onc s&i longitudinal coordination of care work group from the present to the future missing from...
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ONC S&I Longitudinal Coordination of Care
Work Group
From the Present
From the Present To the
Future To the Future Missing from the Health Care Discussion: Missing from the Health Care Discussion:
LTPACLTPAC
Thesis
• Provide health care more efficiently or face limits on utilization and the adoption of new technologies
• The key to improved efficiency: LTPAC and two critical functions– Effective Transitions of Care– Longitudinal Coordination of Care
Figure 1. Typical pattern of health care expenditures among a health plan’s membership. Adapted and reproduced by permission of the publisher and author from: Halvorson GC, Isham GJ. Epidemic of care: a call for safer, better, and more accountable health care. San Francisco (CA): Jossey- Bass;
2003.1:p41 (This figure was based on data obtained from the Milliman 2001 Health Cost Guidelines-Claims Liability Distributions.) From “Managing High Risk, High Cost Patients: The Southern California Kaiser Permanente Experience in the Medicare ESRD Demonstration Project” P Crooks. Permanente
Journal, Spring 2005, Volume 9, No. 2 , 93-97
5% members account for 60% to 65% total costs
Why This Matters
A Study of Stroke Post-acute Care Costs and Outcomes: Final Report.Kramer A, Holthaus D, Goodrish G, Epstein A. HHS Dec 28, 2006 aspe.hhs.gov/daltcp/reports/2006/strokePACes.htm
What Complexity?
Transitions to (Receivers)
Transitions In Patient ED Out patient BH LTAC IRF SNF/ECF HHA Hospice PCP BH Community Patient/
From Acute Care Services In patient PCMH Community Based orgs Family
(Senders) Hospitals Facilties Office based Services
In patient
ED
Out pt services
BH Facilities
LTAC
IRF
SNF/ECF
HHA
Hospice
Office basedCliniicians
CommunitybasedBH sites
CBOs
Patient/Family
LTPAC and Acute Care: Senders and Receivers
Transitions to (Receivers)Transitions In Patient ED Out patient BH LTAC IRF SNF/ECF HHA Hospice PCP BH Community Patient/
From Acute Care Services In patient PCMH Community Based orgs Family
(Senders) Hospitals Facilties Office based Services
In patient
ED
Out pt services
BH Facilities
LTAC
IRF
SNF/ECF
HHA
Hospice
Office basedCliniicians
CommunitybasedBH sites
CBOs
Patient/Family
LTPAC to Emergency Dept:
15% of ER admissions and $8 Billion wasted annually from ADEs could be avoided if outpatient information known
LTPAC to ED
Transitions to (Receivers)Transitions In Patient ED Out patient BH LTAC IRF SNF/ECF HHA Hospice PCP BH Community Patient/
From Acute Care Services In patient PCMH Community Based orgs Family
(Senders) Hospitals Facilties Office based Services
In patient
ED
Out pt services
BH Facilities
LTAC
IRF
SNF/ECF
HHA
Hospice
Office basedCliniicians
CommunitybasedBH sites
CBOs
Patient/Family
20% of patients are readmitted within 30 days. Preventable readmissions estimated at $25B nationwide annually.
Preventable Readmissions
Transitions to (Receivers)Transitions In Patient ED Out patient BH LTAC IRF SNF/ECF HHA Hospice PCP BH Community Patient/
From Acute Care Services In patient PCMH Community Based orgs Family
(Senders) Hospitals Facilties Office based Services
In patient
ED
Out pt services
BH Facilities
LTAC
IRF
SNF/ECF
HHA
Hospice
Office basedCliniicians
CommunitybasedBH sites
CBOs
Patient/Family
1.5 Million preventable adverse events annually nationwide from discharge treatment plans not followed
Acute to LTPAC, LTPAC to LTPAC
Current Status: Care Coordination
Medpac observes that:• “For those very-high-spending beneficiaries who already have multiple
chronic conditions and many hospitalizations, care coordination efforts could focus on making sure information is communicated between providers, managing the patient’s symptoms, and closely monitoring patients during transitions between the hospital, home, and other settings.” (p. 49)
• “…no easy way exists to communicate information across providers and settings, and interoperability is poor among existing information systems.” (p.37)
http://www.medpac.gov/chapters/Jun12_Ch02.pdf
• A community led initiative with multiple public and private sector partners, supports and advances health information exchange (HIE) on behalf of LTPAC stakeholders and promotes longitudinal coordination of care (LCC) on behalf of medically-complex and/or functionally impaired persons.
• Goal: identify standards that support LCC of medically-complex and/or functionally impaired persons that are aligned with and could be included in the EHR Meaningful Use programs.
• Three sub-workgroups (SWGs): • Patient Assessment Summary • LTPAC Transition of Care (ToC) • Longitudinal Coordination of Care (LCP)
S&I Longitudinal Coordination of Care Workgroup
Key Accomplishments: PAS SWG• Supported and advanced, in collaboration with HL7,
refinements to the Consolidated-CDA (C-CDA) for the interoperable exchange of: – functional status, cognitive status, and pressure ulcers data
elements; and – Long-Term/ Post-Acute Care (LTPAC) patient assessment
summary documents.
• Enabled the inclusion in Stage 2 Meaningful Use (MU) program EHR requirements for the interoperable exchange of functional and cognitive status information in the Summary Care Record
Key Accomplishments: LTPAC Care Transition SWG• Supported and assisted in the identification of 480+ data
elements needed by receiving clinicians to safely and appropriately care for patients at times of transitions of care (ToC)
• Reviewing specifications for the exchange of ToC documents
• Seeking to refine the HL7 C-CDA for the exchange of more robust interoperable ToC documents for MU Stage 3– Collaborators needed
Key Accomplishments: LCC WG
• Developed White Paper describing the need to exchange care plans to support the longitudinal care needs of medically complex /functionally impaired persons: http://wiki.siframework.org/LCC+Longitudinal+Care+Plan+SWG
• Developing a glossary of key care plan definitions and terms for consideration for MU Stage 3: http://wiki.siframework.org/LCC+Longitudinal+Care+Plan+SWG#Care Plan Glossary Archive (most recent postings on top)
• Seeking to refine the HL7 C-CDA to include requirements for the exchange of care plans for MU Stage 3– Collaborators needed
What’s Needed from You?
• Respond to the ONC/HIT Policy Committee RFC on Meaningful Use Stage 3 (comments due: Jan. 14, 2013): – http://www.healthit.gov/sites/default/files/
draft_stage3_rfc_07_nov_12.pdf
• Participate in S&I LCC webinar on care plans:– Week of Dec. 10th and 17th
• Build and use platforms to exchange: functional and cognitive status, LTPAC Assessment Summaries, care plans, and ToC data elements
• Be ready to capitalize on MU3 requirements
Questions?
• S&I LCC WG wiki site: http://wiki.siframework.org/Longitudinal+Coordination+of+Care
• Contact:– Evelyn Gallego, LCC Initiative Coordinator
Organizational Structure
Organizational Structure
Longitudinal Coordination of Care Workgroup (LCC WG)