Longitudinal Coordination of Care Pilots WG Monday, 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 recorded o 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

3 Reminder Join the LCC WG & Complete Pilot Survey ** If your contact information has recently changed, please send your updated information to Becky Angeles at

TopicPresenter Welcome & AnnouncementsLynette Presentation: North Shore Integrated Direct (ILHIE)Raul Recarey Presentation: IMPACT Logic ModelLarry Next StepsLynette Agenda 4

Meeting Reminders S&I Framework Hosted Meetings: 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: Dial In: ; Access Code: Focus on ballot reconciliation of HL7 C-CDA R2 Ballot comments Thursdays from 10:00 – 12:00pm Eastern –WebEx: –Dial In: ; Access Code: –Focus on block voting of HL7 C-CDA R2 Ballot comments

Meeting Reminders HL7 Patient Care WG Meetings Care Plan every 2 nd Wednesday from 4:00 – 5:00pm ET Focus on Care Plan DAM Ballot Reconciliation –Next meeting scheduled for Nov. 27 th –Phone: , Participant Code: NEW* Patient Care Health Concern Topic Meetings every 2 nd Thursday from 4:00 – 5:00pm ET Next meeting scheduled for Dec. 5th Phone: , Participant Code: 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. 4 th from 9:30 – 3:00pm ET Update from CAW re: Care Planning & voluntary LTPAC certification HITPC Meaningful Use WG Next meeting scheduled for Dec. 2 nd from 9:00 – 10:30am ET Update on MU3 Recommandations HIT Standards Committee Next meeting scheduled for Dec. 18 th from 9:00 – 3:00pm ET

LCC Pilot WG Timeline: Aug 2013 – Sept 2014 Aug-Sept 13Nov 13Dec- Jan 14Feb- Mar 14Apr- May 14Jun- Jul 14Aug- Sep 14 Milestones 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 Ballot LCC Pilot 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 9

10 Illinois Health Information Exchange North Shore Integrated Direct Raul Recarey

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 20 th (kick-off) September 23 rd (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

14 IMPACT Logic Model Update Larry Garber

IMPACT: Adapting to Change S&I Framework Longitudinal Coordination of Care Pilots Workgroup Meeting November 25 th, 2013 Larry Garber, MD

Adapting to Change  Changes in scope  Changes in strategies  Changes in metrics  Changes in timeline 16

IMPACT Grant February 2011 – HHS/ONC awarded $1.7M HIE Challenge Grant to state of Massachusetts (MTC/MeHI): I mproving M assachusetts P ost- A cute C are T ransfers ( IMPACT) 17

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 outcomes 18

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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 outcomes 20

Disseminating the Seeds IMPACT Advisory Committee Massachusetts Care Transitions Forum Massachusetts QIO (MassPRO) Massachusetts eHealth Institute Massachusetts EOHHS Worcester Galaxy Pilot Sites Core IMPACT Team 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 Another Galaxy Pilot Sites Core Project Team 21

 Grantees & their trading partners by location 32 grantees 80 unique trading partners $2.3M OutreachSalesImplementationSupport HIway Implementation Grants 22

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 23

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 24

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 method 25

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 method 26

Timeline 27

Be prepared for change 28

Summary  Even with the best of planning, changes will take place  Include risk mitigation into your planning  Be willing to adapt to change

Questions?

Homework Assignments: –Complete Pilot Survey –Sign up as an LCC Committed Member –Submit Pilot Documentation Proposals Available on the LCC Pilot SWG Wiki: to Lynette Elliott Next Steps 31

LCC Leads –Dr. Larry Garber –Dr. Terry O’Malley –Dr. Bill Russell –Sue Mitchell LCC/HL7 Coordination Lead –Dr. Russ Leftwich Federal Partner Lead –Jennie Harvell Initiative Coordinator –Evelyn Gallego Project Management –Pilots Lead: Lynette Elliott –Use Case Lead: Becky Angeles LCC Initiative: Contact Information 32 LCC Wiki Site: