Transcript IMPACT: High Level Process Flow

Preliminary Findings From IMPACT
(Improving Massachusetts Post Acute Care Transitions)
Leveraging IMPACT to Accelerate
S&I Framework’s LTPAC WG
October 12, 2011
Larry Garber, MD
PI/Informatics
Terry O’Malley, MD
Metrics
Dawn Heisey-Grove, Project Manager
Proposed Modifications to the
LTPAC Roadmap
• Define LTPAC more broadly
• Include in the Relevant Scenarios
information exchange to and from Acute
Care Hospitals to and from LTPAC sites
• Identify high priority transitions
• Determine transition-specific data
elements
• Modify high level process flow
Summary
• We have implemented a survey process
resulting in a draft data set of 300 elements
identified as “required” by one or more
“receivers” in 39 priority LTPAC transitions.
• This same process can be used to further refine
the core data set for LTPAC and help leverage
the reuse of currently available electronic data in
MDS and OASIS
Draft LTPAC Data Set
• The next eight slides contain the data
elements.
• Headers are in light blue.
• Red elements need further consideration
• Elements at the end are duplicates
The slides that follow explain our approach
to prioritizing transitions and the results of
the survey
Data Set: Slide 1 of 8
DATA ELEMENTS
Date of Transfer
Demographic information- Patient
Last name, First name, Middle Initial
Date of birth
Next of Kin
Address
Phone
Gender
Marital Status
Religion
Race
Ethnicity
Primary Language: English Y/N
Primary Language if not English_______
Links to patient or other computer applications for patient results, summaries, etc.
Email of Patient
Contact Name, Contact Number
Last name, First name, Middle Initial
Telephone
Relationship (relative, guardian, durable power of attorney)
Is this the health care proxy?
If health care proxy is different: Name, Telephone
Has health care proxy been invoked? Y/N
Insurance Name, Phone #, Group #, Type, Member #, Subscriber Name, Financial responsibility
Insurance Name
Insurance Phone #
Insurance Group #
Insurance Type
Member #
Subscriber Name
Financial responsibility
Data Set: Slide 2 of 8
Origin of Transfer (Sent From)
Name of Sending Site
Role/Title of individual providing transfer information
Address of "Sending" site
Phone number of "Sending" site
Type (HHA, SNF, etc)
Date patient first arrived at the "Sending" site
Where patient was before arrival at the "Sending" site
Pager
Email
Links to provider or other computer applications for patient results, summaries, etc.
Clinician at "Sending" site who is availble to answer questions (Sender)
Clinician to call with questions about this patient
Name
Telephone
Pager
Email
Cell phone
Clinician(s) if different from above to call for each active problem (with contact info)
Receiving Site
Name of "Receiving" site
Unit:
Receiving Clinician (Receiver)
Clinician Assuming Responsibility for Care at "Receiving" site
Name
Telephone
Pager
Email
Name of clinician accepting transfer if different than above
Has either clinician received a verbal hand-off Y/N
Data Set: Slide 3 of 8
Patient Specific Medical Information
Allergies (name of inciting agent, type of reaction, severity)
Medications
Food
Other
Date:
Adverse medication reactions (name of medication, type of reaction, severity)
Current Active Clinical Conditions
Status
Past Medical History
Social History
Chief Complaint
Reason Patient is being referred
Reason for Transfer
History of Present Illness
History of Major Surgeries with dates
Hospital admissions in the past 12 months
Issues requiring ongoing management
Medications
Current Active Medications on Transfer or Discharge
Indication
Route
Dose
Frequency
Date and time last dose administered
Pre-Admission Medication List (patient's home medications prior to admission)
List of historical medication names, dose, route, frequency, date patient has taken prior
Discharge Medications
Medication Reconciliation: Discharge Medication List
Discharge medications unchanged from Pre-admission Medication List
Discharge medications on the Pre-admit Med List but with change of dose or frequency
Explanation of change
New medications (not on pre-admission medication list)
Reason for addition
Medications removed from the Pre-admission Medication List
Reason for deletion
Pertinent medications administered during the course of this episode of care not on Discharge medication list
Data Set: Slide 4 of 8
Summary of expectations for care
Code Status
Do not resuscitate
Do not hospitalize
Full
If not addressed, why not?
Orders for Life Sustaining Treatment (POLST or MOLST Form) attached (Y/N)
Summary of goals of care discussion attached (Y/N)
Other Advance Care Planning information
Immunizations
Immunizations name
dose
route
date administered to the patient
Physical Findings (with time recorded)
Heart rate
Resp Rate
Pulse
Oxygen Saturation
Temperature
Blood Pressure
Pain scale
Weight
Mental status at discharge/transfer
Treatment Course by Active Problem
Pertinent Findings by Active Problem
Results and dates of Diagnostic Procedures
Pertinent test results with dates
Assessment of patient's active issues at discharge/transfer
Proposed interventions and procedures for patient after transfer/discharge
Follow-up plans
Tests pending at Discharge/transfer
Who is responsible for following up
Number(s) to call for results
Pressure ulcers at Discharge/Transfer
Location(s)
Stage
Appearance
Treatments
Other wounds
Wound care sheet attached Y/N
VAC Dressing
Setting
Who will change dressing
Frequency
Teaching materials used for patient/family
Data Set: Slide 5 of 8
Functional Status at Discharge/Transfer
Activities of Daily Living (ADLs)
Bathing
Dressing
Toileting
Transfers
Ambulation
Eating
Can ambulate _______distance with device or independent
Continent of bowels Y/N
Continent of bladder Y/N
Last Bowel Movement
Catheter last changed or removed
Known risks or unidentified problems
Devices, drains
pacemaker
foley
IR drains
Internal defibrilator (AICD)
drains
High risk lines
Hemodialysis
Ports
Epidural catheters
Total Parenteral Nutrition (TPN) Line
PICC
Placement documentation (chest xray, line length)
Special treatments/interventions
dialysis
chemotherapy
radiation
Total Parenteral Nutrition (TPN)
fluid restriction
fingersitcks
weight checks
Nebulizers
Tracheostomy
Oxygen #liters via___
Suctioning
Continuous Positive Airway Pressure (CPAP)/ Bilevel Positive Airway Pressure (BiPAP)
Bariatric equipment
IV medications (dose, frequency, duration, who supplies)
Method of administration (push, cassette)
Type of Pump
Who is managing IV in home
Other
Data Set: Slide 6 of 8
Alerts, Restrictions
Elopement
Pain
Restraints
Trouble swallowing Y/N
Special diet or consistency Y/N
Needs assist with feeding Y/N
Tube feeing Y/N
Fall Risk Y/N interventions
Aspiration
Limited/non-weightbearing left/right, Upper/Lower
Seizure Precautions
High risk for pressure ulcer
Wanderer
Other
Violent behavior
Infection precautions
methicillin-resistant Staphylococcus aureus (MRSA), VISA
vancomycin-resistant enterococci (VRE)
Clostridium difficile
ESBL
Other
Pregnant, Y/N
special circumstances or potential complications
Know Limitations and Disabilities
Cognitive
Speech
Hearing
Vision
Sensation
Ability to consent to treatment
Amputation
Paralysis
Contractures
Adaptive devices sent with patient (Y/N)
clearance to drive
Pain Assessement and Treatment
Pain score (x out of 10) at transfer (time recorded)
Location(s)
Medications. Y/N
Scripts/Meds sent Y/N
Other modalities
Time last medicated prior to transfer (time recorded)
medication administered
dose
Clinician providing consultation or follow-up (name, contact information)
Pain narrative
Data Set: Slide 7 of 8
Home Care Specific Elements
Address where care is to be provided
name of referring physician
name of primary care physician
Were supplies ordered Y/N
If yes, were they sent Y/N
What was ordered
Quantity
Where ordered from (contact information)
Anticipated delivery date/time
Name of Identified Learner for education
Face to Face Certification
Name of certifying physician
Homebound
Specific conditions requiring treatment
Attestation of face to face encounter
Condition Specific Elements
Anticoagulation
Warfarin
Prescribed by
Indication
Target International Normalized Ratio
Duration
Who will prescribe dose changes
Last 3 International Normalized Ratios
Last 3 doses
Next recommended dose and International Normalized Ratio
Low Molecular Weight Heparin/Direct Thrombin Inhibitors
Prescribed by
Medication
Dose
Frequency
Route
Indication
Duration
Required lab work
Contact information of prescriber
Data Set: Slide 8 of 8
Congestive Heart Failure
Ejection Fraction
Goal weight
Current weight
Atrial Fibrillation or not
Anticoagulation
if not why not
Beta blocker
if not why not
Angiotension Converting Enzyme Inhibitor/ Angiotension Receptor Blocker
if not why not
Last Hematocrit, Blood Urea Nitrogen, Creatinine, Potassium, Sodium
Major Psychiatric Conditons
Psychosis
Severe depression
Bipolar
Potential New Elements for addition to data set
Patient likes and dislikes
Alternative Items-Duplicates in above list
Diseases & Conditions Patient has suffered in the past
Sequence of events proceeding patient's disease/condition
Description of Patient's Complaint (narrative)
All Surgeries with dates
List of Hospital Diagnosis and dates
Admission Diagnoses
Conditions/Diseases identified during hospital stay and dates
Problem list
Medications names, doses, frequency, route ordered for the patient for after discharge
Assessment of patients conditions and expectations/goals of care
Headers
Elements included in initial survey but to be removed in final version
Expand Purview of LTPAC ToC WG
• Traditional LTPAC
Sites
–
–
–
–
–
–
LTAC
IRF
SNF
ECF
Home Health Agency
Hospice
• “Additional” LTPAC
Sites
– Ambulatory Care
(PCP)
– CBO (Community
based organizations)
– Patient/Family
– Others as needed
Rationale: traditional sites of care will blur as
care is organized more around patient needs
and less around the site of care. Information
exchange will grow in importance
Include the Acute Care Hospital
Connection
• Most transitions to LTPACs start in the Acute
care hospital
– Discharges to LTPACs from In-patient units
– Discharges or returns to LTPACs from the ED
– Return to LTPACs from out-patient testing and
treatment sites
• Many transitions from LTPACs go to ACH sites
– In-patient
– ED
– Out-patient testing or treatment
• This expanded “Scope” results in a grid of
eleven “sending sites” and eleven “receiving
sites”
11x11 Sender (left column) to Receiver (top) Grid
Transitions to (Receivers)
In Patient
ED
Out patient
Transitions From (Senders)
Services
In patient
ED
Out patient services
LTAC
IRF
SNF/ECF
HHA
Hospice
Ambulatory Care (PCP)
CBOs
Patient/Family
LTAC
IRF
SNF/ECF
HHA
Hospice
Amb Care
(PCP)
CBOs
Patient/
Family
Four Relevant Scenarios from the
Expanded Scope
1. Exchange information between LTPAC
providers
2. Exchange information from LTPAC providers
to the patient/family
3. Exchange information from LTPAC providers
to three Acute Care Hospital units:
1. In-patient floor
2. ED
3. Outpatient testing and treatment sites
4. Exchange information from Acute Care
Hospital units to LTPAC providers and
patient/family
Four Relevant Scenarios: Transitions by Origin and Destination
Transitions to (Receivers)
In Patient
ED
Out patient
Transitions From (Senders)
Services
LTAC
IRF
SNF/ECF
HHA
Hospice
Amb Care
(PCP)
CBOs
Patient/
Family
In patient
4
ED
Out patient services
LTAC
IRF
SNF/ECF
3
1
HHA
Hospice
Ambulatory Care (PCP)
Scenario 1: Exchange between LTPAC sites
CBOs
Patient/Family
Scenario 2: Exchange from LTPAC sites to patient
Scenario 3: Exchange from LTPAC sites to ACH sites
Scenario 4: Exchange from ACH sites to LTPAC sites
2
Identifying High Priority Transitions
• Three variables determine the priority of each transition:
– Volume
– Clinical instability of the patient
– Time/Value of the clinical information
• On the next grid, each transition is represented by a cell
• Each cell has three sections, one for each variable
• Each variable is either High (red), Medium (yellow) or
Low (blue)
• Cells with two or more “High” scores indicate priority
transitions
• Cells in grey or black are either out of scope or rare
Prioritizing Transitions by Volume, Clinical Instability and Time-Value of Information
Transitions to (Receivers)
In Patient
ED
Out patient
Transitions From (Senders)
Services
In patient
ED
Out patient services
LTAC
IRF
SNF/ECF
HHA
Hospice
Ambulatory Care (PCP)
V=H
CI = H
TV = H
V=H
CI = H
TV = H
V=H
CI = H
TV = H
V=H
CI = H
TV = H
V=L
CI = H
TV = H
V=M
CI = H
TV = H
V=H
CI = H
TV = H
V=H
CI = H
TV = H
V=H
CI = H
TV = H
V=H
CI = H
TV = H
V=M
CI = H
TV = H
V=H
CI = H
TV = H
V=H
CI = H
TV = H
V=H
CI = M
TV = H
V=H
CI = M
TV = H
LTAC
IRF
SNF/ECF
HHA
Hospice
V=H
CI = H
TV = H
V=H
CI = H
TV = H
V=H
CI = H
TV = H
V=H
CI = H
TV = H
V=H
CI = H
TV = H
V=H
CI = M
TV = H
V=M
CI = M
TV = H
V=H
CI = M
TV = H
V=H
CI = H
TV = H
V=H
CI = M
TV = H
V=H
CI = M
TV = H
V=H
CI = L
TV = H
V=L
CI = M
TV = M
V=H
CI = M
TV = H
V=H
CI = M
TV = H
V=H
CI = M
TV = H
V=H
CI = M
TV = H
V=H
CI = L
TV = H
V=H
CI = M
TV = H
V=L
CI = L
TV = L
V=L
CI = L
TV = M
V=M
CI = M
TV = M
V=H
CI = L
TV = H
V=M
CI = M
TV = H
V=L
CI = L
TV = H
V=M
CI = M
TV = H
V=L
CI = M
TV = H
V=M
CI = M
TV = M
V=M
CI = L
TV = L
V=L
CI = L
TV = M
V=L
CI = L
TV = H
V=L
CI = H
TV = H
V=M
CI = H
TV = M
V=L
CI = M
TV = M
V=M
CI = M
TV = M
V=L
CI = M
TV = H
CBOs
Patient/Family
Black circles = highest priority
Green circles = high priority
Amb Care
(PCP)
V=H
CI = M
TV = H
V=H
CI = L
TV = H
V=H
CI = L
TV = H
V=H
CI = M
TV = H
V=H
CI = L
TV = H
V=H
CI = L
TV = M
V=H
CI = L
TV = L
V=L
CI = M
TV = L
V=L
CI = L
TV = M
CBOs
V=H
CI = L
TV = H
V=M
CI = L
TV = H
V=H
CI = M
TV = H
V=H
CI = L
TV = H
V=H
CI = M
TV = H
V=H
CI = L
TV = L
V=M
CI = L
TV = L
V=M
CI = L
TV = M
Patient/
Family
V=H
CI = M
TV = H
V=H
CI = M
TV = H
V=H
CI = L
TV = L
V=H
CI = M
TV = H
V=H
CI = L
TV = H
V=H
CI = L
TV = H
V=H
CI = L
TV = L
V=L
CI = M
TV = M
V=L
CI = L
TV = L
Prioritizing Transitions by Volume, Clinical Instability and Time-Value of Information
Transitions to (Receivers)
In Patient
ED
Out patient
Transitions From (Senders)
Services
LTAC
IRF
SNF/ECF
HHA
Hospice
In patient
ED
Out patient services
LTAC
IRF
SNF?ECF
HHA
Hospice
Ambulatory Care (PCP)
CBOs
Patient/Family
Black circles = highest priority
Green circles = high priority
Amb Care
(PCP)
CBOs
Patient/
Family
Scenario #1: LTPAC TO LTPAC Priority Transitions
Transitions to (Receivers)
In Patient
ED
Out patient
Transitions From (Senders)
Services
In patient
ED
Out patient services
LTAC
IRF
SNF
ECF
HHA
Hospice
Ambulatory Care (PCP)
CBOs
Patient/Family
LTAC
IRF
SNF
ECF
HHA
Hospice
Amb Care
(PCP)
CBOs
Patient/
Family
Scenario #2: LTPAC To Patient/Family Priority Transitions
Transitions to (Receivers)
In Patient
ED
Out patient
Transitions From (Senders)
Services
In patient
ED
Out patient services
LTAC
IRF
SNF/ECF
HHA
Hospice
Ambulatory Care (PCP)
CBOs
Patient/Family
LTAC
IRF
SNF/ECF
HHA
Hospice
Amb Care
(PCP)
CBOs
Patient/
Family
Scenario #3: LTPAC To Acute Care Hospital Units Priority Transitions
Transitions to (Receivers)
In Patient
ED
Out patient
Transitions From (Senders)
Services
In patient
ED
Out patient services
LTAC
IRF
SNF/ECF
HHA
Hospice
Ambulatory Care (PCP)
CBOs
Patient/Family
LTAC
IRF
SNF/ECF
HHA
Hospice
Amb Care
(PCP)
CBOs
Patient/
Family
Scenario #4: Acute Care Hospital Units to LTPAC Sites Priority Transitions
Transitions to (Receivers)
In Patient
ED
Out patient
Transitions From (Senders)
Services
In patient
ED
Out patient services
LTAC
IRF
SNF/ECF
HHA
Hospice
Ambulatory Care (PCP)
CBOs
Patient/Family
LTAC
IRF
SNF/ECF
HHA
Hospice
Amb Care
(PCP)
CBOs
Patient/
Family
Priority Transitions by Relevant Scenario
Transitions to (Receivers)
In Patient
ED
Out patient
Transitions From (Senders)
Services
LTAC
IRF
SNF/ECF
HHA
Hospice
Amb Care
(PCP)
CBOs
Patient/
Family
In patient
ED
4
Out patient services
LTAC
IRF
SNF/ECF
HHA
Hospice
3
1
Ambulatory Care (PCP)
CBOs
Scenario 1: Exchange between LTPAC sites
Scenario 2: Exchange from LTPAC sites to patient
Patient/Family
Scenario 3: Exchange from LTPAC sites to ACH sites
Scenario 4: Exchange from ACH sites to LTPAC sites
2
Different Transitions Within
Each Scenario
• Transitions can be one of four different types
depending on whether they are
– “Permanent” or “Temporary”
– “Elective” or ‘Urgent”
• The types are:
– Permanent and Elective: standard discharge
– Temporary and Elective: out-pt testing and treatment
or discharge from the ED
– Temporary and Urgent: transfer to the ED
– Permanent and Urgent: in-pt admission following ED
• These transitions also vary by content and
receiver types
Scenarios, Priorities and Transition Types
Total
Transitions From (Senders)
Total Surveys All Receivers
Transitions to (Receivers)
In Patient
ED
Out patient
Services
LTAC
IRF
SNF/ECF
HHA
Hospice
Amb Care
(PCP)
CBOs
Patient/
Family
1135
42
43
21
36
27
664
132
18
77
30
45
In patient
194
0
0
0
9
9
125
22
5
11
6
7
ED
188
0
0
0
9
9
125
22
5
11
0
7
Out patient services
96
0
0
0
9
9
39
22
3
11
0
3
LTAC
198
7
8
7
0
0
125
22
5
11
6
7
IRF
202
7
8
7
9
0
125
22
0
11
6
7
SNF/ECF
68
7
8
7
0
0
0
22
0
11
6
7
HHA
164
7
8
0
0
0
125
0
0
11
6
7
Hospice
10
7
3
0
0
0
0
0
0
0
0
0
Ambulatory Care (PCP)
15
7
8
0
0
0
0
0
0
Transition Categories
CBOs
0
0
0
0
0
0
0
0
0
Elective
Patient/Family
0
0
0
0
0
0
0
0
0
Permanent
Temporary
Urgent
Transition-Specific Data sets
• Transitions can vary by:
–
–
–
–
–
Type: permanent or temporary
Urgency: elective or emergent
Origin
Destination
Essential “receivers” (RN, MD, CM, PT, etc): mix of
roles varies by site
• The essential elements are what the receivers
identify as “essential”.
• Transition-specific data sets share many
common elements but vary in others
Process to Develop
Transition-specific Data Sets
• The purpose of the data sets is to assure safe and
efficient transfer of clinical responsibility
• Receiving sites identified all essential role groups
• Each role group reviewed a draft data set created by
merging the S&I ToC Framework document with the
Massachusetts Universal Transfer Form (UTF)
• They classified elements as “required”, “optional” and
“not needed”.
• The sum of all “required” data elements constitutes the
Transition-specific Data Set (TSDS) for that site.
Role-groups by Receiving Site
Priority Transitions
Role Groups Responding
Respondants by Role
Transitions to (Receivers)
Total
In Patient
ED
Unit
49
6
6
5
Admin
Out pt
Services
3
LTAC
IRF
SNF/ECF
HHA
Hospice
CBOs
1
Amb Care
(PCP)
6
4
Patient/
Family
5
4
3
5
6
4
4
5
5
9
7
3
8
4
2
X
X
X
X
X
X
X
X
Care Transition Coach
X
Case Manager
X
EMT
X
MD
X
X
X
X
OT
X
X
X
X
X
X
X
X
X
X
Patient
X
PT
X
RN
X
X
X
X
X
X
X
X
X
X
Social Work
X
Speech
X
Technician
X
X
X
X
X
X
X
X
X
Surveys received for each Priority Transition
Total
Transitions From (Senders)
Transitions to (Receivers)
In Patient
ED
Out patient
Services
LTAC
IRF
SNF/ECF
HHA
Hospice
Amb Care
(PCP)
CBOs
Patient/
Family
Total Surveys All Receivers
1135
42
43
21
36
27
664
132
18
77
30
45
In patient
194
0
0
0
9
9
125
22
5
11
6
7
ED
188
0
0
0
9
9
125
22
5
11
0
7
Out patient services
96
0
0
0
9
9
39
22
3
11
0
3
LTAC
198
7
8
7
0
0
125
22
5
11
6
7
IRF
202
7
8
7
9
0
125
22
0
11
6
7
SNF/ECF
68
7
8
7
0
0
0
22
0
11
6
7
HHA
164
7
8
0
0
0
125
0
0
11
6
7
Hospice
10
7
3
0
0
0
0
0
0
0
0
0
Ambulatory Care (PCP)
15
7
8
0
0
0
0
0
0
0
0
0
CBOs
0
0
0
0
0
0
0
0
0
0
0
0
Patient/Family
0
0
0
0
0
0
0
0
0
0
0
0
Survey Responses by Role-group
by Site
Priority Transitions
Priority Transitions with Data
Number of Responding Sites
Role Groups Responding
Respondants by Role
Admin
Transitions to (Receivers)
Total
In Patient
ED
Unit
49
6
6
49
6
6
46
1
2
5
4
201
Out pt
Services
3
3
1
4
LTAC
IRF
SNF/ECF
HHA
Hospice
CBOs
1
1
1
3
Amb Care
(PCP)
6
6
2
8
4
4
2
4
Patient/
Family
5
5
4
2
4
4
1
5
3
3
2
5
5
5
26
9
6
6
4
7
32
0
1
1
0
1
20
3
3
1
2
0
2
0
0
0
0
0
0
0
0
0
2
0
20
1
0
0
1
0
16
1
0
1
0
0
3
3
0
0
0
0
0
0
0
0
0
0
MD
18
1
2
0
1
3
10
0
0
1
0
0
OT
16
0
0
0
1
0
11
3
0
1
0
0
4
0
0
0
0
0
0
0
0
0
0
4
PT
23
1
0
0
0
1
17
3
0
1
0
0
RN
39
1
2
1
3
1
17
7
3
2
2
0
Social Work
19
0
0
0
0
0
19
0
0
0
0
0
Speech
19
0
0
0
0
0
12
2
0
1
0
4
6
0
0
2
0
0
0
0
0
0
0
4
Care Transition Coach
Case Manager
EMT
Patient
Technician
Summary of Survey Results
• 48 of 49 high priority transitions have four
or more survey responses
• Hospice to ED has EMT surveys only
• 1135 transition-specific responses
• From 12 role groups
• Made up of 201 individuals
• From 46 facilities
Findings
• More than 50 changes made to the initial
draft data set
• The “Current LTPAC Draft Data Set” has
300 data elements that include every
required element by every essential role
group in all priority transitions
• Next step is to vet this more widely with
essential receivers.
Proposed High Level Process Flow
Merged
S&I ToC
Data
elements
with UTF
elements
Created
draft data
element
list for all
PAC
receivers
Surveyed PAC
receivers to
determine
required and
optional
elements
10/14/11
Map MDS
3, OASIS,
IRF-PAI,
CARE,
VNS NY
to data list
Re-map data
elements to
S&I ToC
CIM. Identify
Gaps
Establish CIM
modifications
& extension
to support
LTPAC HIE
Identify,
define, and
ballot CDA
modifications
& extensions