Series 1: “Meaningful Use” for Behavioral Health Providers

PowerPoint Presentation

Series 1: Meaningful Use for Behavioral Health Providers9/2013From the CIHS Video Series Ten Minutes at a Time

Module 9: A Closer Look at Exchanging the Continuity of Care Record (CCR) and Clinical Summary

Welcome to the SAMHSA-HRSA Center for Integrated Health Solutions video series Ten Minutes at a Time. This information on how to meet the standards for Meaningful Use and how to select and successfully implement an electronic health record system is organized into brief, convenient modules targeted to Behavioral Health providers. This is Series 1: Meaningful Use for Behavioral Health Providers Module 9, A Closer Look at Exchanging the Continuity of Care Record and Clinical Summary. The goal of this module is to provide a frame of reference that supports both the integration of care and the standard for Meaningful Use through the exchange of patient information.1OverviewNational data and technology standards for exchanging informationWhat information is shared When it is sharedHow it is shared (HIPAA compliant, 42 CFR Part 2 compliant)Who it is shared with

Developing health information exchange processes and procedures the Referral Loop

We will take this opportunity to show examples of the Clinical Summary and the Continuity of Care Record, review the minimum requirements in place for populating the data sets, and explain when and how these data are used in communication. Note that sharing of patient information must follow all of state and federal rules and regulations concerning the confidentiality, privacy and security of this information. But also keep in mind that these rules and regulations are not obstacles rather, they provide a clear path to sharing key patient information using policies and procedures that support the quality, effectiveness and efficiency of care.

2Behavioral Health Role in PBHCI

Jeffrey - 33 year old male, presents at Stepping Stones BH Center

Patient psychiatric and medical conditions need to be stabilized

BH screens and admits, develops psychosocial summary, collects information on Active Medications, enters initial diagnosis, preliminary treatment plan

Referral to psychiatrist generates psychiatric medicationsReferral to PCP to address physical health issues, initiate engagement in Wellness Activities (warm transfer)

BH primary ensures the patient is adequately supported in attending appointments, conducts follow up on referrals outcomes and ensures any additional support

This is a summary and initial plan from the Behavioral Health provider perspective. The patient walked into the Behavioral Health provider looking for assistance. The Behavioral Health provider followed existing policies and procedures for conducting the screening, assessment and evaluation, which includes asking the patient if they have a physician. The patient did not, and is eligible for the PBHCI initiative. He will receive a referral to the Primary Care Partner. But the first order of business is for the patient to receive stabilizing psychiatric medications and to set up a routine of therapy and medications management. 3Primary Health Role in PBHCI

Jeffrey - 33 year old male, presents at the Community Cares FQHC, referred by Behavioral Health partner Nurse Care Manager conducts health screenings, collects vital signsPrimary Care Provider refers to patient data collected by nurse AND to patient data from the referral source, conducts physical exam Orders diagnostic tests, places medications orders and makes referrals for specialty carePatient engaged in Wellness activitiesBH Provider routinely receives information on outcome and Wellness Plan, plays supporting role in patient medications compliance, participation in Wellness as part of treatment plan

The patient presents for their appointment at the primary care provider location, receiving whatever supportive services are required to ensure follow through. They are seen by the physician who conducts an exam, then creates orders and referrals. After this appointment, the patient meets with the Wellness Educator (or coordinator) who initiates engagement with the patient. In this scenario, there is a need for referral and also for follow up information, as well as a need to communicate with the patient. Lets start with reviewing the Meaningful Use data sets intended for this purpose.4Continuity of Care Document / Continuity of Care Record (CCR/CCD) Minimum Data Set

1) Allergies and other adverse reactions2) Medications (including current meds) a. Admission medications history b. Hospital Discharge Medications (hospital) c. IV Fluids administered (hospital) d. Medications administered3) The problem list (diagnoses) a. Active problems b. History of past illness c. Hospital Admission Diagnosis (hospital) d. ED diagnosis (hospital) e. Discharge diagnosis4) List of surgeries (if hospital)5) Diagnostic results (i.e., labs, imaging, etc.)

Originating Entity InformationPatient Informationhttp://www.healthit.gov/providers-professionals/achieve-meaningful-use/menu-measures/transition-of-care

The CCR/CCD was mentioned in Module 3. To meet the minimum standard for ambulatory care, it must contain a minimum data set. In this slide the grayed-out text applies to in-patient hospital settings. For ambulatory treatment settings it must include the Medications Allergy List, Active Medications List, the Problem (or Diagnosis) List, and Diagnostic Test Results such as clinical lab results. The originating entity information and the patient information are also included. This should look familiar the minimum data set is cited in several Core and Menu Objectives.5http://www.corepointhealth.com/sites/default/files/whitepapers/understanding-the-continuity-of-care-record-ccr.pdf CCR/CCD May Also Contain

Vital signsInsurance informationHealth care providersEncounter informationProceduresNecessary medical equipmentSocial historyFamily historyCare plan

The CCR can include additional information including vital signs, social history, family history and so on. It can be used for transitions of patient care from one setting to another, and also for referrals. In the past, this information did not follow the patient to another provider, so it was not available to inform patient care. Now the data can be transmitted and received as part of an operationalized workflow. 6Everything in the minimum CCR/CCD data set PLUSImmunizations or medications administered during visit topics covered/considered during the visit things to do before the patient leaves the building when next appointment is recommended other appointments/testing patient needs to schedule patient decision aids recommended appointments/testing already scheduled test results symptoms personalized instructions/notes considerations (i.e., timing of meds with work/school schedule) health information related to topics discussed

Clinical Summaryhttp://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/downloads/13_Clinical_Summaries.pdf

The Clinical Summary was also reviewed in Module 3. This is also called an after-visit summary. Most of us have received something like this at the conclusion of a medical appointment. It contains all pertinent patient information that is generated from the patient office visit.7Clinical Summary

Full Clinical Summary is given to the patient at end of visitCan also be used to follow up with referring entities HRSA Guidelines for engaging patients and family can be helpful in conceptualizing information exchange

http://www.hrsa.gov/healthit/toolbox/HealthITAdoptiontoolbox/MeaningfulUse/intro2meaningfuluseandpatientandfamily.html

The standard data set does not change regardless of the type of provider. The Behavioral Health data would include the patient demographics, the presenting problem or reason for the visit, any active medications, a brief summary of assessment results and the plan for care. In the example case, the patient referrals would be included, with locations and appointment times and dates. To ensure that the patient attends the primary care provider referral, the Behavioral Health professional may enlist the support of a peer support specialist, family or friends. 8How is Critical Information Shared? State or Regional Health Information Exchange http://www.healthit.gov/providers-professionals/health-information-exchange/getting-started-hie

Nationwide Health Information Network Direct http://wiki.directproject.org/User+Stories Simple, secure, scalable (a type of email system)Point-to-point transmission / receipt on network of verified providers Supports policies and procedures that ensure adherence to HIPAA and 42 CFR Part 2More info http://nwhin.siframework.org/Direct+Project+Basics

The CCR/CCD and Clinical Summary can be transmitted over the Internet via state or regional Health Information Exchange (HIE), or generated as a .pdf or image file and exchanged using Nationwide Health Information Direct. This is discussed in Module 8. The .pdf file is encrypted using open source software (7ZIP), and attached to a message transmitted and received over a secure email system. The NwHIN Direct procedures and protocols allow point-to-point secure transmission of patient information over a network of providers. Everyone on the network applies for an email address and is certified as an authentic system user. This allows Behavioral Health providers who are not yet allowed to participate in state HIE to meet the standards for exchanging patient information under Meaningful Use and also remain in compliance with HIPAA. Since patient consents can also be transmitted and received in this system, the patient consent can precede the data exchange, ensuring compliance with 42 CFR Part 2.

State or Regional Health Information Exchange http://www.healthit.gov/providers-professionals/health-information-exchange/getting-started-hie Nationwide Health Information Network Direct http://wiki.directproject.org/User+Stories http://nwhin.siframework.org/Direct+Project+Basics 9Integrated Care Referral Loop Scenario1. Transmit CCR/CCD data to PCP, via NwHIN Direct / or other means2. Patient receives Clinical Summary from BH, and social support is engaged3. PCP integrates BH data into patient record. Low no-show rate due to warm transfer and use of social support 5. BH also receives PCP Clinical Summary, plays ongoing supportive role in patient care4. Results and referrals from PCP visit are in the Clinical Summary that the patient receives at the end of the visit.

In our scenario, the Behavioral Health provider can use the CCR/CCD data set to facilitate the referral to the primary care provider. The patient receives a Clinical Summary from the Behavioral Health visit that includes the referral information. Please note that in the PBHCI project, a warm transfer is the preferred method in the referral to primary care. Even if it is just an opportunity to show the patient around and introduce them to a few staff, it is essential to engaging the patient in care. The patients families, friends or a peer support specialist should be part of the behavioral health treatment plan and their help can be enlisted, too. The nurse care manager is often the individual that the patient connects with first, and becomes the ongoing point of contact in patient engagement. At the end of the visit, the patient receives the Clinical Summary from the PCP, and a copy of this is also sent to the Behavioral Health provider, who integrates the information with the patients record in the EHR, especially any information about new prescriptions, or recommendations for Wellness activities. 10SummaryExchange of patient information is the new normal in health care. Adoption of EHRs and implementation of Meaningful Use is happening all over the country.

The data and technology standards are well-established and thoroughly endorsed by a host of federal and international agencies. There is no question that Meaningful Use will continue to evolve and expand over time.

Behavioral health providers can and should participate in Meaningful Use and the exchange of patient information. It is possible to do so while remaining in full compliance with applicable federal and state regulations.

So, here are the important things to keep in mind. Patient information must follow the patient whenever there is a transition of care or referral. The Continuity of Care Record (CCR/CCD) and the Clinical Summary represent the data and technology standards for this. Behavioral Health providers can exchange patient information in compliance with all standards and regulations using either the State or Regional Health Information Exchange, the Nationwide Health Information system called Direct or a combination of both. Integration of primary and behavioral healthcare is essential to the overall health of those with serious mental illness so these methods of communication should be used to support both the grant requirements for Meaningful Use and the PBHCI initiative integration efforts. 11We Have Solutions for Integrating Primary and Behavioral Healthcare

Contact CIHS for all types of primary and behavioral health care integration technical assistance and training needs

1701 K Street NW, Ste 400 Washington DC 20006

Web: www.integration.samhsa.govEmail:[email protected]:202-684-7457

Prepared and presented by Colleen ODonnell, MSW, PMP, CHTS-IM for the Center for Integrated Health Solutions

Our thanks go to SAMHSA and to HRSA for providing support to the Center for Integrated Health Solutions (CIHS) for this and many other forms of training and technical assistance related to the integration of primary and behavioral health care. Please visit our web site at www.integration.samhsa.gov, email us at [email protected], or just pick up the phone and give us a call at 202-684-7457.

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