Enabling Strong Health Systems – LTPAC Partnerships with Innovative Approaches and Technologies LeadingAge NY 2017 Annual Meeting May 23, 2017 • Al Kinel: President Strategic Interests • Mark Klyczek: VP, Long Term Care Division Rochester Regional Health • Travis Masonis: CIO Jewish Senior Life • Elizabeth Amato: Director, Statewide Services NYeC
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Enabling Strong Health Systems – LTPAC Partnerships
with Innovative Approaches and Technologies
LeadingAge NY 2017 Annual Meeting
May 23, 2017
• Al Kinel: President Strategic Interests
• Mark Klyczek: VP, Long Term Care Division Rochester Regional Health
• Travis Masonis: CIO Jewish Senior Life
• Elizabeth Amato: Director, Statewide Services NYeC
Agenda
IT Enablers Impacting LTPAC
Perspectives of Health Systems
Perspectives of LTPAC Partners
Enhancing Transitions of Care with RHIOs & SHIN-NY
Discussion: Enabling Health Systems & LTPAC to Partner
LTPAC IT Application Assessment
Application Module Score
Administrative ERP
Billing / Coding / MDS
HR / Staffing / Payroll
Managed Care / Analytics
Automated Admit / Doc Mgmt
Clinical Orders
Documentation
Meds Management / eRx
Interoperability In
Interoperability Out
Wellness
Disease Management
Population Health / Rounding
Application Module Score
Telehealth Behavioral Health
Post-Acute Consult/Monitor
Virtual Consultation
Facilities Safety & Security
Business Continuity
Concierge
Point of Sale
Analytics Management Dashboards
Value-Based Payment / Pricing
Readmission Management
Marketing CRM / Admissions
Donor Management
Volunteer Management
Enhancing Hospital-LTPAC Partnership with IT
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Process Technologies
Discharge Planning Care Management Tool - Creation of Care Plan
Risk Profile Scoring Tool
Referral Admin Process Discharge-Referral Process
LTC Admit Process
Metrics Reporting
Exchange Clinical Data Key Data from Hospital EMR in C-CDA
Transport Data (RHIO, DIRECT, Other)
Ability to Load Key Data in LTC EMR
Manage Patients at Risk Population Health
Dashboard & Rounding Tool with Alerts & Gaps
Telehealth: Surgeon, Care Team, Behavioral Health
LTC Discharge Process Key Data from LTC EMR in C-CDA
Transport Data (RHIO, DIRECT, Other)
Ability to Load Key Data in Home Health/PCP EMR
Transition
Of
Care
Transition
Of
Care
Hospital(s) Home Care / PGHD
Non-PCP Specialist
Urgent Care
CBOs / Social
Services
Labs, Rads, Geneticists
Behavioral Health
Disabilities
PT/OT
Community - PCMH
Transitions of CareWhere Information Gaps Appear & Compromise Care
SNF
Assisted Living
Inpatient Rehab
LTPAC
Health Home
PCP / FQHC
• Use Case 1:
– HOSPITAL to HOME
• Use Case 2:
– HOSPITAL to LTPAC
• Use Case 3:
– LTPAC to HOME
• Use Case 4:
– PCMH – PCP to Other
• Use Case 5:
– HOME to HOSPITAL
• Use Case 6:
– LTPAC to HOSPITAL
• Use Case 7:
– HOSPITAL to HOSPITAL
• Use Case 8:
– HOME to LTPAC
• Use Case 9:
– PROVIDER to BH/CBOs
• Use Case 10:
– Specialist to Specialist
Key Transitions
Improving LTPAC Transitions of Care (ToC)
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Hospitals & LTC partners can jointly improve ToC effectiveness by reviewing
areas on both sides to change discharge planning, admit process & HIE:
• Improve Hospital-LTC ToC: discharge/admit Screening and discharge efficiently getting patients to right facility
Process & tools to provide LTC data needed to receive patient
• Collaborate After ToC: address patients & risks together Process, tools, and alignment to identify patients at risk, gaps in care, actions to address
them and means for team to communicate
• Improve LTC-Home ToC: discharge/admit Discharge efficiently to home health agency, PCP, or both
Process and tools to provide data and alert hospital
Keys for Successful ToCs – More than HIE
Right information, right time, right format…without extra noise
Comprehensive Care Coordination, Health Coaching and PCMH Model
Medication Management
Effective Hand-offs to Providers and Social Workers
Timely Post Discharge Follow-up
Self-Management Care Plans with Patient Education and Clear Follow-up
Identify and Provide Resources for Social Determinants of Care
High Patient Satisfaction (correlated with lower 30 day readmit rates)
Sources:• Project BOOST (Better Outcomes by Optimizing Safe Transitions) – www.hospitalmedicine.org• Care Transitions Interventions (CTI) –www.caretransitions.org• CMS Community-Based Care Transitions Program (CCTP) – www.innovations.cms.gov/initiatives/CCTP/• Guided Care Comprehensive Primary Care for Complex Patients – www.guidedcare.org• Project RED (Re-Engineered Discharge) – www.bu.edu• State Action on Avoidable Rehospitalizations (STAAR) – www.ihi.org
1100 Employees including Therapy Department & Medical Staff
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Referral Tracking
• Internal database measures– Response time
– Acceptance rates
– Referral patterns
– Diagnosis Classes
– Reason for bed denial
– Reason for bed refusal (by patient), where possible
• Curaspan– Similar metrics noted above
Understanding, managing, and improving LTPAC performance as a partner receiving referrals
Referral Tracking
• Allows JSL to understand mathematically the shifts and trends in referral types:– Dx classes
– hard to place patients
– etc.
• More information = Better partnerships
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Readmission Reduction Tools/Analytics
• PointClickCare EMR
• eINTERACT
• Telemedicine (URMC Cardiac)
• Practitioner Engagement Mobile App for providers– Providers have more information at their
fingertips from the mobile device after hours
Readmission Management Process
Quality Management Team:• Track patient/resident transfers to ED using version of
INTERACT’s Hospitalization Rate Tracking Tool
• Monthly analysis to calculate readmission rate & ID trends– Total readmission rate
– By payor, key diagnosis, hospital admitted from, etc.
– Transfer by day of week, shift, provider, etc.
• Monthly/Quarterly summary reports to management & QAPI Committee
• Quarterly update to organization’s KPI dashboard to Senior Management and Board
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Readmission Management Process
QAPI Hospital Transfer/Readmission Work Teams
• 1 for LTC & 1 for TCP
• Meet monthly to review transfer data
• Identify trends, problems, root cause of transfer– Identify contributing factors – clinical & non-clinical
• Determine/develop action items for improvement – Education/training
– Process improvement
Cost Accounting
• Measures activity based costs for the patient profiles. Includes cost information pertaining to:– Diagnoses (primary and co-morbidities)
– Demographics (age, gender, etc.)
– Payor type
– Ancillary Charges
– Therapy Minutes
– Physician Visits
– LOS
• Shows value to referring hospital partners; not only demonstrates improving quality, but also reducing and controlling costs– You can’t improve what you aren’t measuring
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Using EMR To Improve ToC
• Integration with RHIO– RHIO to PCC
• Lab
• Radiology
• CCD/CDA
– Perhaps ToC specific documents
– PCC to RHIO to make available to Hospital, Surgeon, Home Health
• ADT
• CCD/CDA
• Discrete data capture via clinical documentation enhance reporting and readmission prevention
Future Opportunities
• Telemedicine
• Advanced Data Sharing– Targeted ToC documents, CCD/CDA
consumption, global readmission risk alerting
• Predictive Analytics
• Biomedical/Telemetry Alerts for Readmission Risks
Statewide Health Information Network for NY (SHIN‐NY)
Elizabeth Amato
Senior Director, Statewide Services
New York eHealth Collaborative
• A secure network for sharing electronic clinical records
• The SHIN‐NY consists of the eight Regional Health
Information Organizations (RHIOs) aka QEs
• Records are accessed and exchanged securely between healthcare providers with appropriate consent
• Patients decide which entities can access or see their records
• Efficient access to clinical records helps providers better manage patient care
• The SHIN‐NY can help reduce healthcare costs, improve healthcare coordination, and increase the quality of care for patients in New York State
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The SHIN‐NY in a Nutshell
State Department of Health
•Oversees SHIN‐NY through contracts and funding of NYeC and QEs
•Additional regulatory oversight as part of new SHIN‐NY Regulation – adopted and released March 9, 2016
Qualified Entities (QEs)
•8 QEs each governed by a board of up to 20 people
•Broad participation by local stakeholders, including providers, employers and community advocates
NYeC
•State Designated Entity to coordinate activities of the SHIN‐NY. Governing Board consists of 18 people from across healthcare industry and across New York State.
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Regional Health Information Organizations (RHIOs) or Qualified Entities (QEs)
• A QE, or RHIO, is a local hub where a region’s electronic
health information is stored and shared.
• The eight QEs in New York State cover different areas
from Buffalo to New York City with more overlap in the
more densely populated downstate area.
• These QEs are the backbone of the SHIN‐NY, providing
the services that make secure, vital access to a
patient’s health information possible statewide.
• While QEs are primarily established within geographical
regions (Upstate more so than downstate), healthcare
organizations may connect with the QE that best aligns
with their business, operational, and service delivery
needs, regardless of county catchment areas.
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• To continue advancing the SHIN‐NY, on March 9, 2016 NYS Department of Health codified the SHIN‐NY Regulation (Addition of Part 300 to Title 10 NYCRR (Statewide Health Information Network for New York (SHIN‐NY))
• Pursuant to the Regulation:• Article 28 Hospitals are to have begun participating in and contributing data to the SHIN‐NY by March 9, 2017
• The following entities* are to participate and contribute data to the SHIN‐NY by March 9, 2018:
• Article 28 nursing homes and diagnostic treatment centers • Article 36 certified home health care agencies, long term home health care programs • Article 40 hospices*if using a Certified EHR
Full Text of the Regulation: https://regs.health.ny.gov/sites/default/files/pdf/recently_adopted_regulations/2016‐03‐09_shin_ny.pdf
SHIN‐NY Regulation
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QE
Clinicians
How does a QE connect providers today?
KEY
= Transmission of Clinical Patient Information
Home Care AgencyCommunity Hospital
Medical Center
Reference Laboratory
Nursing Home
Primary Doctor’s Office
Since March 2015, all RHIOs must provide the following Core Services to Participants
1. Statewide Patient Record Lookup
2. Statewide Secure Messaging (Direct)
3. Notifications (Alerts / Subscribe and Notify)
4. Provider & Public Health Clinical Viewers
5. Consent Management
6. Identity Management and Security
7. Public Health Reporting Integration
8. Lab Results Delivery
The SHIN‐NY Core Services
No charge for these services beyond initial setup
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Who Is Connected and What Data Is Available?
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Who is hooked up to the SHIN‐NY?
All data above as of March 18, 2017 …. Data continuously being updated, improved, & refined
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97% 98%
81%
55%
47%
57%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
FQHCs Hospitals Public Health Dept LTC Facilities Home Care Agencies Physicians
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Types of information that may be available in the SHIN‐NY
Diagnoses Microbiology Reports Social/Family History
Allergies Other Transcribed Reports OB/GYN/Resp/Card Reports
Contacts/Next of Kin Prescribed Medications Discharge Summary
Insurance Medications Advanced Directives
Radiology Reports Medication History Clinician Information
Lab Test Reports Medication Allergies Care Plan
Microbiology Results Vital Signs/Observations ACO/Health Home Status
Clinical Data Available in the SHIN‐NY
The Value of the SHIN‐NY and How to Get Connected
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How HIE Can Support Healthcare Initiatives
Access to clinical data has widespread benefits to healthcare:• Statewide Clinical Event Notifications (Alerts)• DSRIP (collaborative care, reducing avoidable admissions)• Care Coordination initiatives• Population Health, Analytics• Care Plan Exchange• Meaningful Use (for hospitals and providers)• Patient Engagement (e.g. Patient Portals)• Patient Centered Medical Home (PCMH)• Quality Reporting (PQRS)• Payers (Quality Reporting, HEDIS, QARR, Care Management)
SHIN-NY Value Studies, Whitepapers, Videos and other Resources: http://www.nyehealth.org/shin-ny/value-of-hie/
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$13,000 per organization in funding is available for eligible LTPAC providers to connect to their QE and exchange clinical data
1. Contact your QE to understand appropriate services for your organization
2. Sign a data sharing/Participation agreement
3. Sign up for Clinical Viewer/Portal to search patients and their clinical data through the web
4. Explore the use of DIRECT secure messaging
5. Enroll in Alerts (admit, discharge, transfer for inpatient and ED settings)
6. Plan for bi‐directional exchange between your EHR and the QE a) Send clinical data to the QEb) Receive data automatically into your EHR (e.g. TOC, labs, alerts)
7. Check opportunities for funding through DSRIP, DEIP, or others
8. Work with your referral sources to determine workflow and content to improve TOCs
How to Get Connected to the SHIN‐NY – Where to Start
To find the QE in your region and obtain contact info, visit http://www.nyehealth.org/shin‐ny/qualified‐entities/
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40 Worth Street, 5th Floor New York, New York 1001380 South Swan Street, 29th Floor Albany, New York 12210