1. Care at Hand 1 10/29/15

2. Agenda Introduction Goal of Pilot Tier Piloting Activity to Pilot Role of Care at Hand in the pilot Standards and Technologies Under Consideration Logistics Ecosystem Defining Success Resources/References

3. Introduction: Pilot Team. Care at Hand – Andrey Ostrovsky, MD – CEO – Lori O’Connor – Chief Nursing and Quality Officer Elder Services of Merrimack Valley – Joan Hatem-Roy – Assistant Executive Director Lawrence General Hospital – Robin Hynds – Senior Director

4. Introduction: Organization 1. AHRQ. Service Delivery Innovation: Community-Based Health Coaches and Care Coordinators Reduce Readmissions Using Information Technology To Identify and Support At-Risk Medicare Patients After Discharge. Rockville, MD. 2014.

5. Pilot Introduction: Business Drivers 5 2. Ostrovsky A, O’Connor L, Marshal O, et al. Predicting 30-120 day readmission risk among Medicare FFS patients using non-clinical workers and mobile technology. Perspectives in Health Information Management. 2015. In press. 3. Munevar D, Drozd E, & Ostrovsky A. Correlation between Medicare A spending and hospitalization risk score using mobile technology. Avalere Independent Analysis. 2015.

6. User Story 2 (Modified) 6

7. Pilot Workflow 7 Beneficiary SystemLTSS/Service Provider SystemEHR SystemCase Management SystemPayer System EHR sends d/c summary of care document AAA receives d/c SOC document and starts transition service MCO nurse care managers identify earlier opportunity to redetermine level of care Risk stratification each time interaction between coach and consumer Hospital care management staff given real-time line of site into community-based intervention State-mandated LTSS reporting system gets periodic data dump

8. Which Tier are you piloting? Tiers 1, 2, & 3, iteratively

9. What are you intending to pilot Pick which one(s) apply – Create Plan – Approve/Authorize Plan/Services – Access, View, Review Plan – Update Plan Have you identified a Service provider with which to work, if so who? Elder Services of Merrimack Vallery & LGH Do you know if they have an electronic system – If so which one? Care at Hand, Harmony Do you know which sub-domains from the FR document will you pilot: – Work, Community, Choice & Decision Making, Relationships, Self-Direction, Demographics, Person-Centered Profile, Medication, ADLs/IADLs, Safety, Behavioral Needs, Restrictions, Service, Financial/Payer Information, Service Information, Family Information, Community Connections, Access & Support Delivery, Information & Planning, Health, Other (specify) (from the FR document and the RTM document)

10. What role do you play in the pilot Beneficiary/Advocate, Beneficiary System, CB-LTSS Provider, Clinical and Institutional based provider, EHR system, Eligibility Determination Form Submitter, eLTSS plan developer, eLTSS plan facilitator/steward, LTSS/case management info, LTSS/Service Provider System, Payer, Payer System – Please describe the role you intend to play in the pilot: Predictive analytics platform with person- centered care plan as backbone

11. Standards Under Consideration: C-CDA; HL7v2.0; RxNorm; HCBS Taxonomy; Care Coordination Atlas; BARHII Health Determinants Direct; REST; SSL; FHIR; HTML5; JSON HL7; IETF; Peebles et al 2014; AHRQ; BARHII Exemplar Standards/Technologies Relevant SDOs/Vendors Content & StructureTransport & SecurityCross Category

12. Pilot Logistics: Timeline – (April 2016 is end date for round one pilots) Kick off: Feb 23, 2015 Identification of Partners/Providers- Sept-Dec 2015 Completion of RTM: March 2016 Completion of Pilots: April 2016 Challenges: – Business case is VERY hard to make: Why should hospitals outsource when “they can just build it themselves?” – HIE has limited attention span for “free connections” – community providers don’t get as much attention as “paying customers” – Maryland AND Mass HIEs are INCREDIBLY good and thoughtful, but business is business – Too many cooks in kitchen required to microwave a lean cuisine – Interface analysts, Senior directors, EMR vendor, admins, care coordination leadership, etc. (that’s just the hospital, there’s equal number of community organization reps “needed”) – Timeframes for operationalizing are so long that turnover starts to kick in – Hospital CIO changed and interoperability lead changed

13. Overcoming objections in MA 1. AHRQ. Service Delivery Innovation: Community-Based Health Coaches and Care Coordinators Reduce Readmissions Using Information Technology To Identify and Support At-Risk Medicare Patients After Discharge. Rockville, MD. 2014. 2. Ostrovsky A, O’Connor L, Marshal O, et al. Predicting 30-120 day readmission risk among Medicare FFS patients using non-clinical workers and mobile technology. Perspectives in Health Information Management. 2015. In press. 3. Munevar D, Drozd E, & Ostrovsky A. Correlation between Medicare A spending and hospitalization risk score using mobile technology. Avalere Independent Analysis. 2015.  39.6% 1 30-day readmissions 257% 1 ROI from prevented readmissions $4,591 3 Reduction in Medicare A & B spending per beneficiary per year Predict admissions up to 120 days 2

14. Overcoming objections in MD

15. How do you define success Run chart demonstrating improve outcomes associated temporally with incremental increase in interoperability Improve outcomes in terms of “payer/provider” and “consumer” – ED utilization – 30 day readmission rates – SNF LOS – NCI – Percent of goals of care met – Consumer confidence (activation subcomponent )

16. Care at Hand’s vision 16 Beneficiary System LTSS/Service Provider System EHR SystemCase Management System Payer System