WHY IS MEANINGFUL USE IMPORTANT TO COORDINATED CARE? Before behavioral health providers can truly participate in coordinated care, the secure exchange of health information must be facilitated. Meaningful Use is setting the stage for health information exchange and, thus, coordinated care. From the electronic health record perspective, this program created a national set of technology and data standards that support the capture and exchange of critical information between all members of the healthcare continuum. As part of Meaningful Use, all certified electronic health records must support direct messaging to allow provider-to-provider communication, via the standard defined in the Direct Project. The Direct Project "specifies a simple, secure, scalable, standards-based way for participants to send encrypted health information directly to known, trusted recipients over the Internet." Currently, the Direct Project standard applies to two stage 1 Meaningful Use requirements: 170.314(b)(1) Transitions of care receive, display, and incorporate transition of care/referral summaries 170.314(b)(2) Transitions of care create and transmit transition of care/referral summaries Exchange of information happens via a secure email server set up to follow the Direct Project requirements. Every health information exchange (HIE) is starting their own email server and getting providers to register so they can use the web-based email of the HIE to exchange information between providers. It may be helpful to think of Meaningful Use and Coordinated Care as the plans for the interstate highway system. For years we have been using mail and fax (trails and local roads) to ferry paper charts (horse and buggy vehicles) between providers, an inadequate method of HIE. The Direct Project is building the information superhighways to transport electronic records, starting with the Continuity of Care Document (CCD), to provide a future path to advanced interoperability. This new healthcare environment does not fully support interoperability - and, thus, coordinated care - yet. The rules of the road, so to speak, are still being defined. We don't know yet, for instance: If consumer-to-provider information exchange via a portal has to follow the Direct Project. How "open" each HIE will be. At this point, Illinois (for instance) cannot send information to Iowa. The HIEs will have to open their distribution so that cross-hie communication can happen.
As an industry we have to start somewhere, and with Meaningful Use and the Direct Project, we're well underway to more efficient and effective coordinated care. At the same time, state-defined health home models are still being developed. The Patient Protection and Affordable Care Act (ACA) provided states with a new Medicaid option along these lines to provide health home services for enrollees with chronic conditions. Further, to encourage states to take up the new option, ACA authorized a temporary 90% federal match rate (FMAP) for health home services specified in the law. The Health Home care coordination model has been rolling out across the country and received early adoption in states such as Missouri, Ohio, New York and Oregon. With success defined at a national level via quality metrics and standards set by CMS in the Meaningful Use program, each state was then given the latitude necessary to develop individual implementation plans that meet their specific state s needs.
WHY COORDINATED CARE? According to an Agency for Healthcare Research and Quality analysis of spending data from 2008 and 2009 released in January 2012, caring for the costliest 1% of patients in this country - including those who suffer from serious mental illness - accounts for more than 20% of what the nation spends on all of its healthcare. Other estimates further indicate that 80% of healthcare resources are utilized by a mere 20% of the population. In a country where healthcare costs are rising faster than inflation, lack of care coordination is a significant driver of spending, and these expenditures are significant. As reported in OPEN MINDS, former federal Centers for Medicare & Medicaid Services (CMS) administrator Donald Berwick, and Andrew Hackbarth of RAND, estimate that failures of care coordination contributed $21 to $39 billion to the cost of Medicare and Medicaid in 2011, or about 10% of total "waste." Payers want a more focused approach to managing the needs of these high-cost consumers with multiple chronic conditions and complex social needs. Coordinating a patient s care across the full spectrum of healthcare and social services is a necessity when focusing on improving outcomes and reducing cost in the current healthcare environment. But what constitutes coordinated care? Models that answer the care coordination question are still being defined, but they broadly fall into four different categories: 1 Collaboration between separate providers Physical and behavioral healthcare providers develop formal or informal agreements as to how they will provide both services to their patients and clients. 2 Co-location Mental health professionals and primary care providers practice at the same site. 3 Consultant model A mental health professional is an on-site member of the primary care team; emulates the Federally Qualified Health Center (FQHC) model. 4 Fully integrated All providers are within one group, which allows the center to manage from one integrated health record and generate one bill for providing services. The primary care physician and behavioral health practitioner work together to create a treatment plan. The one thing these models have in common is they all require the use of electronic health records and secure data exchange. Smart behavioral health agencies are planning now to make sure they are working with an EHR vendor partner that is comprehensive and flexible enough to accommodate the complex future of healthcare.
20 QUESTIONS FOR YOUR VENDOR: HOW DO YOU KNOW YOUR EHR IS READY FOR COORDINATED CARE? Just because as an industry we are in the early stages of coordinated care, that does not mean that your organization can afford to sit back and wait for more definitive answers. The time is now for your agency to become better positioned to capitalize on opportunities as they become available. To achieve that position, look for a vendor that has demonstrated leadership above and beyond the current state, understands your business and is flexible enough to adjust to the changing times. Specifically, ask your EHR vendor: 1 Because so much of the Health Homes rules and guidelines for coordinated and integrated care are embedded in Meaningful Use, when will the EHR be certified to the 2014 final rules of Meaningful Use? Will it be certified as a Complete EHR? If not, which modules will it be certified in? 2 How does the certified EHR technology (CEHRT) track referrals for admission as well as patient specific referrals for external consultation? How does it track follow up to referrals? If we want to capture more or different information on referrals, is the referral form customizable? 3 What types of assessments are available to identify medical, mental health, chemical dependency, and social service needs? Can the assessment be customized or modified? 4 Can the system support a single plan of care that integrates the continuum of care across disciplines (medical, behavioral health, rehabilitative, long term care and social service needs)? 5 Can the plan of care be made accessible to the individual and their families or other caregivers when that is the individual s preference? If so, how? What are the patient s options for accessing their plan of care? 6 Can the goals, objectives, and assessment results be pulled into a progress note? 7 What kind of alerts are available to remind the user about upcoming due dates for plan or care or assessments? 8 How does the CEHRT handle medication reconciliation? Will medications electronically transmitted from another source be available as structured and formatted data in the CEHRT? Can I include those medications from the external source in the medication reconciliation form?
9 How does the CEHRT capture access to care data such as the time between contact for services and the first delivery of service appointment? Can a report be run on this across all consumers or a subset of consumers? 10 How does the CEHRT assist the user to identify patient-specific resources for evidence-based wellness and prevention, such as smoking cessation, diabetes, asthma, hypertension, and selfhelp recovery? 11 What tools are available to monitor patient outcomes over time as well as alert a user to initiate changes in care, as necessary? 12 What data elements can be used in the clinical decision support rules (CDSR)? Can primary care diagnoses be used as part of a CDSR? 13 How does the system capture preferred language, literacy, and cultural preferences for each patient? How does the system ensure those preferences are utilized? 14 What kind of alerts, notifications, reminders, messages are available to remind the user of the need for follow up on tests, treatments, services, and referrals which are incorporated in the patients plan of care. 15 What capability does the CEHRT have to exchange data through the regional health information organization (RHIO), other providers, or other Qualified Entities? 16 How does the CEHRT support evidence based clinical decision making? Are there any resources or libraries of evidence based clinical information available in the CEHRT? 17 What Clinical Quality Measures and/or PQRS measures are include in the standard product? What is the process is we require additional CQMS or PQRS measures to be added to the product? 18 What tools are available for tracking timely post hospital follow up? Can the CEHRT track appointments offered as well as first appointment taken? 19 How does the CEHRT allow for the patient to send secure communications to the providers within the EHR? 20 What is the suggested workflow to meet each of these needs?
7 QUESTIONS FOR YOUR AGENCY: WHAT IS YOUR COORDINATED CARE STRATEGY? How can your behavioral health and human services organization participate in this transformative model that is emerging as the future of healthcare? Every organization needs an integration-compatible strategy but whether that is actively pursuing a coordinated care model or not is a big question. Monica Oss, CEO of OPEN MINDS, asks behavioral health and human services organizations seven questions to help them think more strategically about any major decision - including coordinated care: 1 What is the size of your market in dollars by payer and consumer type? 2 For each of those market segments, how does that market break down in terms of current (and future spending) on specific services? 3 What organizations control the spending in each of those market segments? In most markets, this is a basic risk-mapping exercise. 4 For these "managers" of the service funding, what is their preferred contracting model (preferred service type, relationship, rates, etc.)? 5 How closely aligned are your current service lines to the current and future preferences of payers and care managers in your market? 6 What would it take (in terms of referrals, unit costs, service characteristics, etc.) for each of my current service lines to be "sustainable" in the future market? What are those sustainability metrics? 7 Based on that analysis, will my current and planned service lines be the basis of a sustainable financial model now and in the near future? The answers to these questions should be based on your strategy your mission, your vision for the future, and your short-term survival and long-term objectives, all taken together. From there, you can think about what level of coordinated care your organization is interested in pursuing, be it partnering, coordinating or providing: Partnering: Do you have a partner that you coordinate care with? What is their system? Does it support electronic exchange? Does your state have an HIE that you are participating in? Coordinating: Are you looking to become a health home/medical home or a participant in that model?
Providing: Have you hired, or are you looking to hire, primary care physicians for your staff? What system, if any, do they use? Keep in mind that if your agency plans to become or participate in a Health Home or Accountable Care Organization, you are going to have to be able to provide: Comprehensive care management; Care coordination and health promotion; Comprehensive transitional care from inpatient to other settings, including appropriate followup; Individual and family support, which includes authorized representatives; Referral to community and social support services, if relevant; and The use of HIT to link services, as feasible and appropriate.
QUALIFACTS: YOUR COORDINATED CARE PARTNER FOR THE FUTURE Enabling a successful transition between healthcare settings and eliminating the burden of duplicate data entry with its inherent inaccuracies is one of the most critical needs when safely coordinating care. To effectively facilitate meaningful and efficient coordination, Qualifacts is working to create a solution that addresses the key opportunities and challenges that exist in care coordination at the federal, state and agency levels. Among our customers there are several different avenues of coordinated care being explored: Most prevalent are partnerships: These customers, like Prestera Center in West Virginia, are coordinating care with an FQHC (or the like) and sending information back and forth via secure email exchange. In another example, Pathways Behavioral Health Services in Tennessee is an affiliate of a larger healthcare group and sends ADT (demographics, procedures, programs, staff) information to their parent organization system. Some are pursuing the health home model: Coleman Professional Services, for instance, has received approval to become a Health Home in Ohio. They will use CareLogic for their health home needs. Fewer are co-locating providers: Customers like AXIS Health System in Colorado have hired a primary care provider on their staff. The behavioral health side uses CareLogic, and the physician uses another system, and they receive data extracts from both systems to combine into a single document. Our focus on coordinated care so far has been through our product development for Meaningful Use certification. This program is allowing behavioral health to get comfortable now with the future of healthcare so they will have what it takes to be a relevant specialty provider now and ten years from now. Meaningful Use provides the building blocks to support integrated/coordinated care: 1 Standardizing electronic data: electronic format means data can be sent and received, and standardized vocabulary means data can be "read" by disparate systems 2 Defining quality: using measures/standards vetted by acute care settings over decades 3 Measuring outcomes Our strategy has been to support what's happening at a federal level (Meaningful Use standards) and going above and beyond that based on the best ideas coming from the innovators (state HIEs and health home models). That strategy has led us to...
Doubling the amount of data required to be in the Continuity of Care Document (CCD) to include information that's most relevant to behavioral health Beyond simply showing the CCD when it's sent to CareLogic Enterprise, the data is loaded into the EHR so it's immediately visible and reportable Creating clinical quality measures (CQM) and clinical decision support beyond what is required to include additional metrics more relevant to behavioral health - and, indeed, in the recently released stage 2 measures, the CQMs were expanded Using HL7 interfaces, the standard space approach to facilitate exchange of information. We're a member and participate in the development of standards. Building consent and release of information directly into the Direct exchange to address 42 CFR part 2 - the biggest challenge to behavioral health information exchange Building new functionality natively into core workflow engine - not bolted on in a module that needs to be purchased separately - for a more elegant, more efficient system. Usability is never an afterthought, even though usability testing is not yet a reality, and is part of our truly versionless solution.