1. ONC S&I Longitudinal Coordination of Care Work Group From the Present To the Future Missing from the Health Care Discussion: LTPAC

2. 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

5. Figure 1. Typical pattern of health care expenditures among a health plans 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

6. 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?

7. LTPAC and Acute Care: Senders and Receivers

8. 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

9. 20% of patients are readmitted within 30 days. Preventable readmissions estimated at $25B nationwide annually. Preventable Readmissions

10. 1.5 Million preventable adverse events annually nationwide from discharge treatment plans not followed Acute to LTPAC, LTPAC to LTPAC

11. 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 patients 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

12. 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

13. 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

14. 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

15. 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 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

16. Whats 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. pdfhttp://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. 10 th and 17 th 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

17. Questions? S&I LCC WG wiki site: http://wiki.siframework.org/Longitudinal+Coordination+of +Care http://wiki.siframework.org/Longitudinal+Coordination+of +Care Contact: –Evelyn Gallego, LCC Initiative Coordinator evelyn.gallego@siframework.org

18. Organizational Structure Organizational Structure Longitudinal Coordination of Care Workgroup (LCC WG)