Transcript Out of Scope

Longitudinal Coordination of
Care (LCC)
Pilots Proposal
CCITI NY
01/27/2014
Pilot Team
Name
Role
Email
Harrison Fox, MPH
Project Director
[email protected]
Kunal Agarwal
Technical Director
[email protected]
Jeffrey Paul
Project Manager
[email protected]
2
Full Disclosure?
• CCITI NY is a partner organization working on the New York
Reducing Avoidable Hospitalizations (NY-RAH) The initiative,
sponsored by CMS, is focused on reducing hospitalizations of longstay nursing facility residents.
NY-RAH Project Overview
• CCITI NY is working on a CMS funded initiative to reduce
avoidable hospitalizations among long-stay nursing home
residents
• Consists of multiple interventions:
• Electronic tools including a transfer application
• Onsite RN Care Coordinators (RNCCs)
• Clinical practices toolkit
• Palliative care support and training
• Collaborate with EMR vendors in order to integrate the
electronic tools into their systems in order to streamline the
clinician workflow
4
Project Participants
• The project consists of the following participants:
• 30 Nursing Facilities in New York State including
Schervier and Silvercrest
• 10+ Hospitals in New York State including New York
Hospital Queens
• Electronic Medical Record Vendors for both acute and
post-acute care settings
Goal of the Pilot
The goal of Continuum of Care Improvement through Information New
York (CCITI NY) is to improve the quality, patient safety, cost and
satisfaction aspects of transferring patients between acute, post-acute,
and ambulatory care organizations.
Project Specific Goals:
• Improve quality of patient care during transitions
• Develop standardized workflows to break down communication
barriers
• Create connectivity between disparate clinical systems to improve
care coordination
• Improve clinician satisfaction with the care transition process
• Reduce avoidable hospitalizations within 30 days of a transfer
6
Common Problems and Our Solution
Problems:
• Avoidable hospitalizations caused in part by a lack of
timely, accurate and comprehensive information for
patients transitioning between the acute and post-acute
care settings
• Harmful events stemming from changes in patient
medications during care transfers
Solution:
• Reduce avoidable hospitalizations through the use of a
standardized electronic transfer form
• Implement a clinical decision support (CDS) tool to prevent
any adverse drug-drug and drug-allergy interactions
Benefits of Our System
• Improve medical decision making by providing
the most critical and pertinent patient
information to clinicians during patient
transfers
• Reduce avoidable hospitalizations by
discharging patients with an accurate record
of their medications and health information
• CDS empowers clinicians to ensure proper
medication use has occurred upon receipt
from a transferred location
Key Metrics
Through these key
metrics, CCITI NY will
be able to offer concrete
results and demonstrate
sustained success
through the use of the
interoperable transfer
form.
Avoidable Hospitalizations
Patient Care Experience
Documentation Time
Adverse Drug Events
Electronic vs Paper Record Transmissions
9
Transition from Nursing Facility to Hospital
Internet
Provider logs into Electronic
Transfer Application (ETA) and
completes information.
Patient ready
for discharge
Patient arrives at
Hospital
Provider logs into
system and accesses
the ETA sent by the
nursing facility
Alert received at
Hospital
Transition from Hospital to Nursing Facility
Internet
Provider logs into ETA and
completes information.
Patient ready
for discharge
Patient arrives at
nursing facility
Provider logs into
system and accesses
ETA
Alert received at
nursing facility
Which of the 5 C-CDA Revisions
are you Piloting?
SDC Standard /
Guidance
Transfer Summary
Specifics to Pilot
Notes
Nursing Facilities will
transmit
standardized transfer
summary to their
hospital partners and
vice-versa
Focus will be on inclusion of
the critical and pertinent
patient information that can
assist in reducing avoidable
hospitalizations
1
What Relevant Scenario (from the
Use Cases) does your Pilot support?
• Exchange of Transfer Summary (LCC Use Case 1.0)
• Exchange of Advance Directives (LCC Use Case 1.0)
Identify the Use Case
Actors/Systems Involved:
•
•
•
•
Sending Entity Care Team
Receiving Entity Care Team
Sending Entity Information System (EHR)
Receiving Entity Information System (EHR)
Role of the RNCC
• The RN Care Coordinator will act as a liaison between the long term
post acute care facility and the Implementation Team
• He or she will assist with the development of the implementation
plan
• Obtain important documentation in order to capture key elements
found in the current paper process
• Help identify potential users of the system from both the Hospital
and the nursing home
CCITI NY Proposed Configuration
Timeline
Milestone
Target Date
Responsible Party
Electronic Transfer
Application (ETA) Go-live
March 2014
CCITI NY
ETA Integrated with EMR
July 2014
CCITI NY
Pilots Evaluation
September 2014
CCITI NY
CCITI NY Success Criteria
• 10% reduction in 30-day avoidable hospitalizations for
long-stay nursing facility residents within 6 months of
go-live
• 10% reduction in medication errors for long-stay
nursing facility residents within 6 months of go-live
In Scope / Out of Scope
In Scope:
• Transfer of demographic and clinical patient data
between two different providers during care transitions
Out of Scope:
• Integration of discrete data elements into the receiving
EHR
Risks & Challenges
• Potential timelines slippage for the EHR vendors
integration with the CCITI NY product
• Incomplete clinical information captured by the EHRs
and provided to CCITI NY product
• Facility IT staff unavailable for support of implementation
and training
• Lack of adoption by the clinical front-line staff at the
facilities due to existing workload
Questions / Needs
• None as of now