Leading Edge Innovations: HIT & Reduction of Avoidable Harm in Revolving Door Pts

(1)

The John A. Hartford Foundation

Leading Edge

Innovations:

HIT & Reduction of

Avoidable Harm in

Revolving Door Pts

Amy Berman

www.jhartfound.org

@jhartfound

(2)

The John A. Hartford Foundation

John A. Hartford Foundation

Mission: To improve the health of

older adults

Goal: -

Comprehensive

- Coordinated

- Continuous

(3)

John A. Hartford Foundation

Strategies/Funding Areas:

• Models of Care

• Tools & Measures for Quality --

HIT

• Policy & Communications

• Linking Education & Practice

• Leadership in Action

(4)

Changing Demographics

%

Percentage of State Population Age 65+

(5)

Chronic Disease is the Norm

• 87% of Medicare beneficiaries have

one or more Chronic Diseases

• 66% have multiple Chronic Diseases

(6)

Prescription Drugs, Chronic Care

& Older Adults

0 chronic conditions

10 prescriptions*

*average

(7)

5+ chronic conditions

57 prescriptions

Prescription Drugs, Chronic Care

& Older Adults

(8)

Physician Visits Per Year:

0-1

Chronic Conditions

• 4% had 13+ visits

Citation: Centers for Medicare and Medicaid Services. Chronic Conditions among Medicare Beneficiaries, Chartbook, 2012 Edition. Baltimore, MD. 2012.

(9)

The John A. Hartford Foundation

Physician Visits Per Year:

6+

Chronic Conditions

• Nearly half -- 46% had 13+ visits

Citation: Centers for Medicare and Medicaid Services. Chronic Conditions among Medicare Beneficiaries, Chartbook, 2012 Edition. Baltimore, MD. 2012.

(10)

Devastating Results

• Poor Care

– Older adults receive <35% care

suggested by guidelines (RAND)

• Poor Quality

– 1.5 million preventable adverse drug

events (7,000 deaths annually)

• High Cost

– $17.5B in avoidable readmissions/yr

– $170B drug-related morbidity &

(11)

Leveraging the Power of

HIT to Prevent Harm

Our Path:

– HIT integrated w/in Care Redesign

– Bridge Providers/Settings of Care

– Decision Support w/Geriatric Expertise

– Target Population Outcomes

– Leverage HIT to improve care, cost &

quality

(12)

(13)

Berman’s Hierarchy of HIT

Self-actualization

Wants

Needs

Redesign

focused on

Cost/Quality

Health Information

Exchange (HIE)

Electronic Medical

Records (EMR)

(14)

Update

from

the

ONC:

Recent

Accomplishments

and

Opportunities

for

the

Future

Janhavi

Kirtane

Fritz

Acting

Director,

Beacon

Community

Program

Office

of

the

National

Coordinator

for

Health

IT

(ONC)

www.healthit.gov

(15)

NOW: Better outcomes, engagement and health!

• She collects daily morning vitals

• She completes the prescribed educational health sessions

• She actively participates in video conferencing with the

nurse monitoring her care.

• With reminders from the nurse, she has been keeping her

physician visits, specialty appointments, and improving

medication adherence.

Spotlight

on

the

Central

Indiana

Beacon

Community

– A

Glimpse

into

the

Future

NOW

CONTEXT: The patient is a 53 year old married female with chronic heart disease, congestive heart failure and eight additional chronic health conditions resulting in 13 admissions during calendar year 2011 at St. Vincent Indianapolis and St. Vincent Heart Center. 12 of these were readmissions within 30 days of being discharged. Total hospital (IP and OP) costs for 2011 was over $156,000.

The patient’s providers were frustrated with her

prescribed care regimen and the home health

agency was no longer able to assist her.

The intervention: Home health

monitoring equipment with video

conference capability is provided at

the time of discharge for patients

with CHF for a 30 day period. A nurse

is stationed at a remote care center

(16)

How

does

IT

Support

the

Needs

of

the

Elderly?

•

Care

transitions

•

Patient

and

care

giver

engagement

•

Community

‐

based

providers,

long

term

and

post

acute

care

•

Appreciate

IT’s

limitations

Flashback:

2010

Launch

of

Beacon

Program

John

A.

Hartford

Support

and

Leadership

•

Beacon

Program

technical

assistance

and

access

to

national

experts

•

Meetings

around

care

transitions

•

Increases

in

writing

to

explore

connections

(17)

Media Partners:Health Affairs and

Health 2.0

Washington DC and Online (#ITrans) October 14, 2011 8am‐3pm EST

Kaiser Permanente Center for Total

Health

Putting

the

IT

in

TransITions

Challenge

Grants:

CO,

MD,

MA

Spotlight

on

Beacons

&

Long

Term

Post

(19)

Other

Bright

Spots

Across

the

Country

19 Indiana: IT‐ enabled GRACE Model with access for social workers Monroe County: Aging community services part of HIE,

with social factors

included in care

planning

Center for Technology and Aging Tech4Impact Grantees (www.techandaging.org)

Partners in Care HomeMeds: Community agencies take on medication safety

John A. Hartford Foundation and Agency on Aging Grantee (www.homemeds.org)

BIG DATA: Wound care

companies, public health

agencies, community‐

based organizations, EMS

mining data for predictive

analytics

New York Times Blog:

Caregivers

across

the country test on‐line

communities and social

media

New York Times “The New Old Age” Blog (www. http://newoldage.blogs.nytimes.com)

Community‐based

organizations: Stewards of

Care, Hilltop Institute and

other private collaboratives

are focusing energy here. Care Management

Plus: Expertise and IT

to support complex

(20)

20

What

are

We

Learning

About

IT

to

Support

the

Elderly?

Innovations

that

Matter

•

Electronic

documentation

and

sharing

of

a

patient

and

care

giver

preferences

and

care

goals,

i.e.

Epolst

•

Devices

and

video

‐

based

capabilities

that

supports

safe

transitions

and

safe

living

at

home

•

Use

of

EHRs

and

other

tools

at

the

point

of

care,

e.g.,

ADT

alerts,

to

support

safer

transitions

and

care

management

of

complex

patients

•

Investments

in

technology,

including

exchange

of

health

information,

to

support

coordination

of

care

with

long

term

post

acute

care

provider,

public

health

and

community

‐

based

organizations

•

Mobile

and

app

‐

based

testing

and

diagnostics

to

help

with

earlier

diagnosis

of

dementia,

Alzheimer’s

and

others

•

Standards and

e

‐

clinical

quality

measures

that

support

the

care

and

wellness

needs

of

the

elderly

For

discussion

(21)

Focal

Points

for

the

Future:

Making

Use

of

What

We

Have

“We’re

about

halfway

through

the

process

of

computerizing

and

digitizing

America’s

hospitals

and

doctor’s

offices,

and

we’re

about

5

percent

of

the

way

through

changing

workflows

and

redesigning

care

to

take

advantage

of

those

technologies.”

Farzad

Mostashari,

May

7

Health

IT

Policy

Committee

Meeting

6/24/2013 Office of the National Coordinator for

(22)

Focal

Points

for

the

Future:

Exchange

and

Interoperability

•

ONC

‐

CMS

Joint

Request

for

Information

(RFI)

on

Advancing

Interoperability

and

Health

Information

Exchange

–

Low

Rates

of

EHR

Adoption

and

Health

Information

Exchange

Among

Post

‐

Acute

and

Long

‐

Term

Care

Providers

–

Low

Rates

of

HIE

Across

Settings

of

Care

and

Providers

–

Low

Rates

of

Consumer

and

Patient

Engagement

–

All

comments

are

being

processed,

see

the

following

link

to

review

comments

from

the

Health

IT

Policy

Committee:

http://www.healthit.gov/sites/default/files/hitpc_comments_on_cms

‐

onc_interoperabilityrfi.pdf

6/24/2013 Office of the National Coordinator for

(23)

(24)

Thank

you!

For

more

information

on

the

Beacon

Community

Program,

please

contact

[email protected]

and

download

Beacon

Community

Fact

Sheets

at

http://www.healthit.gov/policy

‐

researchers

‐

(25)

Health

Information

Technology

&

Proactive

Patient

Care

from

Care

Management

Plus

David

A.

Dorr,

MD,

MS

(

[email protected]

)

Associate

Professor

/

Vice

Chair

Department

of

Medical

Informatics

&

Clinical

Epidemiology

General

Internal

Medicine

&

Geriatrics

OHSU

Funding

for

this

research

from

The

John

A.

Hartford

Foundation,

AHRQ,

Intermountain

Healthcare,

the

Gordon

and

Betty

Moore

Foundation

and

the

National

Library

of

Medicine

(26)

Why

do

we

need

care

innovation?

Ms.

Viera

a

75

‐

year

‐

old

woman

with

diabetes,

systolic

hypertension,

mild

congestive

heart

failure,

arthritis

and

recently

diagnosed

dementia.

She

comes

to

clinic

with

5

issues

…

+

two

more

‘hallway

issues’!

What

can

a

primary

care

team

(27)

Intervention:

Care

Management

Plus

Larger infrastructure: Electronic Health Record, quality focus

Past:

Heroism

in

the

face

of

multiple

illnesses

Multiple diseases increase risk and coordination exponentially (5+ : 90 x risk of

hospitalization; 10x Rx; 13 providers vs. 2) . Managing in a primary care panel would take 18 hrs/day. Patients have better process scores, but worse preventable Hospitalizations.

Dissemination

to

over

350

clinical

teams

(28)

Summary

of

studies

from

CM+

The

TRIPLE

aim

of

health

care

www.caremanagementplus.org/pubs.html

Improved

diabetes,

depression

outcomes;

mortality

Improved

patient,

care

manager,

and

provider

experience

24

‐

40%

reduction

in

hospitalizations,

(29)

0%

10%

20%

30%

40%

50%

In One Year

In Two Years

CM

CTL

Reduction

in

hospitalizations

from

CM+

OR=0.65; p=0.036

OR=0.56; p=0.013

Dorr, JAGS, Dec 2008

*

$200k

per

clinic

saved

per

year

*

RVU

cost

$100K

per

clinic

(30)

Dissemination:

750

people

in

>350

clinical

teams

SFHP (12 sites)

Intermountain (16 teams)

OHSU (9 teams)

PeaceHealth (20 teams)

Daughters of Charity (5 teams)

Colorado Access (16 teams)

HealthCare Partners (2 sites) SEARHC

(31)

Before

HIT,

there

are

people

(and

TEAMS)

The

right

people

on

the

team

with

the

right

training

is

a

core

principle.

Patients

are

taught

to

self

‐

manage

and

have

a

guide

through

the

system.

Care

managers

receive

special training

in

•

Education,

motivation,

coaching

•

Disease

specific

protocols,

Care

for

seniors,

Caregiver

support

•

Connection

to

community

resources

Providers

/

Other

Staff:

•

Participate

in

protocol

development,

implementation,

adaptation

•

Need

to

learn

about

care

management

(usually

from

the

(32)

People

can

create

HIT

that

implements

flexible

algorithms

in

a

USEFUL

way

•

Combine

the

personal

– targeted

and

flexible

based

on

values

•

Make

it

efficient

– population

management

functions

•

Help

remind

me

about

the

highest

priorities

0

5

10

15

20

25

30

Additional

Care

Management

elements

requested

from

7

(33)

Integrated

Care

Coordination

Information

System

(ICCIS)

Randomized

Trial

Care Management Training Randomize by clinic

All clinics participate; both quality measurement and

coordination of care taught

Arm1. Coordination of care

1.1 Complete assessment / care plan 1.2 Education (self‐management, etc)

1.3. Goal setting and follow‐up 1.4 Communication 1.5 Motivation / Coaching 1.6 Completing CM services

Arm2. Quality

Choose 5 of 20 quality measures Prevention, Diabetes, Vulnerable Elderly,

Asthma, Congestive Heart Failure PCPI/NQF approved Medical Home Based Data for patients with complex healthcare needs

Evaluation:

Cost of patient illness / Patient Satisfaction and Relationship to

implementation and use of information technology

Goals

for

IT

use

Needs

and

requirements;

(34)

Risk

stratification

and

care

management

can

be

FACILITATED

by

IT

– but

not

replace

a

hands

‐

on

(35)

The

tickler

is

a

centralized

reminder

list

of

tasks

and

communications

that

were

proactively

planned,

but

incomplete,

which

allows

population

‐

based

tasks

to

be

merged

with

individual

encounter

tasks

into

one

(36)

We

can

catalyze

Health

Information

Exchange

by

providing

a

specific,

immediate

use

•

Many

Health

Information

Exchange

efforts

falter

due

to

the

complexity

of

the

task

•

With

ICCIS,

we

mapped

7

different

EHRs

to

a

population

management

system

/

registry

(PracticePartner,

Epic,

Centricity,

TouchWorks,

Intergy,

CPRS,

eClinicalWorks)

•

BUT

limited

the

exchange

to

targeted

areas

and

pragmatic

approaches

to

maximize

value

(37)

Intervention

Incentives

with

multiplier

Focused

Practice

Support

Rapid

cycle

IT

improvement

Control

Same

incentives

without

multiplier

General

Practice

Support

Same

IT

components

Transforming

Outcomes

for

Patients

through

Medical

home

Evaluation

and

reDesign (TOPMED)

Patient

Centered

Primary

Care

Home

evaluation,

Training

Cluster

Randomized

Controlled

Trial

in

8

clinics

(38)

High

Value

elements

for

intervention

High

Value

Element

Description

Patient

‐

centered

Medical

Home

mapping

Identification

of

At

‐

Risk

Populations

Identifies and proactively

addresses patients with high

risk

‘Comprehensive care planning’

Care

Management

Based

on

Need

Assigns person or team to

work closely with high risk

patients, providing higher

access and services

‘Care Management for

complex patients’

Patient

Engagement

and

Proactive

Goal

Setting

Coaches patients to set goals

and follow‐up

‘Education & Self‐

Management Support’

Integrated

Information

and

Procedures

Across

Settings

Receives/shares and monitors

utilization and referrals

Meets ‘Clinical information

exchange’,‘Specialized care’

standard’, ‘Care coordination’

Population

Management

Tools

Uses quality improvement for

identification of need,

corrective action, and

longitudinal tracking

Demonstrates

improvement/meets benchmarks in quality

(39)

Oregon

Health

&

Science

University

–

David

Dorr,

PI

(

[email protected]

)

–

Susan

Butterworth

–

Marsha

Pierre

‐

Jacques

Williams

–

Kimberley

Gray

–

Jesse

Wagner

–

Doug

Rhoton

Columbia

University

–

Adam

Wilcox

Intermountain

Healthcare

–

Cherie

Brunker,

Co

‐

PI

(UU)

–

Liza

Widmier

–

Ann

Larsen

–

Iona

Thraen

For

more

information:

http://topmedtrial.org

http://Caremanagementplus.org

(40)

(41)

(42)

(43)

(44)

(45)

(46)

(47)

(48)

(49)

Standards and Technology

for Longitudinal

Coordination of Care

Academy Health

Annual Research Meeting

June 24

th

, 2013

(50)



What is LTPAC?



IMPACT – addressing the data needs for care

coordination



HL7 – Promoting national standards for

transitions of care and care plans



LAND & SEE - Technology to connect the rest

of the healthcare system

Agenda

(51)

National care transitions experts

overwhelmingly identified

“improving information flow and

exchange” as the most important

tool to improve care transitions

(ONC, 2011)

(52)

Physician Office

52

Living at Home

CBS Outpt. Rehab Home Health Adult Day Care PACE Acute Care Hospital Psych Hospital Hospice Facility Home Hospice Outpt. Behav. Health

Acuity of Illness

Intensity of Car

e

Adapted from Derr and Wolf, 2012 Low

High

The Spectrum of Care

(53)

53

Living at Home

Home Health PACE Hospice Facility Home Hospice

Acuity of Illness

Intensity of Car

e

Adapted from Derr and Wolf, 2012 Low

High

Traditional Long-Term and

Post-Acute Care (LTPAC)

(54)

Where do patients go after hospital?

54

(55)

MU’s impact on LTPAC

• Hospitalized patients are the sickest population

and account for ~75% of Medicare costs

• ~40% of Medicare patients are discharged to

traditional LTPAC settings (SNF, Home Health,

Inpatient Rehab Facility, etc…)

• 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

(56)

IMPACT Grant

February 2011 – HHS/ONC awarded

$1.7M HIE Challenge Grant to state of

Massachusetts (MTC/MeHI):

Improving Massachusetts Post-Acute

Care Transfers

(

IMPACT

)

(57)

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

(58)

“Receiver” Data Needs Survey

58

• Largest survey of Receivers’ needs

• 46 Organizations completing evaluation

• 11 Types of healthcare organizations

• 12 Different types of user roles

(59)

Additional Contributor Input

•State (Massachusetts)

– 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)

•National/International

– American College of Physicians

– 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

(

Inter

ventions to

R

educe

A

cute

C

are

T

ransfers)

– IHE Patient Care Coordination Technical Committee

(60)

Comparison to Continuity

of Care Document (CCD)

60

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 C-CDA templates with applied

constraints

(61)

Testing the

IMPACT

Transfer of Care Dataset

(62)

62

Testing the Dataset

Spring 2012, on paper:

2 hospitals, 2 large group practices, 2 home

health agencies, 8 SNFs, 1 IRF, 1 LTACH, and

(63)

Senders found the data

(64)

Receivers got most of their needs

(65)

Turning Datasets into

National Standards

(66)

66

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

Home Health Plan of Care

(with esMD Digital Signature)

Care Plan

NYeC, Healthix, CCITINY, ASPE, S&I LCC,

HL7, and Lantana update C-CDA for MU3

Shared Care Encounter Summary

(Update to Consult Note)

:

• Office Visit to PHR

• Consultant to PCP

(67)

Getting Connected:

LAND & SEE

(68)

LAND & SEE

• Sites with EHR or electronic assessment tool

use these applications to enter data elements

–

LAND

(“

L

ocal”

A

daptor for

N

etwork

D

istribution) acts as a data courier to gather,

transform, and securely transfer data if no

support for Direct SMTP/SMIME or IHE XDR

• Non-EHR users complete all of the data fields

and routing using a web browser

to access their “

S

urrogate

E

HR

E

nvironment” (

SEE

)

(69)

Further testing of IMPACT Dataset

• Massachusetts ePilot starting in July

2013 with 2 hospitals, 2 large group

practices, 2 home health agencies,

8 Skilled Nursing Facilities (SNF),

1 Inpatient Rehab Facility (IRF),

1 Long Term Acute Care Hospital

• Electronic exchange of full Transfer

of Care dataset using LAND & SEE

• >1000 document transfers/month

(70)

IMPACT Evaluation Metrics

70

• 30 day hospital readmission rates

• ER visit rate

• Hospital admission rate from ER

• Total Resource Utilization

(71)

Summary



IMPACT is helping to develop and evaluate

national standards to meet the needs of the

healthcare system



National HL7 standards for Transitions of Care

and Home Health Plan of Care will be available

at the end of 2013



LAND & SEE software will facilitate integrating

LTPAC organizations into electronic health

information exchanges and enable reusing

data

(72)

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doi:10.1046/j.1525-1497.2000.91119.x. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1495590/.

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(73)

The John A. Hartford Foundation

Discussion

www.jhartfound.org

@jhartfound