1. Longitudinal Coordination of Care (LCC) Pilots Proposal CCITI NY 01/27/2014

2. Pilot Team 2 NameRoleEmail Harrison Fox, MPH Project Directorhfox@ccitiny.org Kunal AgarwalTechnical Directorkagarwal@ccitiny.org Jeffrey PaulProject Managerjpaul@ccitiny.org

3. Full Disclosure? CCITI NY is a partner organization working on the New York Reducing Avoidable Hospitalizations (NY-RAH) The initiative, sponsored by CMS, is focused on reducing hospitalizations of long- stay nursing facility residents.

4. NY-RAH Project Overview CCITI NY is working on a CMS funded initiative to reduce avoidable hospitalizations among long-stay nursing home residents Consists of multiple interventions: Electronic tools including a transfer application Onsite RN Care Coordinators (RNCCs) Clinical practices toolkit Palliative care support and training Collaborate with EMR vendors in order to integrate the electronic tools into their systems in order to streamline the clinician workflow 4

5. Project Participants The project consists of the following participants: 30 Nursing Facilities in New York State including Schervier and Silvercrest 10+ Hospitals in New York State including New York Hospital Queens Electronic Medical Record Vendors for both acute and post-acute care settings

6. Goal of the Pilot 6 The goal of Continuum of Care Improvement through Information New York (CCITI NY) is to improve the quality, patient safety, cost and satisfaction aspects of transferring patients between acute, post-acute, and ambulatory care organizations. Project Specific Goals: Improve quality of patient care during transitions Develop standardized workflows to break down communication barriers Create connectivity between disparate clinical systems to improve care coordination Improve clinician satisfaction with the care transition process Reduce avoidable hospitalizations within 30 days of a transfer

7. Problems: Avoidable hospitalizations caused in part by a lack of timely, accurate and comprehensive information for patients transitioning between the acute and post-acute care settings Harmful events stemming from changes in patient medications during care transfers Solution: Reduce avoidable hospitalizations through the use of a standardized electronic transfer form Implement a clinical decision support (CDS) tool to prevent any adverse drug-drug and drug-allergy interactions Common Problems and Our Solution

8. Benefits of Our System Improve medical decision making by providing the most critical and pertinent patient information to clinicians during patient transfers Reduce avoidable hospitalizations by discharging patients with an accurate record of their medications and health information CDS empowers clinicians to ensure proper medication use has occurred upon receipt from a transferred location

9. Key Metrics 9 Avoidable Hospitalizations Patient Care Experience Documentation Time Adverse Drug Events Electronic vs Paper Record Transmissions Through these key metrics, CCITI NY will be able to offer concrete results and demonstrate sustained success through the use of the interoperable transfer form.

10. Patient ready for discharge Transition from Nursing Facility to Hospital Internet Provider logs into Electronic Transfer Application (ETA) and completes information. Alert received at Hospital Provider logs into system and accesses the ETA sent by the nursing facility Patient arrives at Hospital

11. Patient ready for discharge Internet Provider logs into ETA and completes information. Provider logs into system and accesses ETA Transition from Hospital to Nursing Facility Alert received at nursing facility Patient arrives at nursing facility

12. Which of the 5 C-CDA Revisions are you Piloting? 12 SDC Standard / Guidance Specifics to PilotNotes Transfer Summary Nursing Facilities will transmit standardized transfer summary to their hospital partners and vice-versa Focus will be on inclusion of the critical and pertinent patient information that can assist in reducing avoidable hospitalizations

13. What Relevant Scenario (from the Use Cases) does your Pilot support? Exchange of Transfer Summary (LCC Use Case 1.0) Exchange of Advance Directives (LCC Use Case 1.0)

14. Identify the Use Case Actors/Systems Involved: Sending Entity Care Team Receiving Entity Care Team Sending Entity Information System (EHR) Receiving Entity Information System (EHR)

15. Role of the RNCC The RN Care Coordinator will act as a liaison between the long term post acute care facility and the Implementation Team He or she will assist with the development of the implementation plan Obtain important documentation in order to capture key elements found in the current paper process Help identify potential users of the system from both the Hospital and the nursing home

16. CCITI NY Proposed Configuration

17. Timeline MilestoneTarget DateResponsible Party Electronic Transfer Application (ETA) Go-live March 2014CCITI NY ETA Integrated with EMRJuly 2014CCITI NY Pilots EvaluationSeptember 2014CCITI NY

18. CCITI NY Success Criteria 10% reduction in 30-day avoidable hospitalizations for long-stay nursing facility residents within 6 months of go-live 10% reduction in medication errors for long-stay nursing facility residents within 6 months of go-live

19. In Scope / Out of Scope In Scope: Transfer of demographic and clinical patient data between two different providers during care transitions Out of Scope: Integration of discrete data elements into the receiving EHR

20. Risks & Challenges Potential timelines slippage for the EHR vendors integration with the CCITI NY product Incomplete clinical information captured by the EHRs and provided to CCITI NY product Facility IT staff unavailable for support of implementation and training Lack of adoption by the clinical front-line staff at the facilities due to existing workload

21. Questions / Needs None as of now