1. Longitudinal Coordination of Care (LCC) Workgroup (WG) LCC Standards Update for the HITPC MU SWG #3 Care Coordination May 8, 2013 1

2. Agenda Limitations in Care Coordination and Standards to support Transitions of Care and Care Plans IMPACT Project: Addressing C-CDA MU3 Transition of Care Gaps ONC S&I LCC WG: Advancing Transitions of Care & Care Planning 2

3. 3 Limitations in Care Coordination & Standards to Support Transitions of Care and Care Plans

4. Failures of Care Coordination 150,000 preventable adverse drug events ($8 Billion wasted) nationwide each year occur at the time of hospital admission 1.5 Million preventable adverse events annually nationwide following hospital discharge Preventable readmissions waste $26B nationwide annually 4 National care transitions experts overwhelmingly identified “improving information flow and exchange” as the most important tool to improve care transitions. (ONC, 2011)

5. MU ToC & Care Plan Requirements CMS MU2 objectives require sending care summaries, including care plan content, during transitions of care ONC HIT Policy Committee received strong public support for referrals, transfers of care and care plans in MU3 5

6. Why C-CDA Does Not Meet MU3 Needs Lack of ability to fully represent needed care plan content and relationships Insufficient C-CDA templates to fully meet the needs and responsibilities of Eligible Professionals and Hospitals as senders and receivers of information during transitions of care 6

7. C-CDA MU3 Care Plan Gaps Limited support for critical Care Plan components: health risks and safety concerns, non-prescription interventions, patients’ overarching goals, barriers, nutrition assessment and diet orders No standard for… –Codifying all of the Longitudinal Care team members –Conveying when and how each section was last reconciled for a given patient –Conveying the many-to-many relationships between the components of the Care Plan –Applying a signature to a previously signed CDA document (e.g. a Home Health Plan of Care) 7 CMS, ASPE, CDE, VA and DoD need a CDA-based HHPoC, independent of MU

8. 8 IMPACT Project: Addressing C-CDA MU3 Transition of Care Gaps

9. IMPACT Grant Improving Massachusetts Post-Acute Care Transitions (IMPACT) Grant Awarded in February 2011 HHS/ONC State HIE Challenge Grant Fund –MA (MTC/MeHI) one of four Challenge Grant Awardees focused on LTPAC HIE –$1.7M total funding 9

10. Datasets for Care Transitions Traditionally—What the sender thinks is important to the receiver Future—Also take into account what the receiver says they need 10

11. “Receiver” Data Needs Survey Largest survey of Receivers’ needs 46 Organizations completing evaluation 11 Types of healthcare organizations 12 Different types of user roles 1135 Transition surveys completed 11

12. 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) 12 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

13. MU3 C-CDA Template Gaps 13 CCD Data Elements IMPACT Data Elements for basic Transition of Care needs Data Elements for Longitudinal Coordination of Care Many “missing” data elements can be mapped to CDA templates with applied constraints 20% have no appropriate templates

14. Five Transition Datasets 1.Report from Outpatient testing, treatment, or procedure 2.Referral to Outpatient testing, treatment, or procedure (including for transport) 3.Shared Care Encounter Summary (Office Visit, Consultation Summary, Return from the ED to the referring facility) 4.Consultation Request Clinical Summary (Referral to a consultant or the ED) 5.Permanent or long-term Transfer of Care to a different facility or care team or Home Health Agency 14

15. 15 Shared Care Encounter Summary: Office Visit to PHR Consultant to PCP ED to PCP, SNF, etc… Consultation Request: PCP to Consultant PCP, SNF, etc… to ED Transfer of Care: Hospital to SNF, PCP, HHA, etc… SNF, PCP, etc… to HHA PCP to new PCP Five Transition Datasets

16. 16 Home Health Plan of Care Care Plan Care Plan & Plan of Care

17. IMPACT Dataset for Testing 17 Transfer of Care: Hospital to SNF, PCP, HHA, etc… SNF, PCP, etc… to HHA PCP to new PCP 16 Pilot sites in central Massachusetts Several hundred transitions tested on paper 93% found the elements 92% receivers’ needs met

18. IMPACT Transfer of Care CDA Document 18

19. Further Testing of IMPACT Dataset Massachusetts ePilot starting in July 2013 with 2 hospitals, 2 large group practices, 2 home health agencies, 8 SNFs, 1 IRF, 1 LTACH Electronic exchange of full Transfer of Care dataset >1000 document transfers/month 19

20. 20 ONC S&I LCC WG: Advancing Transitions of Care & Care Planning

21. Longitudinal Coordination of Care Workgroup Patient Assessment Summary (PAS SWG LTPAC Care Transition SWG Longitudinal Care Plan SWG Engage directly with HL7 to establish the standards for the exchange of patient assessment summary documents Inform the development of the Keystone Beacon PAS Document Exchange Identify the key business and technical challenges that inhibit LTC data exchanges Define data elements for long-term and post- acute care (LTPAC) information exchange using a single standard for LTPAC transfer summaries Identify standards for an interoperable, longitudinal care plan* which aligns, supports and informs person- centric care delivery regardless of setting or service provider 21 ONC S&I LCC WG Organization *Care Plan standards will enable providers to create, transmit and incorporate care plans and needed content for the benefit of medically complex and/or functionally impaired individuals, their families and caregivers. GOALSGOALS COMMUNITY-LED INITIATIVE HL7 Tiger Team SWG Educate the LCC Community on related HL7 processes, framework and evolving standards relevant to LCC Gather and generate comments for HL7 Care Plan related evolving standards (Care Coordination Services & Care Plan Domain Analysis Model (DAM))

22. LCC WG Coordination with Other National Initiatives CMS esMD: advancing standards for Electronic Submission of Medical Documentation (esMD) ASPE: sponsoring and collaborating with LCC WG to identify standards for interoperable assessments, assessment summary documents, and care plans DoD and VA: working to specify Home Health Plan of Care data HL7 Structured Document, Patient Care, and Care Coordination Services Workgroups IHE Patient Care Coordination Technical Committee AHIMA LTPAC HIT Collaborative HIMSS: Continuity of Care Model 22

23. Lantana C-CDA Revisions Project Lantana contracted to work with LCC WG to make and ballot revisions to C-CDA for Aug/Sept 2013 HL7 Ballot Cycle One ballot package to address 4 revisions based on IMPACT Dataset: –Update to C-CDA Consult Note –NEW Referral Note –NEW Transfer Summary –NEW Care Plan document type (will include HHPoC digital signature requirements and will align with HL7 Patient Care WG's Care Plan Domain Analysis Model- DAM) 23

24. LCC WG Care Plan Glossary: Key Terms & Components 24 Term/ Component LCC Proposed Definition Care Plan The term “care plan” considers the whole person and focuses on a number of health concerns to achieve high level goals related to healthy living. Care Plan and Plan of Care share the SIX components: health concern, goals, instructions, interventions, outcomes, and team member Health ConcernReflect the issues, current status and 'likely course' identified by the patient or team members that require intervention(s) to achieve the patient's goals of care, any issue of concern to the individual or team member GoalsA defined outcome or condition to be achieved in the process of patient care. Includes patient defined goals (e.g., prioritization of health concerns, interventions, longevity, function, comfort) and clinician specific goals to achieve desired and agreed upon outcomes. InstructionsInformation or directions to the patient and other providers including how to care for the individual’s condition, what to do at home, when to call for help, any additional appointments, testing, and changes to the medication list or medication instructions, clinical guidelines and a summary of best practice. Detailed list of actions required to achieve the patient's goals of care. InterventionsActions taken to maximize the prospects of achieving the patient's or providers' goals of care, including the removal of barriers to success. Instructions are a subset of interventions. OutcomesStatus, at one or more points in time in the future, related to established care plan goals. Team MemberParties who manage and/or provide care or service as specified and agreed to in the care plan, including: clinicians, other paid and informal caregivers, and the patient.

25. LCC WG Timeline: Mar 2013 – Dec 2013 Mar 13Apr 13May 13Jun 13Jul 13Aug 13Sep 13Oct 13Dec 13 Milestones Pilot Identification & Engagement Care Plan IGs Complete Lantana Contract Awarded HL7 Project Scope Statement Due HL7 Intent to Ballot Due HL7 Fall Ballot Open NY Pilots Monitoring LCC Care Plan Use Case 2.0 Development & Consensus IMPACT ToC Pilot Monitoring IMPACT Care Plan Pilot Monitoring HL7 Ballot Publication ToC IGs Development (Transfer Summary, Referral Note, Consult Note) ToC IGs Complete HL7 Final Ballot Due LCC Stakeholder Engagement: Lantana, IMPACT, ASPE, NY, CMS Care Plan/ Home Health Plan of Care IG Development HL7 Ballot Package Development HL7 Ballot & Reconciliation FACA LCC WG Briefings LCC & HL7 Care Plan Coordination IMPACT Go-Live NY Care Coordination Go-Live

26. EP, Hospital, and LTPAC EHR vendors want these standards Multiple vendors are participating in S&I LCC WG Multiple vendors are exploring incorporating the standards into their products Several intend to pilot the pre-balloted versions in their products in Massachusetts, New York and Tennessee Several national LTPAC providers are exploring piloting and incorporating these standards into their products 26

27. Summary & Next Steps  ONC and CMS have identified requirements for Meaningful Use Stage 3 that require updates to the Consolidated CDA this fall  CMS, ASPE, CDC, VA and DoD have identified the need for a CDA-based Home Health Plan of Care that require updates to the C-CDA this fall  ONC funded IMPACT and S&I Framework to specify the required updates to the C-CDA  NY state HIEs (NYeC, Healthix, CCITY-NY) have hired Lantana to complete these updates to the C-CDA and ballot these revisions with HL7 in advance of MU3 NPRM  ASPE will sponsor development of new Care Plan/HHPoC Document types 27

28. 28 Questions?

29. LCC Initiative: Resources & Questions LCC Leads –Dr. Larry Garber (Lawrence.Garber@reliantmedicalgroup.org)Lawrence.Garber@reliantmedicalgroup.org –Dr. Terry O’Malley (tomalley@partners.org)tomalley@partners.org –Dr. Bill Russell (drbruss@gmail.com)drbruss@gmail.com –Sue Mitchell (suemitchell@hotmail.com)suemitchell@hotmail.com LCC/HL7 Coordination Lead –Dr. Russ Leftwich (Russell.Leftwich@tn.gov)Russell.Leftwich@tn.gov Federal Partner Lead –Jennie Harvell (jennie.harvell@hhs.gov)jennie.harvell@hhs.gov Initiative Coordinator –Evelyn Gallego (evelyn.gallego@siframework.org)evelyn.gallego@siframework.org Project Management –Becky Angeles (becky.angeles@esacinc.com)becky.angeles@esacinc.com –Lynette Elliott (lynette.elliott@esacinc.com)lynette.elliott@esacinc.com 29 LCC Wiki Site: http://wiki.siframework.org/Longitudinal+Coordination+of+Carehttp://wiki.siframework.org/Longitudinal+Coordination+of+Care

30. 30 Supporting Documentation

31. Communication & Adverse Events Poor care coordination increases the chance that a patient will suffer from a medication error or other health care mistake by 140% (Lu, et al., 2011) Communication failures between providers contribute to nearly 70% of medical errors and adverse events in health care (Gandhi, et al., 2000) 150,000 preventable ADEs ($8 Billion nationwide wasted) each year occur at the time of admission due to inadequate knowledge of outpatient medication history (Stiell, et al., 2003) 31

32. Problems with ED Visits Physicians in the Emergency Department (ED) lack important or critical patient information 32% of the time 15% of ED admissions could be avoided if the ED had outpatient information (Stiell, et al., 2003) 32

33. Problems After Hospital Discharge 1.5 Million preventable adverse events annually nationwide from discharge treatment plans not followed (Forster, et al., 2003) When multiple physicians are treating a patient following a hospital discharge, 78% of the time information about the patient’s care is missing (van Walraven, et al., 2008) 20% of Medicare patients are readmitted within 30 days. Preventable readmissions waste $26B nationwide annually (McCarthy, et al., 2009) 33

34. Ambulatory Care is just as bad 68% of specialists receive no information from the referring PCP prior to referral visits 25% of PCPs do not receive timely post-referral information from specialists (Gandhi, et al., 2000) 34

35. Physician Office 35 Living at Home CBS Outpt. Rehab Home Health Adult Day Care PACE Assist Living Nursing Home SNF LTACH IRF Acute Care Hospital Emergency Department Urgent Care Psych Hospital Hospice Facility Home Hospice Outpt. Behav. Health Acuity of Illness Intensity of Care Adapted from Derr and Wolf, 2012 Low High The Spectrum of Care Outpatient Testing/Pharmacy/DME

36. Where do patients go after hospital? 36 Everywhere!

37. MU’s Impact on LTPAC ~40% of Medicare patients are discharged to traditional LTPAC settings (SNF, Home Health, Inpatient Rehab Facility, etc…) These patients are the sickest population and account for ~75% of Medicare costs Hospitals must be responsible, and given the tools, to convey the information needed by the recipient of a patient during care transitions Sources: http://aspe.hhs.gov/health/reports/2011/pacexpanded/index.shtml#ch1 http://www.medpac.gov/documents/Jun11DataBookEntireReport.pdf 37

38. 38 Testing the IMPACT Transfer of Care Dataset

39. 39 Transfer of Care: Hospital to SNF, PCP, HHA, etc… SNF, PCP, etc… to HHA PCP to new PCP IMPACT Dataset for Testing

40. 40 Spring 2012, on paper: 2 hospitals, 2 large group practices, 2 home health agencies, 8 SNFs, 1 IRF, 1 LTACH, and several hundred patient transfers… Testing the Transfer of Care Dataset

41. Senders found the data 41

42. Receivers got most of their needs 42

43. Home Care needed even more! 43

44. LCC WG Key Successes to meet MU3 needs (JUNE 12) LCC Use Case 1.0: Expanded from S&I ToC Use Case; identified 360+ additional data elements (AUG 12) Care Plan Whitepaper “Meaningful Use Requirements For: Transitions of Care & Care Plans” (OCT 12) IMPACT Dataset: Consensus built Transitions of Care and Care Plan/HHPoC dataset (483 data elements). Deep dive of LCC Use Case 1.0 (MAY- SEPT 12) Balloted 3 standards through HL7: Stage 2MU C- CDA Refinements interoperable exchange of Functional Status, Cognitive Status, & Pressure Ulcer; Questionnaire Assessment; and LTPAC Summary IG (OCT 12) Stage 3 MU Care Plan Questions for HITPC MU WG (DEC 12) Care Plan Glossary (JAN 13) Community Led submission to HITPC RFC Stage 3 MU (MAR 13) IMPACT Transfer of Care High-level IG 44