable hospitalizations by discharging patients with an accurate record of their medications and health information

• CDS empowers clinicians to ensure proper medication use has occurred upon receipt from a transferred location

Key Metrics

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Through these key metrics, CCITI NY will be able to offer concrete results and demonstrate sustained success through the use of the interoperable transfer form.

Patient readyfor discharge

Transition from Nursing Facility to Hospital

Internet

Provider logs into Electronic Transfer Application (ETA) and completes information.

Alert received atHospitalProvider logs into

system and accesses the ETA sent by the nursing facility

Patient arrives at Hospital

Patient readyfor discharge

Internet

Provider logs into ETA and completes information.

Provider logs into system and accesses ETA

Transition from Hospital to Nursing Facility

Alert received atnursing facilityPatient arrives at

nursing facility

Which of the 5 C-CDA Revisionsare you Piloting?

12

SDC Standard / Guidance

Specifics to Pilot Notes

Transfer Summary

Nursing Facilities will transmit standardized transfer summary to their hospital partners and vice-versa

Focus will be on inclusion of the critical and pertinent patient information that can assist in reducing avoidable hospitalizations

What Relevant Scenario (from the Use Cases) does your Pilot support?• Exchange of Transfer Summary (LCC Use Case 1.0)• Exchange of Advance Directives (LCC Use Case 1.0)

Identify the Use Case Actors/Systems Involved:

• Sending Entity Care Team• Receiving Entity Care Team• Sending Entity Information System (EHR)• Receiving Entity Information System (EHR)

Role of the RNCC

• The RN Care Coordinator will act as a liaison between the long term post acute care facility and the Implementation Team

• He or she will assist with the development of the implementation plan

• Obtain important documentation in order to capture key elements found in the current paper process

• Help identify potential users of the system from both the Hospital and the nursing home

CCITI NY Proposed Configuration

Timeline

Milestone Target Date Responsible Party

Electronic Transfer Application (ETA) Go-live

March 2014 CCITI NY

ETA Integrated with EMR July 2014 CCITI NY

Pilots Evaluation September 2014 CCITI NY

CCITI NY Success Criteria

• 10% reduction in 30-day avoidable hospitalizations for long-stay nursing facility residents within 6 months of go-live

• 10% reduction in medication errors for long-stay nursing facility residents within 6 months of go-live

In Scope / Out of Scope

In Scope:•Transfer of demographic and clinical patient data between two different providers during care transitions

Out of Scope:• Integration of discrete data elements into the receiving EHR

Risks & Challenges

• Potential timelines slippage for the EHR vendors integration with the CCITI NY product

• Incomplete clinical information captured by the EHRs and provided to CCITI NY product

• Facility IT staff unavailable for support of implementation and training

• Lack of adoption by the clinical front-line staff at the facilities due to existing workload

Questions / Needs

• None as of now