IMPACT Challenge Grant May 19, 2011 Carole L. Rodenstein
MA HIE Challenge Grant - IMPACT Improving Massachusetts Post-Acute Care Transfers - $1.7 Million IMPACT Objectives: Complete development and testing of Universal Transfer Form (UTF) Extend Continuity of Care Document (CCD) to include all UTF data elements Develop application to view/edit/send CCD+ Develop consumer-oriented translator Build on existing learning collaboratives to help implement and disseminate tools Integrate tools across continuum of care Measure outcomes 2
Complete Universal Transfer Form Involved stakeholders across continuum of care and review of existing forms Current version 7 pages long Latest review suggested minor changes 11 hospitals and 6 nursing facilities starting pilot Determining which fields should be required vs. recommended vs. optional for each type of transition 3
UTF CCD + Extend Continuity Care Document Coordinating with ONCs Transitions of Care Coordinating with CCD Consolidation Initiatives Bob Dolin (President of HL7 and father of CCD) will work on CCD+ balloted/standard 4
Application to view/edit/send CCD+ Application to be developed to accommodate these assumptions: CCD+ transmitted with each patient transfer CCD+ should leverage data from EHRs Some EHRs will not have all required CCD+ data elements Some facilities have no EHRs Users should only have to use one system to complete their work 5
LAND & SEE EHR users complete all of the required clinical data fields from within their EHR LAND - Local Application for Network Distribution Case Manager uses locally-hosted portal to route CCD+ to next facility SEE - Surrogate EHR Environment Non-EHR users complete all of the data fields and routing from within the application 6
LAND & SEE 7
Advantages of LAND & SEE Most role-based authentication uses EHR, using work that local organizations have already done Most users (particularly physicians and nurses) will only work out of one system Data are re-used whenever possible No central clinical data repository Case managers will control when and where to route documents since theyre often the only ones that know that information Non-EHR users get same functionality as EHR users Relatively low-cost to deploy and support Easily scalable and replicable 8
Develop consumer-oriented translator Translate medical summaries and treatment plans into consumer-friendly Terminology Format Medium RFI was released to establish the current state of the art. RFP to follow Goal is to have a single vendor develop the translator Development will be iterative with stakeholder input and feedback 9
Existing programs/learning collaboratives Care Transitions Forum State Strategic Plan on Care Transitions Division of Health Care Finance and Policy PPR Committee; potentially preventable readmission data provided to hospitals HCQCC Expert Panel on Performance Measurement vetting measures DPH quality inspectors trained in elements of a good transition Pilot universal transfer forms between settings of care (now IMPACT) Hospital requirement to form patient/family advisory councils MOLST pilot (Medical Orders for Life Sustaining Treatment) INTERACT roll out (Interventions to Reduce Acute Care Transfers) BCBSMA STAAR elements in pay for performance contracts Multi-payer medical home demonstrations; new applications coordinate training on principles of optimal transitions with STAAR ASAPs trained in care transitions coaching; on cross continuum teams State-wide response to CMS 3026 funding to reduce readmissions
IMPACT Advisory Committee Massachusetts Tech Collaborative/ MA e-health Institute Massachusetts Department of Public Health Massachusetts Care Transitions Forum Massachusetts Coalition for Prevention of Medical Errors Massachusetts Health Data Consortium Massachusetts Hospital Association Massachusetts League of Community Health Centers Massachusetts Medical Society Massachusetts Senior Care Association Home Care Alliance of Massachusetts Health Care For All Fallon Clinic/SAFEHealth Partners HealthCare System 11
Integrate tools across continuum of care Integrate LAND with EHRs Identify a trusted authority to host the servers for SEE Go-live for Worcester pilot participants Integrate with SAFEHealth Integrate with statewide HIE/HISP 12
Measure outcomes Evaluate pre- and post-implementation: Efficiency of transfer process Utilization of health care services Adverse events, Unplanned Readmissions, Unplanned Emergency Department (ED) visits Adoption of the CCD+ content and process Satisfaction with transfer process: Patients, Families, Senders, Receivers 13
Carole Rodenstein rodenstein@masstech.org 617-371-3999 x211 Thank You!