longitudinal coordination of care pilots wg monday, november 25, 2013
TRANSCRIPT
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 [email protected]
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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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
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
• 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 ([email protected])
Next Steps
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• LCC Leads– Dr. Larry Garber ([email protected])– Dr. Terry O’Malley ([email protected]) – Dr. Bill Russell ([email protected]) – Sue Mitchell ([email protected])
• LCC/HL7 Coordination Lead– Dr. Russ Leftwich ([email protected])
• Federal Partner Lead– Jennie Harvell ([email protected])
• Initiative Coordinator– Evelyn Gallego ([email protected])
• Project Management– Pilots Lead: Lynette Elliott ([email protected])– Use Case Lead: Becky Angeles ([email protected])
LCC Initiative: Contact Information
32LCC Wiki Site: http://wiki.siframework.org/Longitudinal+Coordination+of+Care