Connected+Partners


 * 2014-2016 Road Map Themes: CONNECTED PARTNERS**


 * Goal: ** Active participation by the LTPAC provider community in the exchange of electronic, interoperable health information to facilitate care coordination, improve care transitions and improve person-centric care.

**Rationale:** LTPAC providers are essential partners in the overall health and social supports eco-systems and touch older adults during the periods between acute care services (i.e., hospitalization). Coordination between the LTPAC community, acute and ambulatory providers, behavioral health and ancillary service providers is key to achieving the CMS Triple Aim of improving care quality, supporting population health and reducing cost. Exchanging key health information such as updated medication lists, allergy list, problem list, summaries of care and assessments, care plans and care recipient’s preferences are key to enabling shared care planning and care coordination, and allow the formation of true collaborative virtual care teams. The formation of such virtual care teams is essential in the emergence of performance driven care models including ACOs, bundled payment models and managed long-term care.

** Key Priorities: **
 * 1) Engaging LTPAC providers in information exchange supported by use of vocabulary, data content, and transport interoperability standards (that are secure)
 * 2) Security standards could be included
 * 3) Not only do we need to engage LTPAC, ,but also need to engage the physicians and hospitals on meaningful exchange beyond the MU requirements
 * 4) //__ Engaging partners in meaningful, timely exchange beyond the limited information around MU, but around the valuable information each partner needs to provide optimal care. __//
 * 5) //__ Many hospitals not using CDA; didn’t have a CCD ready for the patient until 3 days after discharge; timing is off; __//
 * 6) Timely and interoperability is not well defined
 * 7) Supporting person-centric longitudinal care
 * 8) Notes: Express formally the desire to pull in the broad spectrum of the care team – friends family, nutrition, spiritual care, massage therapist
 * 9) Address security measures and in bringing in the broader scope need to communicate securely;
 * 10) Harmonizing quality measures across the spectrum of care // (also in health intelligence) //
 * 11) __ ACO Measures __

Other Notes; - Education on accessing the HIE, when to use - ACO agreements are emerging more about accountability; the industry would be served well by defining standard sets of measures and reporting for ACOs. - Need to coordinate with hospital on their discharge workflows in addition to the information to exchange
 * With an ACO agreement that mandates exchanges – often targeted specifically for hospital to get MU dollars –it is direct or HIE link; not seeing the seamless exchange of information the way we envision

** Objectives and Strategies to Pursue: **
 * LTPAC providers should implement technology that enables interoperable information exchange and engage in health information exchange (HIE) across the spectrum of health care, services and supports providers in order to promote and support person-centric longitudinal care
 * Acquire technology that supports use of recognized vocabulary, data content, and transport standards
 * Engage provider organization clinicians/physicians in negotiations/decisions regarding information to be sent and received between the LTPAC provider and their information exchange partners
 * Engage in state HIE
 * Engage in regional HIE if unable to participate in state HIE
 * Engage in ad hoc direct one-to-one HIE (e.g., local system, provider-to-provider exchange) if unable to participate in state or regional HIE
 * LTPAC providers should implement practices that support person-centric longitudinal care, including:
 * Shared care planning across internal and external health care, services and supports providers
 * Care coordination across internal and external health care, services and supports providers
 * Capture and exchange of advance directives (especially at transitions of care)
 * Chronic disease management, including integration of telehealth, home and personal monitoring devices
 * Support comprehensive and effective medication management, including electronic exchange and reconciliation of medication, allergy, and problem list at transitions of care
 * Capture and exchange social determinants of health as identified by IOM


 * ** Socio-demographic Factors ** ||  ** Psychological Factors **  ||  ** Behavioral Factors **  ||
 * * __ Gender & __ Sexual orientation
 * Race/ethnicity
 * Country of origin/U.S. born or non–U.S. born
 * Education
 * Employment
 * Financial resource strain: Food and housing insecurity
 * __ Religion __
 * Health literacy
 * Stress
 * Negative mood and affect:
 * Depression and anxiety
 * Psychological assets: Conscientiousness, patient engagement/ activation, optimism, and self efficacy
 * Dietary patterns
 * Physical activity
 * Nicotine use and exposure
 * Alcohol use ||  ||   ||
 * Source: //IOM, April 2014, Capturing Social and Behavioral Domains in Electronic Health Records// [] ||


 * Exchange care plans and care recipient’s preferences, including advance directives.
 * Engage in/promote efforts to harmonize quality measures across the spectrum of care

Notes: - Need to address education on when to access, how to access HIE, also the security features. - //__ Do we need an interoperability framework to measure levels – similar to HIMSS levels, but applicable to LTPAC? __// - //__ How do we build in the ONC Road Map? __// - Getting two kinds of integration requests – direct or integration with HIE requests; Hospitals are sending things to direct, but not caring if the NH is looking at the information - Discussing the real dollars - Script standard doesn’t cover LTC – disconnected processes; have the standards and vocabularies - needed for every data element (e.g how to embed snomed into entire system. - Address data provinence – it will be the next big issues that will need to be addressed. Infrastructure is beginning
 * What is the road map to move the cheese because there is zero incentive for hospitals to do even more
 * HIE is primarily to satisfy the MU measures
 * Need guidance to the EMR vendor – what do you do with the direct message? How can guidelines be developed on what can be taken and embedded
 * Med reconciliation with x data
 * What is done with x data
 * Providers need to map from RxNorm, Loinc, etc. to the data that they are using in their operations. Until they do that we won’t have interoperability
 * How to codifying the data elements under transition of care that drives the handoff; can tech standard be used to drive the transitions of care standards.

** Next Steps: **

**// For Provider Community: //**
 * Encourage vendors to support interoperability standards in their products and to seek voluntary certification (see ONC HIT Policy Committee Certification and Adoption recommendations for voluntary EHR certification by Long Term Care (LTC) and the ONC [|Certification Guidance for EHR Technology Developers Serving Health Care Providers Ineligible for Medicare and Medicaid EHR Incentive Payments] )
 * Upgrade to systems that support the exchange of interoperable health information
 * Identify opportunities and partners for health information exchange and actively engage in HIE across the spectrum of providers of healthcare, services, and supports.
 * If provider does not have an EHR, seek products from vendors that implement interoperability standards, support HIE and pursue certification, including the voluntary LTPAC EHR certification.


 * // For Vendor Community: //**
 * LTPAC EHR vendors must pursue the implementation of interoperability standards and certification, including the ONC [|Certification Guidance for EHR Technology Developers Serving Health Care Providers Ineligible for Medicare and Medicaid EHR Incentive Payments] and adoption of voluntary certification expected to be proposed by ONC for LTPAC and Behavioral Health in 2015
 * Implement the C-CDA IG and key interoperability standards (including the Clinical notes)
 * Compile listing of specific standards that are key priorities
 * Support medication management in general, particularly reconciliation


 * // For Policy Makers //**
 * Continue to support development, implementation and adoption of standards and certification programs that are relevant to LTPAC settings.
 * Support the identification of quality measures that are meaningful for LTPAC and vulnerable populations, particularly related to care coordination, the e-specification of such measures, and the adoption of such measures across the care continuum including by hospitals, physicians, and LTPAC providers.
 * Incorporate the e-specified quality measures in EHR certification criteria.
 * Consider grants, low interest loans and financial incentives to smaller, unaffiliated and rural providers who are less likely to have the resources and the partnership opportunities to support their health IT and quality improvement initiatives.
 * Provide technical assistance to support the acquisition, implementation and use of health IT, HIE and the use of these technologies in emerging service delivery and payment models.


 * Notes: **