2014-2016 Roadmap Themes: CONNECTED PATIENT

2014-2016 Roadmap Themes: CONNECTED PATIENT[WU1] /CONSUMER

The CONNECTED PATIENT objective in the Roadmap encompasses the individual whether they are a Patient of the healthcare system or a Consumer of healthcare products and services while in a state of wellness. In this Roadmap, LTPAC [WU2] providers, as well as Health Information Technology (HIT) vendors and all LTPAC service and support vendors cover a wide patient base. In LTPAC [WU3] it ranges from residents that reside in Skilled Nursing Homes (SNFs), Nursing Facilities (NF), Assisted Living Facilities (ALF) and Long Term Care Acute Hospitals (LTACs) to providers of short-term rehabilitation, Home Care and Hospice Care Agency. Throughout the spectrum of care LTPAC providers and vendors have the opportunity of connecting with the patient and assisting them with their longitudinal care. Longitudinal Care is defined as the care provided in the implementation of the patient centric Longitudinal Care Plan. The Longitudinal Plan is dynamic in that it covers the patient's health over a long period of time providing analytics, trending, alerts, and goals to assist the patient in being connected. Heretofore LTPAC was considered mainly a post acute care provider, within the new care models, where care team coordination is important, LTPAC will provide care services as required to maintain wellness or maintenance of a of a patient under chronic care. This will require many new initiatives including: educating the patient to live within his/her capabilities, setting agreed upon patient health goals, as well as striving for a higher quality of life. Currently this is being accomplished in rehabilitation and other educational and practical functional programs. Achieving the new role of LTPAC in the new healthcare system will be difficult as the current payment and quality measure systems are based on the old system. With a new strategic focus on the person and empowering the person to be involved in his/her own care, LTPAC can be a valuable member of the care coordination team.


To identify and define the role of LTPAC providers and vendors in the person-centric electronic longitudinal care and the support mechanisms that will be required in a way that encourages transparency and value.

In order for the healthcare system to undergo the paradigm shift from episodic to a predictive and then to a preventive person-centered healthcare system with a focus on improving clinical outcomes and wellness, the patient consumer and, if appropriate, their caregiver must be fully engaged and be an active participant[WU4] in their healthcare and wellness.

Key Priorities:
  1. LTPAC providers and vendors must support and advance patient engagement standards and best practices (could refer to the connected, informed, engaged sequence/scale)
  2. LTPAC vendors must keep up with current technology and provide products and services that enable providers to meet the highest clinical outcomes
  3. LTPAC HIT infrastructure must offer and support patient engagement tools (such as a patient portal, integration with PHR, telemedicine/telehealth, remote monitoring, data analytics, HIE used at Transitions of Care and instances of shared care)
  4. LTPAC providers must operationalize a longitudinal care plan that incorporates an entire extended care coordination team, including the patient/caregiver, utilizes best practices in managing patient generated health information, and is multi-dimensional addressing chronic illnesses, co-morbidities and comprehensive medication management.
  5. LTPAC providers with the assistance of vendors, provide patient centric care goals upon transition of care to their home or next care provider.[WU5]
Objectives and Strategies to Pursue:

This 2014-2016 Roadmap section is truly a long-range strategic objective. Many initiatives have to be started and completed before fully achieving the Goal. This is not a revolutionary Goal but an evolutionary Goal with time to implement as other initiatives are completed. Today providers should continue to provide high quality of care within the current provider payment system working with hospitals on patient engagement post-acute care. Understanding that when an LTPAC Provider receives a patient transfer from a hospital’s episodic short length of stay care that the MDS, OASIS, and other assessments are just the beginning of the Person Centric Electronic Longitudinal Care Plan that eventually will have to be electronically transmitted to the next care setting after care is completed in their setting. There are many initiatives under development that LTPAC providers and HIT Vendors can initiate and become involved in during the 2014-2016 strategic time frame. There are CMS and ONC pilots, grants, challenges as well as demonstrations that are open to LTPAC providers and vendors. With this stated, LTPAC providers and vendors have to begin Strategic Planning in the early 2014-2016 period.

The major Strategies and Objectives to pursue are:
  1. Involvement of LTPAC Providers and Vendors In Patient Engagement: Identify the role of LTPAC Providers and Vendor Services in the Engagement of the Patient in person centric electronic longitudinal care model.
    1. Support Connect Patient Programs: Providers and Vendors should support existing resources/research as well as initiate their own programs as long as they adhere to approved standards of interoperability of care, quality, and secure privacy.
    2. Connected Patient Resources: Since the paradigm shift from episodic care to person centric electronic longitudinal care there are many organizations that have initiated programs that provide background information, tools, strategic direction in support of the Connected Patient. To mention a few Organizations: AHIMA Practice Briefs, ONC Policy and Standards Committee Patient Engagement Workgroup, ONC HITECH Act Meaningful Use Criteria, and HIMSS Patient and Family Care Center.
    3. Alignment: Align with other care settings in Transitions of Care interoperability standards to remain contiguous
    4. Care Plan Involvement: Ensure that the patient is involved with their own care plan and that they approve and agree to set personal goals of care.
  2. LTPAC Provider Clinical Health Information Technology (HIT) Infrastructure: Providers and HIT Vendors should be working together during this strategic period to develop and implement a Strategic Clinical Technology infrastructure based on the role they have determined they will play in the new healthcare system of Person Centric Electronic Longitudinal Care and payment models
    1. Patient Centric Tools: Delineate, integrate, and utilize patient Blue Button, patient portals, personal health information technology (PHIT) devices, telehealth, and other technologies to involve the patient in their own healthcare plan and care goals
    2. Health information Technology (HIT): Identification of technology (hardware/software) that meets the patient’s and patient’s care team agreed upon the electronic longitudinal care record requirements
    3. Dynamic Trending Histograms: The Person Centric electronic longitudinal care plan has to provide the patient and care coordination team with dynamic clinical support software. The clinical support software has to allow both the aggregation and trending of clinical information so the patient benefits from these predictive analytic tools and can prepare for enhanced preventive care coordination with improved clinical outcomes and quality of life
    4. Clinical Communication Capability: Within the care coordination system there has to be devices that provide information on preventive, monitoring, and clinical alert care. For example: Telehealth, Telemedicine, Sensors, etc. Mobile apps with reminders for patients, remote monitoring
    5. Electronic Health Record: Establish patient centric longitudinal care by upgrading their facility's electronic medical record to the newer applications that have the MDS and OASIS as a by-product and not as the primary outcome.
  3. Person Centric Electronic Longitudinal Care Coordination: Develop and implement a patient centric electronic longitudinal health plan that is interoperable with a person's care coordination care team, is accessible to the patient, provides care goals and is based on approved standards.
    1. Patient Engagement: Focus on patients/caregivers involvement in care plan, ensure that patient's goals are reflected in care plan
    2. Chronic Care, Co-Morbidities, and Comprehensive Medication Management: In order to achieve the Goal, thinking of healthcare in one disease dimension has to be replaced by 4 Dimension Care. The care dimensions being: Multi-disease (Chronic Disease not a Singular Disease State), Time (Longitudinal Care over a lifetime), Cost (The true and productive cost of quality of care and quality of life), and Care Coordination Team (Patient, Primary Care Physician, in addition to required support services and professionals.
    3. Clinical Technology: All patient centric technology has to be aggregated and in harmony with standards and security. This is important as more consumer software apps are developed, in harmony, and marketed to the patient and available to the care coordination team so as to avoid conflicts in care and mutually agreed upon care goals
    4. Education: Due to the fact that patient engagement is a paradigm shift from episodic physician directed care the education and understanding of the patient and the patient’s caregiver on their care responsibilities is mandatory. As an example, care training similar to the training provided to Certified Nursing Assistants could be rewritten to train patient’s and their family and caregivers.
    5. Nomenclature and Vocabulary: To involve the patient and caregiver and have them take responsibility of care goals the communications have to be in a language that they understand and can communicate with their care coordination team. They have to have access to their electronic care record and communicate to be involved.
Next Steps:

For Provider Community: To assess their current health information technology (HIT) infrastructure as it pertains to providing patient centric electronic longitudinal care in accordance with an electronic medical record within current technology and best practices taking into consideration the direction of clinical technology and the transitions of care between providers of the patient’s care team.

For Vendor Community: Understand, participate, and adhere to the standards of patient centric longitudinal care for the clients they serve and the interoperability of transitions of care between members of the care coordination team as well as developing a visionary roadmap for the evolving healthcare system.
For Policy Makers: Understand that there are more providers in the spectrum of care within the care coordination team besides HITECH Act eligible hospitals and eligible professionals and that all members require understanding of their roles in person centric care and financial assistance to upgrade their HIT that was imposed on them by Legislation, Meaningful Use, and interoperability between members of the healthcare community and the patient. In order to have continuity of care patient Assessments and eQuality Measurements have to be in harmony across the spectrum of care within approved standards including standards for patient engagement.
For Patient/Consumer:

[WU1]In exec summary could disuss when is a person considered a patient, consumer, resident, etc.
[WU2]Should we continue to limit our focus to LTPAC or expand to include LTSS. Many policy docs are coming out that are focusing on LTSS

Is there an umbrella term? Is it LTSS?
- CMS definition includes NH and HCBS (not LTACs, rehab hospitals, etc)
[WU3]Consider the discussion and whether the settings can go to the exec summary. Add to the highlighted sentence, including other “long term services and supports”
Remove reference to setting and use more inclusive words such as spectrum.
[WU4]There is a scale – starts with being connected, and then informed, and then fully engaged.

Recognize the patient’s priorities for their care, interventions and outcomes. (Such as a term extended care team)
[WU5]This is the vendor support for #4; 4 should span settings and provider types and services and supports