Longitudinal Coordination of Care

Pilots WGMonday, September 16, 2013

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

All Participants

Topic Presenter

Introductions and Purpose Evelyn

Aims of LCC Pilot WG Evelyn

Overview of standards to Pilot Terry

Timeline for Piloting Evelyn

Overview of LCC Committed Pilots: IMPACT Larry

Overview of LCC Committed Pilots: NY Downstate Tom

Agenda

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• Let’s discuss…– Why you should pilot LCC standards– Who should consider being a pilot– What standards you can pilot– How we can help you pilot these standards– How you can learn for those already committed to

piloting LCC standards

Why are we here today?

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• Initiated in October 2011 as a community-led initiative with multiple public and private sector partners, each committed to overcoming interoperability challenges in long-term, post-acute care (LTPAC) transitions

• Supports and advances interoperable health information exchange (HIE) on behalf of LTPAC stakeholders and promotes LCC on behalf of medically-complex and/or functionally impaired persons

• Goal is to 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 (focus on MU3)

• Activities supported via 4 sub-workgroups (SWGs):– Longitudinal Care Plan (LCP) *– LTPAC Care Transition (LTPAC) *– HL7 Tiger Team*– Patient Assessment Summary (PAS)*

Background of LCC WG

5* The work of the LCP and LTPAC completed in SEP2013, HL7 Tiger Team completed in AUG13 and PAS SWG completed in JAN13

Additional Contributor Input

• MA Universal Transfer Form workgroup• Boston’s Hebrew Senior Life eTransfer Form• IMPACT learning collaborative participants• MA Coalition for the Prevention of Medical Errors • MA Wound Care Committee• Home Care Alliance of MA (HCA)

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• NY’s eMOLST• Multi-State/Multi-Vendor EHR/HIE Interoperability

Workgroup• Substance Abuse, Mental Health Services

Agency (SAMHSA)• Administration for Community Living (ACL)• Aging Disability Resource Centers (ADRC)• National Council for Community Behavioral

Healthcare• National Association for Homecare and Hospice

(NAHC)• Transfer of Care & CCD/CDA Consolidation

Initiatives (ONC’s S&I Framework)

• Longitudinal Coordination of Care Work Group (ONC S&I Framework)

• ONC Beacon Communities and LTPAC Workgroups

• Assistant Secretary for Planning and Evaluation (ASPE): Standardizing MDS and OASIS

• ASPE/Geisinger/HL7 : LTPAC Summary Documents (using MDS and OASIS)

• Centers for Medicare & Medicaid Services (CMS)(MDS/OASIS/IRF-PAI/CARE)

• INTERACT (Interventions to Reduce Acute Care Transfers)

• Transfer Forms from Ohio, Rhode Island, New York, and New Jersey

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ONC Programs & Grantees

Community S&I Framework

FACAs

SDOs

• State HIE Program & CoPs• REC Program & CoPs• Beacon Program

• Technology Vendors• System Integrators• Government Agencies• Industry Associations• Other Experts

• HL7• OASIS• Other SDOs

• HIT Standards Committee• HIT Policy Committee• Tiger Team

ENABLING

S&I Framework: The Value of Community Participation

(LCC WG)

• Strong collaboration and engagement with broad stakeholder groups to address gaps in standards for ToC and Care Plan exchange– Other ONC S&I Initiatives: Transitions of Care (ToC) and esMD– HL7 WGs: Structured Documents, Patient Care– IHE Patient Care Coordination Technical Committee– AHIMA LTPAC HIT Collaborative– FACAs: MU3 Recommendations

• Contracts with Lantana to make and ballot revisions to C-CDA for HL7 August 2013 Ballot Cycle– One ballot package to address C-CDA revisions based on

IMPACT dataset

LCC WG Partnerships

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S&I Framework Phases

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Phase Planned Activities Pre-Discovery Development of Initiative Synopsis

Development of Initiative Charter Definition of Goals & Initiative Outcomes

Discovery Creation/Validation of Use Cases, User Stories & Functional Requirements Identification of interoperability gaps, barriers, obstacles and costs Review of Vocabulary

Implementation Creation of aligned specification Documentation of relevant specifications and reference implementations such as guides,

design documents, etc. Validation of Vocabulary Development of testing tools and reference implementation tools

Pilot Validation of aligned specifications, testing tools, and reference implementation tools Revision of documentation and tools

Evaluation Measurement of initiative success against goals and outcomes Identification of best practices and lessons learned from pilots for wider scale deployment Identification of hard and soft policy tools that could be considered for wider scale

deployments

• Bring awareness on available national standards for HIE and care coordination

• Provide tools and guidance for managing and evaluating LCC Pilot Projects

• Create a forum to share lessons learned and best practices

• Real world evaluation of parts of most recent HL7 C-CDA Revisions Implementation Guide (IG)– Is this implementable? Useable?

• Validation of ToC and Care Plan/HHPoC datasets– Do these data elements address your organization’s

information needs for effective care coordination??

Aim for the LCC Pilot SWG

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• Demonstrate compliance with MU2 requirements and proposed standards for MU3

• Increase efficiency of development and maintenance of these standards – LCC C-CDA IG can inform changes to existing HIT systems and the

process by which ToC & Care Plan information is exchanged – These specifications are being harmonized with a broad consortium of

Standards Development Organizations (SDOs) including HL7 and IHE

• Meet CMS Quality Reporting Requirements– i.e. Reduce Readmission Rates

• Enable LTPAC (non-eligible) providers to participate in HIE• Increase access to LTPAC data to support caregiving (including

access by other members of clinical care team)• Contribute to the community• Be recognized as an early HIE adopter

Why Pilot LCC Standards?

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• HIE capability exists• High proportion of dual eligibles• Integrated Delivery Networks including Managed Care

Organizations (MCO), ACOs and other at-risk provider groups

• Other organizations participating in various CMS/CMMI Demonstrations

• Providers with high readmission rates• Those interested in addressing transition of care issues• Those interested in exchanging care plans

Who Should Pilot LCC Standards?

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Transition Datasets

1313

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• Test/Procedure Report & Request• i.e SNF to IRA

• Consultation Request & Response

• i.e. SNF to ED

• Transfer Summary/ Care Plan/HHPoC• i.e. Hospital to Home Health Agency;

HHA PCP

1 2

• New exchange standards for: – MU2 Patient Care Summary and proposed MU3 updates for:

• Care Plan• Home Health Plan of Care• Report from Outpatient testing, treatment, or procedure• Referral to Outpatient testing, treatment, or procedure (including for

transport)• Shared Care Encounter Summary (Office Visit, Consultation

Summary, Return from the ED to the referring facility)• Consultation Request Clinical Summary (Referral to a consultant or

the ED) • Permanent or long-term Transfer of Care to a different facility or

care team or Home Health Agency

• Exchange standards that easily enable low cost interoperable HIE by LTPAC providers

• New software for HIE access

What Standards Can You Pilot?

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Sample Pilot Options

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User Scenario S&I Use Case1. Exchange of CCD ToC Use Case

2. Exchange of Transfer Summary

LCC Use Case 1.0

3. Exchange of Consultation Request

LCC Use Case 1.0

4. Exchange of Consult Note

LCC Use Case 1.0

5. Exchange of Test/Procedure Report

LCC Use Case 1.0

6. Exchange of Test/Procedure Request

LCC Use Case 1.0

7. Exchange of HHPoC LCC Use Case 2.0

User Scenario S&I Use Case8. Exchange of Care Plan LCC Use Case 2.0

9. Exchange of Patient Goals LCC Use Case 2.0

10. Exchange of Advance Directives

LCC Use Case 1.0

11. Exchange of Pre-Test Screening Process

LCC Use Case 1.0

12. Exchange of Care Plan components for Patient Centered Value Management

LCC Use Case 2.0

13. Concordance- the extent to which the patient’s goals, interventions, concerns, outcomes match to the provider’s prioritization

LCC Use Case 2.0

14. Exchange of Transfer of Care (Discharge and ED Consult request)

LCC Use Case 2.0

• http://wiki.siframework.org/LCC+Pilots+WG

How Can You Participate in the LCC Pilot SWG?

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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

LCC Pilot WG Tasks

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Target MM Pilot WG Tasks (Agenda) WG Homework

Sept 13 • Launch LCC Pilot WG• Review Pilot Planning Tools

• Review and submit LCC Pilot Documentation Templates

Oct 13 • Present MA IMPACT Go-Live Plan• Review Pilot Requirements Traceability Matrix (RTM)• Review Pilot Proposal Criteria Matrix• Present Pilot Proposals

• Review: LCC Pilot RTM• Submit LCC Pilot Proposals• Evaluate Pilot Proposals

Nov-Dec 13 • Present NY Downstate Go-Live Plan• Present and evaluate Pilot Proposals• Present IMPACT Pilot Status• Present NY DD Pilot Status

• Review: Pilot Evaluation Template

Jan-Feb 14 • Present LCC Pilots Status• Review Phase 1 Performance Metrics for IMPACT & NY DD Pilots

• Gather Pilot Performance Data

Mar-Apr 14 • Present LCC Pilots Status• Review Phase 1 Performance Metrics for NEW* Pilot Sites

• Gather Pilot Performance Data

May-Jun 14 • Present LCC Pilots Status• Review Phase 1 Performance Metrics for NEW* Pilot Sites• Review Phase 2 Performance Metrics for IMPACT & NY DD Pilots• Review recommended revisions to C-CDA IG

• Gather Pilot Performance Data• Submit recommended C-CDA

revisions

July-Sept 14 • Review Phase 2 Performance Metrics for NEW* Pilots• Review and consolidate recommended revisions to C-CDA IG• Close out Pilots• LCC Pilots Open House

• Gather Pilot Performance Data• Review recommended C-CDA

revisions

Summary of Documentation Templates & Reference Materials (Pilot Materials)

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Document Name DescriptionPilot Overview Document

An overview of the LCC Pilots Workgroup including a Value Statement for Participating Entities, Benefits of Participation as an LCC Pilot Site and steps for How to Get Started.

Work Group Planning Presentation

A Reference presentation for potential pilots that provides an overview of the Transition of Care and Longitudinal Coordination of Care Problems, the Role of Standards for Problem Resolution, and Overviews of the IMPACT and Downstate New York Care Coordination Projects.

Pilot Documentation Template

A PowerPoint template for potential pilots to use to present their Pilot Team; Goal of the Pilot; C-CDA of Interest; Use Case Scenario and Actors/Systems; Minimum Configuration; Timeline; Success Criteria; In Scope/Out of Scope; and Risks & Challenges details of their pilot.

Pilot Plan TemplateA word template for potential pilots to use to present their Pilot Team; Goal of the Pilot; C-CDA of Interest; Use Case Scenario and Actors/Systems; Minimum Configuration; Timeline; Success Criteria; In Scope/Out of Scope; and Risks & Challenges details of their pilot.

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Improving Massachusetts

Post-Acute Care Transfers

• February 2011 – HHS/ONC awarded $1.7M HIE Challenge Grant to state of Massachusetts (MTC/MeHI)

• Sites with EHR or electronic assessment tool use these applications to enter data elements– LAND (“Local” Adaptor for Network Distribution) acts as a data

courier to gather, transform, and securely transfer data if no support for Direct SMTP/SMIME or IHE XDR

• Non-EHR users complete all of the data fields and routing using a web browser to access SEE, their – “Surrogate EHR Environment”

IMPACT Grant

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LAND– Orion Health’s Rhapsody Integration Enginehttp://www.orionhealth.com/solutions/packages/rhapsody– Currently Modular EHR certified for MU1. MU2 (2014)

pending– We’re trying to make some standard configurations

availableSEE

– Written in JAVA– Baseline functionality software and source code that can

connect to Orion’s HISP mailbox via API available for free starting ~December 2013 (Apache Version 2.0 vs. MIT open source license)

– Innovators can develop and charge for enhancements, for example:

• Integration with other vendors’ HISP mailboxes• Automated CDA document reconciliation

Sharing LAND & SEE

• Selection Criteria:– High volume of patient transfers with other pilot sites– Experience with Transitions of Care tools/initiatives

• Winning Pilot Sites:– St Vincent Hospital and UMass Memorial Healthcare– Reliant Medical Group (formerly known as Fallon Clinic) and

Family Health Center of Worcester (FQHC)– 2 Home Health agencies (VNA Care Network & Overlook VNA)– 1 Long Term Acute Care Hospital (Kindred Parkview)– 1 Inpatient Rehab Facility (Fairlawn)– 8 Skilled Nursing and Extended Care Facilities

Pilot Sites to Test the IMPACT Datasets

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IMPACT Pilot Participants

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Org. Name Type Vendor/ Solution Type LCC Standards to Implement

Reliant Medical Group PCMH Epic EHR CCD; Transfer of Care Summary

Family Health Center of Worchester FQHC NextGen EHR CCD; Transfer of Care Summary

Saint Vincent Hospital ACH Meditech EHR CCD; Transfer of Care Summary

UMass Memorial Healthcare ACH Siemens Soarian EHR CCD; Transfer of Care Summary

VNA Care Network HHA Delta Health Technologies

EHR CCD; Transfer of Care Summary

Overlook VNA HHA Homecare Homebase

EHR CCD; Transfer of Care Summary

Kindred Parkview LTACH

SEE HIE Transfer of Care Summary

Fairlawn Rehab IRF SEE HIE Transfer of Care Summary

Beaumont Rehabilitation of Westborough

SNF SEE HIE Transfer of Care Summary

Christopher House of Worcester SNF SEE HIE Transfer of Care Summary

Holy Trinity Nursing & Rehab SNF SEE HIE Transfer of Care Summary

Jewish Healthcare Center SNF SEE HIE Transfer of Care Summary

LifeCare Center of Auburn SNF SEE HIE Transfer of Care Summary

Millbury Healthcare Center SNF SEE HIE Transfer of Care Summary

Notre Dame LTC SNF SEE HIE Transfer of Care Summary

Worcester Rehabilitation & Health Care Center

SNF SEE HIE Transfer of Care Summary

• November 2013• 10 SEE sites (full Transfer of Care dataset)• 6 LAND sites (initially send CCD but receive any

CDA document)• 4/week starting with trading pairs (e.g. Hospital

SNF)

IMPACT Pilot Go-Live

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Downstate New York Care Coordination Project

September 16, 2013

Context• NYS Medicaid Health Homes have implemented (or are

implementing) care coordination solutions to meet their near term requirements

• Each Health Home currently uses a separate care management system or EHR

• In the Downstate NY region, there are many providers who are in multiple Health Homes and multiple RHIOs and their patients will cross borders

• If various care management tools do not support interoperability, providers may have to use 2 or 3 different systems and this is not sustainable

• Current state leaves untenable situation of no care plan interoperability

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Goals and Objectives• Develop consensus around functionality that would

enable enhanced care coordination, care plan management and interoperability across Health Homes and RHIOs through the SHIN-NY

• Align activity with developments at the national level• Develop Requirements to support the interoperability

and joint management of Care Coordination Plans across organizations

• Phase I implementation - Demonstrate the ability for two sites with two different care management tools to exchange Care Coordination Plans

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Requirements

• Enrollment of Health Home patients• Linking of patients and providers: care teams• Exchange of interoperable care plans• Clinical Event Notifications• Secure Messaging• Access to medical records for clinicians• Access to care plans for non-clinicians

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The DCC Workgroup agreed upon the following seven functions:

NY Downstate Pilot Participants30

Org. Name Type Vendor/ Type LCC Standards

Addiction Institute of NY- Methodone Mgmt Program Behavioral Health Netsmart Care Mgmt Care Plan

Addiction Institute of NY- Outpatient Treatment Program Behavioral Health Netsmart Care Mgmt Care Plan

St. Luke’s Roosevelt Hospital Acute Care Caradigm HIE/ Care Mgmt Care Plan

Continuum Health Home Network (CHHN) IDN Caradigm HIE/ Care Mgmt Care Plan

CHHN AIDS Service Center CBO Caradigm/ HealthIX HIE Care Plan

CHHN Americare Home Care Caradigm/ HealthIX HIE Care Plan

CHHN Argus Community CBO Caradigm/ HealthIX HIE Care Plan

CHHN Association for Rehab CM & Housing CBO Caradigm/ HealthIX HIE Care Plan

CHHN Beth Israel Medical Center Acute Care Caradigm/ HealthIX HIE Care Plan

CHHN Callen Lorde Community Health Center PCP Caradigm/ HealthIX HIE Care Plan

CHHN Dennelisse CBO Caradigm/ HealthIX HIE Care Plan

CHHN NADAP CBO Caradigm/ HealthIX HIE Care Plan

CHHN Project Renewal CBO Caradigm/ HealthIX HIE Care Plan

CHHN Puerto Rican Family Institute CBO Caradigm/ HealthIX HIE Care Plan

CHHN Ryan Health Center PCP Caradigm/ HealthIX HIE Care Plan

CHHN Services for the Under Served CBO Caradigm/ HealthIX HIE Care Plan

CHHN Westside Federation for Senior & Supportive Housing CBO Caradigm/ HealthIX HIE Care Plan

CHHN Institute for Family Health PCP Caradigm/ HealthIX HIE Care Plan

CHHN Isabella Nursing Home NH Caradigm/ HealthIX HIE Care Plan

• Care Coordination Plan (CCP) refers to a shared document that is used to track problems, goals, interventions and outcomes related to both clinical and social issues

• CCPs are a focus of collaboration for diverse care teams across organizations

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Care Coordination Plan (CCP) CollaborationWhat is a CCP?

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Care Coordination Plan (CCP) CollaborationUse Case

1. Author will create and edit the CCP in a care management tool that uses a national agreed upon structure for interoperable CCPs

2. Editor will view the CCP in their local care management tool, and suggest edits to the Author for review and approval. The Author retains editorial control of the CCP

3. Reader can view the most recent CCP in the RHIO, and provide comments to the Author through secure messaging

Iterative process based on interoperability standards

EditorAuthorv1

v1 edits

v1

RHIO

Reader

v1

View only

Healthix HEAL 17 – Project Highlights• Identified two sites with two different vendors to participate in Phase 1

implementation, both part of Continuum Health Partners• Addiction Institute of New York

• Methodone Treatment Program (Netsmart) • Outpatient Treatment Program (Caradigm)

• Held kick off meeting with stakeholders in early June• Agreed on Requirements and Phase 1/2 development• June – July: Design phase; engaged Lantana to align the data model

with proposed standard as closely as possible• July - August: Development, finalize draft data model for the standard

Care Coordination Plan with the LCC Standards Workgroup• September: Testing, Acceptance• October: Phase 1 Implementation, Evaluation

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

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

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

• NO Meeting next week due to HL7 WGM in Boston, MA

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

35LCC Wiki Site: http://wiki.siframework.org/Longitudinal+Coordination+of+Care