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TRANSCRIPT
© 2012
Health Information Exchange Activities for LTPAC and
Behavioral Health Communities ASPE Sponsored Webinar
December 4, 2012
To ask a question during the live webinar –
1) Post a question at any time in the Chat Box 2) Live Q&A will be held at the end of the webinar
© 2012
Session Overview • Health IT and Health Information Exchange are
powerful tools supporting transformation in health care
This session will – – Highlight activities that are paving the way for improved
communication between providers including LTPAC and BH
– Provide an overview of meaningful use and its impact on LTPAC and BH communities related to HIE
– Present examples of the use of technology to transform health care delivery and payment impacting LTPAC and BH communities
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Speakers: • Jennie Harvell, Sr. Policy Analyst, ASPE • Travis Broome, CMS/Office of E-Standards &
Services • Effie R. George, Disabled & Elderly Health
Programs Group, CMCS • Anita Yuskauskas, Disabled & Elderly Health
Programs Group, CMCS • Lynda K. Hohmann, PhD, MD, MBA, NY State
Department of Health • Maria Moen, Healthcare Applications Director,
Brookdale Sr. Living
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Health Information Exchange Involving LTPAC and BH:
A Necessary Component for Health System Transformation
Jennie Harvell, ASPE December 4, 2012
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The Need for Health Information Exchange • Persons who receive long-term/post-acute care and behavioral
health services are medically fragile, functionally impaired, and/or have serious and complex behavioral health problems.
• These individuals have frequent contact with the health care delivery system, experience frequent transitions and referrals in care, and are among the most costly patients.
• Poor health information exchange is believed to be a factor that
contributes to: readmissions, duplicative testing treatment, adverse medication events, and poor coordination and integration of care. – Improved health information exchange (HIE) on behalf of
persons who receive LTPAC and BH services is anticipated to improve quality and reduce unnecessary health care costs. 5
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National Quality Strategy Aims
Better Health for the
Population
Lower Cost Through
Improvement
Better Care for
Individuals
NQS Priorities: Making care safer by reducing harm caused in the delivery of care.
Ensuring that each person and family are engaged as partners in their care.
Promoting effective communication and coordination of care.
Promoting the most effective prevention and treatment practices for the leading causes of mortality, starting with cardiovascular disease.
Working with communities to promote wide use of best practices to enable healthy living.
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Success requires delivery system and payment transformation
Value-based
purchasing ACOs Episode-based
payments Patient-centered
Medical Homes Data transparency
Volume Driven
Outcomes Driven
Payment systems support
collaboration Payment systems support
fragmentation
Fragmented payment systems (IPPS, OPPS, RBRVS, SNF PPS, HH PPS, etc.)
Fee-for-service payment models
Lack of transparency
Private Sector + Public Sector + Innovation Center
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CMS Innovation Center (CMMI)
“The purpose of the Center is to test innovative payment and service delivery models to reduce program expenditures under Medicare, Medicaid, and CHIP… while preserving or enhancing the quality of care furnished.”
- The Affordable Act • Opportunity to “scale up”: The HHS Secretary has the
authority to expand successful models to the national level • Measures of Success focus on:
• Better health care • Better health • Reducing costs through improvement
Charge: Identify, Test, Evaluate, Scale
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Innovation Center Portfolio Primary Care Transformation • Comprehensive Primary Care Initiative (CPC) • Multi-Payer Advanced Primary Care Practice (MAPCP)
Demonstration • Federally Qualified Health Center (FQHC) Advanced
Primary Care Practice Demonstration • Independence at Home Demonstration • Graduate Nurse Education Demonstration
Accountable Care Organizations (ACOs) • Medicare Shared Savings Program • Pioneer ACO Model • Advance Payment ACO Model • PGP Transition Demonstration
Bundled Payment for Care Improvement • Model 1: Retrospective Acute Care • Model 2: Retrospective Acute Care Episode & Post Acute • Model 3: Retrospective Post Acute Care • Model 4: Prospective Acute Care
Capacity to Spread Innovation • Partnership for Patients • Community-Based Care Transitions • Million Hearts • Innovation Advisors Program
Health Care Innovation Awards
State Innovation Models Initiative
Initiatives Focused on the Medicaid Population • Medicaid Emergency Psychiatric Demonstration • Medicaid Incentives for Prevention of Chronic Diseases • Strong Start Initiative
Medicare-Medicaid Enrollees • Financial Alignment Initiative • Initiative to Reduce Avoidable Hospitalizations of Nursing
Facility Residents
http://innovations.cms.gov/
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ACO Vision
• An ACO promotes seamless coordinated care – Puts the beneficiary and family at the center – Remembers patients over time and place – Attends carefully to care transitions – Manages resources carefully and respectfully – Proactively manages the beneficiary’s care – Evaluates data to improve care and patient outcomes – Innovates around better health, better care and lower
growth in costs through improvement – Invests in team-based care and workforce
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Accountable Care Organizations
Medicare Shared Savings Program (Center for Medicare and CMMI): Facilitates coordination of care and shared savings on behalf of Medicare FFS beneficiaries by creating of participating in ACOs.
Pioneer ACO Model: Organizations including several integrated delivery systems that include LT/PAC and/or BH services, and use health IT to support care coordination.
Advance Payment Model: Physician-based and rural providers that work to coordinate care for Medicare beneficiaries.
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Bundled Payments for Care Improvement
Four patient-centered approaches – Focus on bundling payment for episodes of care:
1. Acute care hospital stay only
2. Acute care hospital stay plus post-acute care: episode bundles the inpatient hospital and PAC stay for either 30 or 90 days post-hospital discharge.
3. Post-acute care only: episode begins with the initiation of PAC services within 30 days of hospital discharge and ends after 30 days of PAC service delivery. PAC services are: SNF, HHA, LTCH, IRF. Bundle includes: physician, PAC, lab, DME, and Part B meds.
4. Prospective payment of all services during inpatient stay
GOAL: Drive care redesign by aligning incentives that improve coordination across services and reduce the cost of care.
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Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents
• 40 percent of hospital admissions among Medicare-Medicaid enrollees who were nursing facility residents were preventable in 2005.
• That’s 314,000 potentially avoidable hospitalizations.
• This cost $2.6 billion in unnecessary Medicare expenditures. • Initiative supports the goal of reducing avoidable hospitalizations by
20% by end of 2013.
• 09/27 - Announced 7 participating organizations
GOAL: Reduce preventable inpatient hospitalizations among residents of nursing facilities. Providing preventive care and treatment without hospital visits.
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Medicaid Health Home State Plan Option
• Open to all states.
• Participating states receive enhanced financial resources from the federal government to support “health homes.”
• Innovation Center will assist with learning, technical assistance, and evaluation activities.
GOAL: Allowing Medicaid beneficiaries with at least two chronic conditions to designate a single provider as their “health home.”
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Community-based Care Transitions Program (CCTP)
GOALS of CCTP: • Improve transitions of beneficiaries from inpatient hospitals to home
or other care settings.
• Reduce readmissions for high risk beneficiaries.
• Document measurable savings to the Medicare program.
• Applications now being accepted and awarded on a rolling basis.
• 30 program participants to date.
Focus on partnerships between community-based organizations and hospitals to reduce 30-day hospital readmissions.
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Medicaid Emergency Psychiatric Demonstration
GOAL: Test whether Medicaid Beneficiaries aged 21 to 64 who are experiencing a psychiatric emergency (suicidal or homicidal thoughts or gestures) get more immediate, appropriate care when institutions for mental diseases (IMDs) receive Medicaid reimbursement
Demonstration provides federal matching funds over 3 years
Demonstration pays for inpatient services necessary to stabilize the psychiatric emergency
11 States – Alabama, California, Connecticut, Illinois, Maine, Maryland, Missouri, North Carolina, Rhode Island, Washington, and West Virginia – and the District of Columbia were selected to participate
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Health Care Innovation Awards
Innovation Awardees will: • Improve care and lower costs for Medicare, Medicaid, and CHIP
beneficiaries.
• Reach diverse populations in underserved and geographically remote communities
• Rapidly implement the proposed model.
• Develop, train, and deploy workforce in innovative payment and delivery models.
• Status: • 107 Projects Awarded for a three-year period in all 50 states
GOAL: Identify and support a broad range of innovative service delivery and payment models that achieve better care, better health and lower costs in communities across the nation.
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Meaningful Use: Advancing Health Information Exchange and Improving Quality
Use technology
Access information
Transformation
Care coordination
Robust CDS (evidence based
medicine & practice goals)
Patient centered, team based care
CQM data enables outcome
improvements
Case management & longitudinal view
Clinical Decision Support
Performance and
population management
Patient engagement
Patient informed
Improved population
health
Enhanced access and continuity
Structured data capture
Stage 2 MU Future Stage 3 MU Stage 1 MU National Quality Strategy. Better Care. Healthy People/Health Communities. Affordable care. 18
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Meaningful Use Opportunities
December 04, 2012 Travis Broome, CMS
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• Doctors of Medicine
• Doctors of Osteopathy
• Doctors of Dental Medicine or Surgery
• Doctors of Optometry
• Doctors of Podiatric Medicine
• Chiropractor
Could be eligible for both Medicare & Medicaid
Medicare-only Eligible Professionals
Medicaid-only Eligible Professionals
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Eligibility – Professionals
• Nurse Practitioners
• Certified Nurse-Midwives
• Physician Assistants (PAs) when working at an FQHC or RHC that is so led by a PA
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Hospitals only eligible for Medicare incentive
Hospitals only eligible for Medicaid incentive
Subsection (d) hospitals in 50 U.S. states and the
District of Columbia*
Critical Access Hospitals (CAHs)
*without 10% Medicaid
Eligibility - Hospitals
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Most subsection (d) hospitals/ acute care
hospitals
Most CAHs
Children’s hospitals
Acute care hospitals in the
territories
Cancer hospitals
Could be eligible for both Medicare & Medicaid
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Stage 2 focuses on actual use cases of electronic information exchange:
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• Stage 2 requires that a provider send a summary of care record for more than 50% of transitions of care and referrals.
• The rule also requires that a provider electronically transmit a summary of care for more than 10% of transitions of care and referrals.
• At least one summary of care document sent electronically to recipient with different EHR vendor or to CMS test EHR.
Closer Look at Stage 2: Electronic Exchange
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Describing Transition of Care and Referrals
Transition of Care: the movement of a patient from one setting of care to another Referral: one provider refers a patient to another, but the referring provider maintains their care of the patient as well
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Counting Transition of Care and Referrals
• Eligible Professionals – The transition or referral is ordered by the EP – For example, the EP is the admitting physician for
the patient to a hospital or LTPAC facility
• Eligible Hospitals – All discharges from the inpatient department – Emergency department visits when follow-up care
is ordered by an authorized provider of the hospital
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Enabling Standards
• Consolidated Clinical Document Architecture (C-CDA) – HL7 Implementation Guide for CDA® Release 2: IHE Health
Story Consolidation
• DIRECT Project – Applicability Statement for Secure Health Transport
• http://healthit.hhs.gov/portal/server.pt/community/healthit_hhs_gov__direct_project/3338
– XDR and XDM for Direct Messaging Specification • http://wiki.directproject.org/XDR+and+XDM+for+Direct+Messaging
• Simple Object Access Protocol (SOAP) – http://modularspecs.siframework.org/SOAP+based+Secure+Transport+Artifacts
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MU Required Data in the C-CDA? Data Standard Data Standard
Patient Name Care plan field(s)
Demographics Multiple Procedures SNOMED CT® ICD-10 PCS
Smoking Status SNOMED CT® Care Team Members
Problems SNOMED CT® Encounter diagnosis ICD -10 CM
Medication RxNorm Immunizations HL7 CVX
Medication Allergies
Cognitive and functional status
SNOMED CT® and LOINC®
Laboratory tests and results
LOINC® Reasons for referral
Vital Signs Referring provider’s name and contact
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Further Info Explanation of MU Required Data in the C-CDA
• Functional status, including activities of daily living, cognitive and disability status
• Care plan field, including goals and instructions
• Care team including the primary care provider of record and any additional known care team members beyond the referring or transitioning provider and the receiving provider
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Certification for Other Settings • Nothing prohibits anyone from getting a technology certified to as many
criteria as they wish even if the technology is not designed for or marketed to eligible providers
• Certification ensures that the technology is capable of sharing a C-CDA with other certified technologies and that it can both create and consume information in C-CDA
• ONC Final Rule: HIT: Standards, Implementation Specifications, and Certification Criteria for EHR Technology, 2014 Edition; Revisions to the Permanent Certification Program for HIT
“We encourage EHR technology developers to certify EHR Modules to the transitions of care certification criteria (§ 170.314(b)(1) and (2)) as well as any other certification criteria that may make it more effective and efficient for EPs, EHs, and CAHs to electronically exchange health information with health care providers in other health care settings.”
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Effie R. George, Ph.D.
Disabled & Elderly Health Programs Group, CMCS
Balancing Incentive Program Section 10202
of the Affordable Care Act
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Balancing Incentive Program
• Goal – increase access to non-institutionally based Medicaid Services and implement key structural reforms
• States must reach benchmarks of either 2 or 5% by the end of the program
• CMS is accepting applications from States immediately through August 1, 2014
• Enhanced FMAP available until September 30, 2015 or until total program funding of $3 billion dollars is expended
• State Medicaid Agencies must apply
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Balancing Incentive Program
• Eligibility – States who submit an application and spend less than 50 % on HCBS
• States may submit expenditure data on total Medicaid expenditures on LTSS as of FY 2009 to be reviewed on case by case basis
• States may not apply based on expenditures by target population(s)
• Funding available for community-based LTSS
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Balancing Incentive Program
• Financial Incentives – 2 or 5 % on eligible HCBS provided under the following Medicaid program authorities:
• HCBS under 1915 (c) or (d) or under an 1115 Waiver; • State plan home health; • State plan personal care services; • The Program of All-Inclusive Care for the Elderly (PACE); • Home and community care services defined under Section 1929(a);
and • Self-directed personal assistance services in 1915 (j), • services provided under 1915(i), • private duty nursing authorized under Section 1905 (a)(8) (provided in
home and community-based settings only) • Affordable Care Act, Section 2703, State Option to Provide Health
Homes for Enrollees with Chronic Conditions • Affordable Care Act, Section 2401, 1915(k) - Community First Choice
(CFC) Option.
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Balancing Incentive Program • Structural Changes:
– No Wrong Door/Single Entry Point system, – Conflict-free case management, and – Core assessment instruments – And data reporting requirements – A User Manual and technical assistance will be
available
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Balancing Incentive Program
• Opportunities for collaboration and
coordination – Community First Choice (CFC), – Health Home, – Money Follows the Person (MFP), and – Aging and Disability Resource Centers (ADRCs)
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Resources
• Balancing Incentive Program Guidance: http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Long-Term-Services-and-Support/Balancing/Balancing-Incentive-Program.html • Questions or comments: [email protected]
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Information Follows the Person: Advancing LTSS Measures & Integrated Electronic Records
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TEFT GRANT INITIATIVE
Anita Yuskauskas
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Demonstration Grant for Testing Experience and Functional Tools
(TEFT) in Medicaid
Long Term Services and Supports
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Four Components of TEFT
• Test and Experience of Care Survey • Test a set of CARE Functional Assessment
Measures • Develop Standards for e-LTSS Records • Demonstrate Personal health Records
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TEFT Initiative Description: $64 million Initiative
Ten + Grants Four Contracts
• EoC Testing • CARE Testing • Technical Assistance • Evaluation
Two Federal Interagency Agreements • ONC – Standards Development • DoD – PHR/EHR
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Better Health for
the Population
Better Care for
Individuals
Lower Cost Through
Improvement
Why TEFT? The “Three-Part Aim”
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Development of a Core Set of Health Care Quality Measures
for Adults Eligible for Benefits Under Medicaid • Includes Individuals with LTSS Needs • 5% Using 55% Resources • Lack of National Measures
Adult Quality Measures: The Affordable Care Act of 2010
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5% Drive 55% of Medicaid Expenditures
55% 45%
0% 0%
Top 5%
Remaining 95%
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• Provides Incentives to targeted “eligible professionals” for
using Electronic Health Technology • Targeted Professionals in Medicaid include:
• Physicians, certified nurse midwife, nurse practitioner, physician assistant practicing in a FQHC or RHC led by a Physician Assistant
• May not be based in an inpatient hospital or emergency room of a hospital
Meaningful Use: The American Recovery & Reinvestment Act of 2009
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WHAT’S MISSING IN THIS PICTURE??
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WHERE IS LONG TERM CARE???
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Complicating Factors in LTSS
• Wide Range Of Settings • Wide Range Of Service Provider Types And Qualifications • Wide Range of Measurement Sets: No Standardization • Wide Variety Of Diagnostic Categories in LTC • No Standard “Treatment Intervention”, i.e., service definitions
& service delivery models • Personal & social outcomes versus illness or disease outcomes
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MESSY!
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System of LTSS Needs to Participate in MU
1. Personal Health Records 2. Trained Providers 3. Standards 4. Measures
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PHR and an E-LTSS Record: Two Goals of TEFT
• Demonstrate personal health records with beneficiaries of CB-LTSS; and
• Curate an electronic Long Term Services and Supports (e-LTSS) standard coordinated through the Office of National Coordinator’s (ONC) Standards and Interoperability Framework.
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• Individuals will have access to their own PHR • States will have the option to include additional
components of interest in the PHRs • Applicable providers are equipped to train and
support individuals to access and use their PHRs through an outreach and training strategy.
Demonstrate personal health records with beneficiaries of CB-LTSS
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• States can develop a strategy in their initial operational protocol to integrate health related information through the use of HIT (Health Information Technology).
• This strategy is intended to engage and integrate information from EHRs into a beneficiary’s PHR.
Curate an electronic Long Term Services and Supports (e-LTSS) standard
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• CB-LTSS providers will be required to enter
information in the e-LTSS record based on standards developed through the S&I Framework.
• At least two iterations of the e-LTSS record will be rolled out to States and their providers for testing.
• State’s will need to develop a crosswalk with their standards for service plan development and reporting.
Curate an electronic Long Term Services and Supports (e-LTSS) standard – More on the process
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States will be able to identify a HIE strategy that aligns with the State’s HIE protocol.
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NYS Medicaid Health Homes Office of Health Insurance Programs (OHIP)
Division of Program Development and Management
Lynda K. Hohmann, PhD, MD, MBA
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• Health Home Framework
• Health Home Roll-out in NYS
• Integrating HIE into Health Homes
New York State Health Homes :
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A health home is an approach to how health care is delivered. A health home is a provider or a team of health care professionals that provide integrated health care. This means that if a person is participating in a health home, that person’s health care, from primary care doctor to dentist to behavioral health professional, all share the same information and coordinate treatment based on that information. Health homes operate under a “whole-person” philosophy – caring not just for an individual’s physical condition, but providing linkages to long-term community care services and supports, social services and family services. The integration of primary care and behavioral health services is critical to achievement of enhanced outcomes. (SAMHSA)
What is a Health Home? It’s not a PCMH…..
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A care manager who knows the member, organizes care, ensures communication with other care providers and assures that the member’s circumstances does not affect his/her progress to better health…
Complex health conditions with complex treatment regimens
Literacy and health literacy issues Homelessness and unreliable food Safety concerns Familial disruption
What is the central theme of Health Homes?
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New York State Health Home Analytical Products ◦ CRG Based Attribution – For Cohort Selection ◦ CRG Based Acuity – For Payment Tiers ◦ Predictive Model – Predicts future negative events
(Inpatient, Nursing Home, Death) using claims and encounters – For Assignment Priority
◦ Ambulatory Connectivity Measure – For Assignment Priority
◦ Provider Loyalty Model – Establishes Patient Connectivity to Existing Care Management, Ambulatory (including BH), ED and Inpatient – For Matching to Appropriate HH and to Guide Outreach activity.
How Eligible Members are Being Identified and Assigned
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• All Other Chronic
Conditions •306,087 Recipients
•$698 PMPM
• Mental Health and/or Substance Abuse
•408,529 Recipients •$1,370 PMPM
• Long Term Care
•209,622 Recipients •$4509 PMPM
• Developmental Disabilities
•52,118 Recipients
•$10,429 PMPM $6.5 Billion 50% Dual 10% MMC
$10.7 Billion 77% Dual
18% MMC
$2.4 Billion 20% Dual
69% MMC
$6.3 Billion 16% Dual 61% MMC
Populations
$25.9 Billion
Total Complex N=976,356
$2,338 PMPM 32% Dual
51% MMC
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• New York currently has 51 designated Health Homes in 57 counties.
• Phase 1 Health Homes are in active outreach and engagement and active care management.
• Phase 2 and 3 Health Homes are pending approval of their SPA.
• Quality process and outcome measures are close to completion.
Status of NYS Health Homes
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◦ Comprehensive care management An individualized patient centered care plan based on a comprehensive health risk assessment – must meet
physical, mental health, chemical dependency and social service needs. ◦ Care coordination and health promotion
One care manager will ensure that the care plan is followed by coordinating and arranging for the provision of services, supporting adherence to treatment recommendations, and monitoring and evaluating the enrollee’s needs. The health home provider will promote evidence based wellness and prevention by linking patient enrollees with resources for smoking cessation, diabetes, asthma, hypertension, self-help recovery resources, and other services based on need and patient preference.
◦ Comprehensive transitional care Prevention of avoidable readmissions to inpatient facilities and oversight of proper and timely follow-up care.
◦ Patient and family support Individualized care plan must be shared with patient enrollee and family members or other caregivers.
Patient and family preferences are considered. ◦ Referral to community and social support services
Provider will identify and coordinate community and social supports ◦ Use of health information technology (HIT) when feasible
Health home providers will be encouraged to utilize RHIOs or a qualified entity to access patient data and to develop partnerships that maximize the use of HIT across providers. Health home provider applicants must submit a plan with their application for achieving compliance with the final health home HIT requirements within 18 months of program implementation
Required Health Home Services:
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Care Management Record Health Information Exchange/RHIO
Member Care Manager
PCP
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HIE Health Home Challenges:
• NYS has developed a strong state HIE infrastructure with the SHIN-NY and local RHIOs. Most development has been focused on hospital and physicians. Very little funding has been available for behavioral health providers aside from HEAL 17.
• RHIOs use different platforms and have different consenting processes for HIE access.
• MU incentives apply to a limited number of providers.
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HIE Health Home Challenges:
• EHR for medical practices are common, there are some EHRs for behavioral health, but there are few electronic care management tools.
• There is wide disparity in HIT sophistication among the Health Homes.
• There is wide disparity in HIT financing among the Health Homes.
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HIE Health Home Challenges:
• In 18 months from the date of the SPA, Health Homes need to meet HIT Health Home standards:
– Health home providers will be encouraged to utilize RHIOs or a qualified entity to access patient data and to develop partnerships that maximize the use of HIT across providers. Health home provider applicants must submit a plan with their application for achieving compliance with the final health home HIT requirements within 18 months of program implementation
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Solutions:
• Several HHs are participating in CMMI grants. • NYS has released HEAL 22 which is providing
HIT technical support to behavioral health providers particularly related to HH.
• NYS OMH has released funding for certain programs for connectivity to RHIOs.
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Solutions:
• NYS DOH has requested budget funding to support HIT development for under resourced HH.
• NYS has submitted a waiver to CMS with funding to support the IT infrastructure for Health Homes.
• NYS is spec’ing a DOH Health Home portal that includes a “Care Management Lite” tool that meets minimal care management record needs.
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Reducing Avoidable Resident Re-Hospitalizations:
A Quality Improvement Project for Skilled Nursing Facilities, Assisted Living and Home
Health
Maria D. Moen, Healthcare Applications Director
November 30, 2012
Brookdale Senior Living
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The Changing Landscape….. Patient Protection & Affordable Care Act (PPACA)
• Accountable Care Organization (ACO): A term that signifies a very specific
CMS program initiative that is outlined in a 696-page Final Rule released in October 2011
• On March 23, 2010, the President signed into law the Patient Protection and Affordable Care Act
• PPACA, and a subsequent amendment to it, form the Affordable Care Act (ACA)
• ACA encourages the development of new patient care models for payment and service delivery to reduce costs and enhance quality
• Accountable Care Organization (ACO) is one major program initiative under ACA
• Proposed Rule for ACO was released March 31, 2011 and it required ACO implementation no later than Jan 1, 2012
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The Changing Landscape & Goals of ACO’s
• ACOs are designed to contain Medicare Fee-for-Service costs • ACOs target the 73% of Medicare beneficiaries who steadfastly
remain in the Medicare Fee-for-Service system
• ACOs that meet established quality standards, and achieve savings beyond a minimum threshold... will share CMS monetary rewards
• ACO legislation allows certain groups of providers to come
together in a specific way (see Appendix) to manage/coordinate care of Medicare beneficiaries across a continuum of service settings
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What Does it Mean for Long Term and Post Acute Care?
• Emphasis on prevention of illness and effective management of chronic
medical conditions
• Reduction in hospitalization & care costs
• Emphasis on Advanced Care Planning/End of Life Care
• Quality Improvement through data exchanges, benchmarking, and quality metrics
• Growing of horizontal relationships across the continuum of care
• Seamless transitions for residents (not discharges)
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CMS Innovations Challenge Grant
Brookdale Senior Living owns / operates 647 senior living communities in 36 states A successful Transitions of Care program was implemented in select skilled nursing
centers CMS Innovations Grant awarded for 3 years (July 2012-July 2015)
Partnerships in the Grant • Brookdale Senior Living • University of North Texas Health Sciences Center (UNTHSC) • Florida Atlantic University (FAU) • Loopback Analytics • University of South Florida (USF) • American Association of Colleges of Nursing (AACN) • Florida Medical Quality Assurance Inc. ( FMQAI)
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Innovations Grant Components
– INTERACT – Clinical Nurse Leaders – Education – Outcomes
• Clinical • Cost Savings
Goals • Improve the quality of care for the resident, NOT prevent hospitalization when warranted.
• 1 out of 4 resident admitted to a nursing home will be readmitted to the hospital within 30days
• INTERACT can result in a more rapid transfer for residents who need acute care. • Implement INTERACT in 67 Brookdale communities over 3 years that provide Skilled Nursing,
Assisted Living, Independent Living and Home Health services and demonstrate success metrics
• Increase care coordination across continuum • Integrate care cost data • Create strong collaborative relationships/partnerships with hospital systems
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What is INTERACT?
INTERventions to reduce Acute Care Transfers
• Developed by a project supported by the Centers for Medicare and Medicaid
Services (CMS) • INTERACT is a Quality Improvement Program designed to identify situations
around residents with acute changes in condition that commonly result in transfers to the hospital.
• INTERACT consists of processes and tools • One study found that 65% of all transfers to the hospital could be prevented
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Clinical Nurse Leaders to Facilitate a LTPAC Case Management Model
• Nurses with specialized training to have an
effect on care transitions and quality of care • Teach and train in our communities • Evaluate data for trends and identify
opportunities for improvement • Report outcomes
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Alignment with the Advancing Excellence Campaign
• Reporting, Analysis and Tracking tools support Quality Improvement and Root Cause Analysis
• Monthly Summaries produced can be entered on the AE website for trend graphing http://www.NHQualityCampaign.org
• Admission logs from Acute Care Hospitals • Transfer logs for Acute Care Transfers • Communication Tool logs and graphs • Transfer Related process logs and graphs • Admissions by Day of Week graph template • Admissions by Hospital graph template ● Transfers by Doctor graph
template • Transfers by Time of Day graph template ● Transfers by Outcome graph
template • Transfers by Primary Reason for Transfer graph template
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Data Targeted for Exchange Between LTPAC and the Acute Care Partner is Key
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Opportunities and Barriers for Technology and Health Information Exchange
• State Initiatives to use as Models for Transfer of Information include Florida and Massachusetts
• S&I Framework work groups related to Assessment and Care Plan exchange of information are also models to evaluate
• Acute Care partners to facilitate information exchange to meet thresholds for Meaningful Use Stage 2 criteria
• Finding that facilitating data exchange is not always high on their development radar
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WRAP UP
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Request for Comment – Weigh In! Possible MU Stage 3 Requirements • HIT Policy Committee Requests Your Comments on Stage 3
MU Definitions – – Comments due January 14, 2013 – Areas under consideration include: care plan, transitions of care,
advanced directives, enhanced patient engagement, and others
• Participate in S&I Sponsored Webinars on the RFC – http://wiki.siframework.org/Longitudinal+Coordination+of+Care
• For more information go to: – http://www.healthit.gov/sites/default/files/hitpc_stage3_rfc_final.pdf
• To Submit a Comment: – http://www.regulations.gov
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Upcoming ASPE-Sponsored Webinars
• All Audiences Information Exchange Activities for LTPAC and BH Communities – December 4 | 12:30–1:45 p.m. ET
• Providers and Affiliated Organizations Implementing HIE in the BH Community
– December 4 | 2:30–3:45 p.m. ET Implementing HIE in the LTPAC Community – December 12 | 1–2:15 p.m. ET
• State and HIE Organizations Implementing HIE in the BH Community – December 5 | 12 Noon–1:15 p.m. ET Implementing HIE in the LTPAC Community – December 14 | 11:30–12:45 p.m. ET
To Register: https://www.ahimastore.org/ProductList.aspx?CategoryID=1324
All sessions are recorded & will be
available Web replay
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© 2012
Resources: • Assistant Secretary for Planning
and Evaluation – Health Information and Technology
Reports (http://tinyurl.com/ASPE-HIT)
• CMS EHR Incentive Program – https://www.cms.gov/Regulations-and-
Guidance/Legislation/EHRIncentivePrograms/index.html?redirect=/ehrincentiveprograms/
• Center for Medicare & Medicaid Innovation – http://www.innovations.cms.gov/
• Office of the National Coordinator – http://healthit.hhs.gov
• Substance Abuse & Mental Health Services Administration
– www.samhsa.gov – [email protected]
– Join the bi-monthly calls federal behavioral health HIT initiative
• Standards and Interoperability Framework: – Data Segmentation for Privacy
• http://wiki.siframework.org/Data+Segmentation+for+Privacy
– Longitudinal Coordination of Care
• http://wiki.siframework.org/Longitudinal+Coordination+of+Care
– Transition of Care • http://wiki.siframework.org/Transitio
ns+of+Care+%28ToC%29+Initiative 82
© 2012
QUESTIONS Thank you for attending.
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