longitudinal coordination of care longitudinal care plan sub workgroup 1
Post on 28-Dec-2015
215 Views
Preview:
TRANSCRIPT
Longitudinal Coordination of Care
Longitudinal Care Plan Sub Workgroup
1
Agenda
• Welcome• LCC Introduction• The LCC Challenge• LCC Structure and Work-to-date• Work Streams• Timeline – High-level• Use Case Scope• White Paper
2
Introductions and Welcome
• Round-robin introductions• Overall LCC F2F Agenda
3
Time Agenda Topic Room
Thursday
8:00 am – 10:00 am
LCC Status and Introduction
Edison E
10:30 am – 12:00 pm
LTPAC Working Session
1:30 pm – 3:30 pm PAS Working Session
4:00 pm – 6:00 pm LCP Working Session
Friday
8:00 am – 10:00 am
Use Case Working Session
10:30 am – 12:00 pm
Use Case Working Session and Recap F2F Progress/ Next Steps
LCC Overview
4
Longitudinal Coordination of
Care Workgroup*
Patient Assessment Summary Sub-
Workgroup
LTPAC Care Transition Sub-
Workgroup
Longitudinal Care Plan Sub-
Workgroup
• Providing subject matter expertise and coordination of SWGs
• Developing systems view to identify interoperability gaps and prioritize activities
• Establishing the standards for the exchange of patient assessment summary documents
• Inform the development of the Keystone Beacon Patient Assessment Summary Document Exchange.
• Inform HL7 balloting of LTPAC-specific enhancements to the C-CDA
• Identifying the key business and technical challenges that inhibit long-term care data exchanges
• Defining data elements for long-term and post-acute care (LTPAC) information exchange and using a single standard for LTPAC transfer summaries
• Near-Term: Developing an implementation guide to standardize the exchange of Form CMS-485 (Home Health Certification and Plan of Care)
• Long-Term: Identify and develop a longitudinal care plan spanning multiple care settings
* 75 interested parties, including 28 active, committed members
Observations on progress to date
• Excellent progress:– Keystone Feedback on PAS CCD– RTI Data feedback– Input on CMS HL7 Balloting– Use Case – Gap Analysis, Scoping and Functional/ Data Requirements
• Complexity– Broad view of trading partner community– Many types of transitions and roles of receivers
• Focus Challenges– External Drivers– Multiple Demands
• Coordination Challenges– Separate SWGs– Lack of cohesive overall plan
5
Related Work Streams
• S&I Process - Use Case/ Requirements to Advance interoperability for the LTPAC community.
– Building on the ToC Initiative work and ToC V1.1 Use Case as a foundation for LCC– S&I process (Use Case, Harmonization, IG) provides actionable implementation path for the
LTPAC community– LLC WG would like implementable specifications to support pilots before the end of 2012
• Influence and impact ongoing policy discussions– LCC WG has a strong set of LTPAC interoperability policy stakeholders at the table– White paper would allow for the articulation of a vision and objectives that would be in a format
that is familiar to policy-makers.
• Support specific WG objectives– Continue to use LCC WG as the working forum to support the Challenge, Beacon and VNSNY
project objectives– Project-specific deliverables based on Challenge, Beacon and other requirements
• Serve as a platform for responding to important and related standards activities– Care/ CMS collaboration with HL7 and S&I LCC WG– Standardization of Content for Functional Status, Cognitive Status and Pressure Ulcer work (C-
CDA structure review, Data Elements Review)– Impacting a variety of Assessment Instruments (MDS, OASIS, CARE, etc…)– All LCC SWGs as well as the LTPAC community at large, looks to leverage the standards work
emerging from this collaboration– Analysis-supporting deliverables
6
White Paper
• Detailed articulation of environment• Detailed articulation of current efforts• Vision for Longitudinal Coordination of Care - Roadmap
• Extend Baseline to other care settings • Extend interoperability interchanges and system functions to more
sophisticated care processes, e.g. CDS
• Articulate how S&I first LCC Use Case (HHA) supports overall vision and roadmap for incrementally building trading-partner specific Use Cases
• Standards-improvement roadmap• NPRM response and implications• Use White Paper to manage any unanticipated complexity• What else??
7
Use Case Content Guidance
• Requirements document for use by business/ clinical analysts to hand-off to technical implementers
• Document designed for business and technical implementers (not policy makers)
• Get the best possible coverage of likely overall data elements with the least number of specifically defined transactions
• Use Baseline Use Case to replicate for other care settings, e.g., IRF, BH, and to add scenarios and more sophisticated process transactions and content
8
ACH to HHA/SNF
Admission to HHA/SNF
Order for Skilled Care (HHA/SNF)
ToC Data
Initial Assessment
(Nsg, etc)
HHA- CMS 485SNF- Start of Care Orders
SNF- Initial Plan of Care
OASISMDS
Comprehensive Plan of Care
PAS
HHA/SNF Episode of Care
Change in Condition
Order for referral to
Acute Care
Referral to specialist
View of LTPAC Flow
Strawman Proposal for Use Case
An evidence-based approach to supporting
LTPAC needs
10
MA DPH Universal Transfer Form
• Started with DPH’s 3-pg Discharge Form• Sought input from LTPAC “receivers”• Reviewed existing forms and datasets:
– MDS– OASIS– IRF-PAI– INTERACT
• Sought expert opinions• Resulted in 7-page UTF
11
Massachusetts Paper UTF Pilot
12
Too Long!
UTF Data Element Survey
13
• 46 Organizations completing evaluation• ~300 Data elements evaluated• 1135 Transition surveys completed
11 Types of Organizations
14
12 User Roles
15
Findings from UTF Survey
• Largest survey of Receivers’ needs• Identified for each transitions which data
elements are required, optional, or not needed
• Each of the 300+ data elements is valuable to at least one type of Receiver
• Many data elements are not valuable in certain care transition
• Paper form can’t represent these needs
16
17
Transitions to (Receivers)In Patient ED Out patient LTAC IRF SNF/ECF HHA Hospice Amb Care CBOs Patient/
Transitions From (Senders) Services (PCP) Family
In patient
ED
Out patient services
LTAC
IRF
SNF/ECF
HHA
Hospice
Ambulatory Care (PCP)
CBOs
Patient/Family
11x11 Sender (left column) to Receiver (top)
17
18
Transitions to (Receivers)In Patient ED Out patient LTAC IRF SNF/ECF HHA Hospice Amb Care CBOs Patient/
Transitions From (Senders) Services (PCP) FamilyV = H V = H V = H V = H V = H V = H V = H V = H
In patient CI = H CI = H CI = M CI = M CI = L CI = M CI = L CI = MTV = H TV = H TV = H TV = H TV = H TV = H TV = H TV = HV = H V = H V = H V = H V = M V = H V = M V = H
ED CI = H CI = H CI = H CI = M CI = M CI = L CI = L CI = MTV = H TV = H TV = H TV = H TV = H TV = H TV = H TV = HV = H V = H V = H V = H V = L V = H V = H
Out patient services CI = H CI = M CI = M CI = M CI = L CI = L CI = LTV = H TV = H TV = H TV = H TV = H TV = H TV = L
V = H V = H V = H V = M V = H V = H V = M V = H V = H V = HLTAC CI = H CI = H CI = H CI = M CI = M CI = M CI = M CI = M CI = M CI = M
TV = H TV = H TV = H TV = H TV = H TV = H TV = H TV = H TV = H TV = HV = H V = H V = H V = L V = H V = H V = L V = H V = H V = H
IRF CI = H CI = H CI = M CI = H CI = L CI = L CI = M CI = L CI = L CI = LTV = H TV = H TV = H TV = H TV = H TV = H TV = H TV = H TV = H TV = HV = H V = H V = H V = M V = L V = L V = H V = M V = H V = H V = H
SNF/ECF CI = H CI = H CI = M CI = H CI = M CI = M CI = M CI = M CI = L CI = M CI = LTV = H TV = H TV = H TV = M TV = M TV = M TV = H TV = M TV = M TV = H TV = HV = H V = H V = L V = M V = H V = H V = H
HHA CI = H CI = H CI = L CI = L CI = L CI = L CI = LTV = H TV = H TV = L TV = L TV = L TV = L TV = LV = L V = M V = M V = L V = L V = L V = M V = L
Hospice CI = H CI = H CI = M CI = L CI = L CI = M CI = L CI = MTV = H TV = H TV = M TV = M TV = M TV = L TV = L TV = MV = M V = H V = L V = M V = L V = L V = M V = L
Ambulatory Care (PCP) CI = H CI = H CI = M CI = M CI = L CI = L CI = L CI = LTV = H TV = H TV = H TV = M TV = H TV = M TV = M TV = L
CBOs
Patient/Family
Prioritize Transitions by Volume, Clinical Instability and Time-Value of Information
Black circles = highest priority Green circles = high priority
18
19
Transitions to (Receivers)
In Patient ED Out patient LTAC IRF SNF/ECF HHA Hospice Amb Care CBOs Patient/Transitions From (Senders) Services (PCP) Family
In patient
ED
Out patient services
LTAC
IRF
SNF?ECF
HHA
Hospice
Ambulatory Care (PCP)
CBOs
Patient/Family
Black circles = highest priorityGreen circles = high priority
49 Documents
Is Too Many!
19
Prioritize Transitions by Volume, Clinical Instability and Time-Value of Information
1. Report from Outpatient testing, treatment, or procedure
2. Referral to Outpatient testing, treatment, or procedure
3. Shared Care Encounter Summary (Office Visit, Consultation Summary, Return from the ED to the referring facility)
4. Consultation Request Clinical Summary (Referral to a consultant or the ED)
5. Permanent or long-term transfer to a different facility or care team or Home Health Agency
20
5 High-priority Transition Datasets
Transitions to (Receivers)
In Patient ED Out patient LTAC IRF SNF/ECF HHA Hospice Amb Care CBOs Patient/Transitions From (Senders) Services (PCP) Family
In patient
ED
Out patient services
LTAC
IRF
SNF?ECF
HHA
Hospice
Ambulatory Care (PCP)
CBOs
Patient/Family
21
24
3
5
5
5
51
5 High-priority Transition Datasets
22
5 – Transfer of Care Summary
4 – Consultation Request Clinical Summary3 – Shared Care Encounter Summary
2 – Test/Procedure Request1 – Test/Procedure Report
Type 3 Dataset:• Office Visit to PHR• Consultant to PCP• ED to PCP, SNF, etc…
Type 4 Dataset:• PCP to Consultant• PCP, SNF, etc… to ED
Type 5 Dataset:• Hospital to SNF, PCP, HHA, etc…• Hospital, SNF, etc… to HHA• PCP to new PCP
5 High-priority Transition Datasets
23
Relationship to Other Transfer Forms
5 – Transfer of Care Summary
4 – Consultation Request Clinical Summary3 – Shared Care Encounter Summary
2 – Test/Procedure Request1 – Test/Procedure Report
Type 3 Dataset:• Office Visit to PHR• Consultant to PCP• ED to PCP, SNF, etc…
Type 4 Dataset:• PCP to Consultant• PCP, SNF, etc… to ED
MA Universal Transfer Form
INTERACT
Type 5 Dataset:• Hospital to SNF, PCP, HHA, etc…• Hospital, SNF, etc… to HHA• PCP to new PCP
24
Relationship to Assessment Tools
Minimum Data Set (MDS)IRF-PAI
OASISContinuity Assessment Record and Evaluation (CARE) Tool
25
Relationship to Plan of Care
5 – Transfer of Care Summary
4 – Consultation Request Clinical Summary3 – Shared Care Encounter Summary
2 – Test/Procedure Request1 – Test/Procedure Report
Plan of Care
26
Relationship to Patient Instructions
5 – Transfer of Care Summary
4 – Consultation Request Clinical Summary3 – Shared Care Encounter Summary
2 – Test/Procedure Request1 – Test/Procedure Report
Plan of Care
Patient Instructions
A.
B.
C.
D.
E.
5 – Transfer of Care Summary5 – Transfer of Care Summary5 – Transfer of Care Summary5 – Transfer of Care Summary5 – Transfer of Care Summary5 – Transfer of Care Summary5 – Transfer of Care Summary5 – Transfer of Care Summary5 – Transfer of Care Summary5 – Transfer of Care Summary5 – Transfer of Care Summary
27
Situation-specific Data Elements
5 – Transfer of Care Summary
4 – Consultation Request Clinical Summary3 – Shared Care Encounter Summary
2 – Test/Procedure Request1 – Test/Procedure Report
Plan of Care
Patient Instructions
Variable Base on Situations:A. SettingB. DiagnosesC. MedicationsD. TreatmentsE. Procedures
5 – Transfer of Care Summary5 – Transfer of Care Summary5 – Transfer of Care Summary5 – Transfer of Care Summary5 – Transfer of Care Summary5 – Transfer of Care Summary5 – Transfer of Care Summary5 – Transfer of Care Summary5 – Transfer of Care Summary5 – Transfer of Care Summary5 – Transfer of Care Summary
28
Optionality of Data Elements
5 – Transfer of Care Summary
4 – Consultation Request Clinical Summary3 – Shared Care Encounter Summary
2 – Test/Procedure Request1 – Test/Procedure Report
Plan of Care
Patient Instructions
Optionality within each dataset:• Shall• Should• May
29
Plan of Care Permeates Datasets
5 – Transfer of Care Summary
4 – Consultation Request Clinical Summary3 – Shared Care Encounter Summary
2 – Test/Procedure Request1 – Test/Procedure Report
Plan of Care
Patient Instructions
30
Sometimes Subsets are Used
5 – Transfer of Care Summary
4 – Consultation Request Clinical Summary3 – Shared Care Encounter Summary
2 – Test/Procedure Request1 – Test/Procedure Report
Plan of Care
Hospital Discharge Instructions is a subset of #5
Patient InstructionsDischarge Instructions
31
Sometimes Subsets are Used
5 – Transfer of Care Summary
4 – Consultation Request Clinical Summary3 – Shared Care Encounter Summary
2 – Test/Procedure Request1 – Test/Procedure Report
Plan of CareCMS- 485
CMS-485 is a subset of #5
32
Timing of Producing Datasets
5 – Transfer of Care Summary
4 – Consultation Request Clinical Summary3 – Shared Care Encounter Summary
2 – Test/Procedure Request1 – Test/Procedure Report
Plan of Care
Patient Instructions
Transition of Care Workgroup recognized that the Patient Instructions may be generated independently and given to the patient prior to the full transition dataset.
Sending a patient to the ED starts with #4, but upon admission, #5 should be sent
Discharge Instructions
Original S&I ToC Use Case
Scenario 1 - Provider to provider: User Story 1 - Hospital/ED to PCP
• Discharge Instructions• Discharge Summary
User Story 2 - Closed Loop Referral • Consult Request• Consult Summary
Scenario 2 - Provider to patient:User Story 1 - Discharge Instructions and Discharge
Summary to patient’s PHR
User Story 2 - Closed Loop Referral where copies of Consult Request and Consult Summary are sent to patient’s PHR
33
34
Relationship to S&I ToC Scenarios
5 – Transfer of Care Summary
4 – Consultation Request Clinical Summary3 – Shared Care Encounter Summary
2 – Test/Procedure Request1 – Test/Procedure Report
Type 3 Dataset:• Scenario 1 & 2/User Story 2
Consult Summary
Plan of Care
Patient Instructions
Type 5 Dataset:• Scenario 1 & 2/User Story 1
Type 4 Dataset:• Scenario 1 & 2/User
Story 2 Consult Request
5 – Transfer of Care Summary5 – Transfer of Care Summary5 – Transfer of Care Summary
35
LTPAC “Poster Child” Scenarios
5 – Transfer of Care Summary
4 – Consultation Request Clinical Summary3 – Shared Care Encounter Summary
2 – Test/Procedure Request1 – Test/Procedure Report
Type 3 Dataset:• Scenario 1 & 2/User Story 2
Consult Summary• ED to SNF
Type 4 Dataset:• Scenario 1 & 2/User
Story 2 Consult Request• SNF to ED
Type 5 Dataset:• Scenario 1 & 2/User Story 1• Hospital to Home Health Agency• HHA PCP (CMS-485 Subset)
Plan of Care
Patient Instructions
CMS- 485
36
LCC - Timeline for Phase 2LCC Work Stream 1: Indirect to S&I Process
37
LCC - Timeline for Phase 2LCC Work Stream 2: S&I Process
38
LCC - Timeline for Phase 2LCC Work Stream 3: Vision/ Policy/ Roadmap
Baseline Transaction and Build
Master Longitudinal Care Use Case
Version 1: Baseline Developed with HHA/ SNFCreates base LCC Use Case Structure and focuses on HHA/ SNF as the starting point that gives the best overall coverage
of data elements.
Version 2: (IRF, Behavioral Health, CBO, ???)White Paper Roadmap lays out priority order to incrementally
add requirements of other trading partners
Version 3: (IRF, Behavioral Health, CBO, ???)
Version 4: (IRF, Behavioral Health, CBO, ???)
Version …: Other trading partnersRound out full longitudinal picture
Now:Foundation
Future:Full LCP Support
Building Incrementally
39
S&I Process: Baseline and Build in Parallel
HHA/ SNF UCNext
LTPAC UC
HHA/ SNF Harmonization
Next LTPAC Harm
Next LTPAC Harm
HHA/ SNF Pilots
Other LTPAC Pilots
Next LTPAC
UC
Next LTPAC
UC
Continue to develop and refine requirements in parallel with developing implementation guidance and pilots
40
Baseline Use Case Transactions
Scenario 1: Transitions of Care and ReferralRepresentative Transitions
1. Acute Care to LTPAC (as represented by HHA) #5:• Note post-condition populating POC and OASIS
2. LTPAC (as represented by SNF/ NF) to ED #4:• Note pre-condition reusing MDS and INTERACT
3. ED to LTPAC (as represented by SNF/ NF) #3:• Note post-condition populating MDS
Scenario 2 –Patient Communications:4. Copy all ToC and PoC transactions to patient/care giver PHR
Scenario 3 – HHA Plan of Care:
5. Initial & Recertification PoC from HHA to Physician, Physician to HHA
6. Interim Changes to PoC from HHA to Physician, Physician to HHA• Requirements for all PoC transactions to consider date stamp/ versioning
requirement
42
PAS SWG Standards and Data Analysis
Determine next steps with Harmonization Team
43
Structuring WG Activities to meet our challenge
• Do we have the right structure?• How might we modify to better fit current and future needs?• Re-engaging the LCC WG-level to build out White Paper
44
Schedule Reminder
45
Time Agenda Topic Room
Thursday
8:00 am – 10:00 am
LCC Status and Introduction
Edison E
10:30 am – 12:00 pm
LTPAC Working Session
1:30 pm – 3:30 pm PAS Working Session
4:00 pm – 6:00 pm LCP Working Session
Friday
8:00 am – 10:00 am
Use Case Working Session
10:30 am – 12:00 pm
Use Case Working Session and Recap F2F Progress/ Next Steps
Confirm Meeting Actions
• Confirm objectives for the F2F?
46
top related