Care at Hand

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10/29/15

Agenda

Introduction

Goal of PilotTier PilotingActivity to PilotRole of Care at Hand in the pilot

Standards and Technologies Under Consideration

Logistics

Ecosystem

Defining Success

Resources/References

Introduction: Pilot Team

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• Care at Hand– Andrey Ostrovsky, MD – CEO– Lori O’Connor – Chief Nursing and Quality Officer

• Elder Services of Merrimack Valley– Joan Hatem-Roy – Assistant Executive Director

• Lawrence General Hospital– Robin Hynds – Senior Director

Introduction: Organization

1. AHRQ. Service Delivery Innovation: Community-Based Health Coaches and Care Coordinators Reduce Readmissions Using Information Technology To Identify and Support At-Risk Medicare Patients After Discharge. Rockville, MD. 2014.

Pilot Introduction: Business Drivers

52. Ostrovsky A, O’Connor L, Marshal O, et al. Predicting 30-120 day readmission risk among Medicare FFS patients using non-clinical workers and mobile technology. Perspectives in Health Information Management. 2015. In press. 3. Munevar D, Drozd E, & Ostrovsky A. Correlation between Medicare A spending and hospitalization risk score using mobile technology. Avalere Independent Analysis. 2015.

User Story 2(Modified)

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Pilot Workflow

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Beneficiary System LTSS/Service Provider System EHR System Case Management System Payer System

EHR sends d/c summary of care

document

AAA receives d/c SOC document

and starts transition service

MCO nurse care managers identify

earlier opportunity to

redetermine level of care

Risk stratification each time interaction

between coach and consumer

Hospital care management staff

given real-time line of site into

community-based intervention

State-mandated LTSS reporting

system gets periodic data

dump

Which Tier are you piloting?

• Tiers 1, 2, & 3, iteratively

What are you intending to pilot

• Pick which one(s) apply– Create Plan– Approve/Authorize Plan/Services– Access, View, Review Plan– Update Plan

• Have you identified a Service provider with which to work, if so who? Elder Services of Merrimack Vallery & LGH

• Do you know if they have an electronic system– If so which one? Care at Hand, Harmony

• Do you know which sub-domains from the FR document will you pilot: – Work, Community, Choice & Decision Making, Relationships, Self-Direction, Demographics, Person-Centered

Profile, Medication, ADLs/IADLs, Safety, Behavioral Needs, Restrictions, Service, Financial/Payer Information, Service Information, Family Information, Community Connections, Access & Support Delivery, Information & Planning, Health, Other (specify) (from the FR document and the RTM document)

What role do you play in the pilot

• Beneficiary/Advocate, Beneficiary System, CB-LTSS Provider, Clinical and Institutional based provider, EHR system, Eligibility Determination Form Submitter, eLTSS plan developer, eLTSS plan facilitator/steward, LTSS/case management info, LTSS/Service Provider System, Payer, Payer System

– Please describe the role you intend to play in the pilot: Predictive analytics platform with person-centered care plan as backbone

Standards Under Consideration:

C-CDA;HL7v2.0; RxNorm; HCBS Taxonomy; Care Coordination Atlas; BARHII Health Determinants

Direct;REST;SSL;

FHIR;HTML5;JSON

HL7;IETF; Peebles et al 2014; AHRQ; BARHII

Exemplar Standards/Technologies Relevant SDOs/VendorsContent & Structure Transport & Security Cross Category

Pilot Logistics:

• Timeline – (April 2016 is end date for round one pilots)• Kick off: Feb 23, 2015• Identification of Partners/Providers- Sept-Dec 2015• Completion of RTM: March 2016• Completion of Pilots: April 2016

• Challenges:– Business case is VERY hard to make: Why should hospitals outsource when “they can just build

it themselves?”– HIE has limited attention span for “free connections” – community providers don’t get as much

attention as “paying customers”– Maryland AND Mass HIEs are INCREDIBLY good and thoughtful, but business is business

– Too many cooks in kitchen required to microwave a lean cuisine– Interface analysts, Senior directors, EMR vendor, admins, care coordination leadership, etc.

(that’s just the hospital, there’s equal number of community organization reps “needed”)– Timeframes for operationalizing are so long that turnover starts to kick in

– Hospital CIO changed and interoperability lead changed

Overcoming objections in MA

1. AHRQ. Service Delivery Innovation: Community-Based Health Coaches and Care Coordinators Reduce Readmissions Using Information Technology To Identify and Support At-Risk Medicare Patients After Discharge. Rockville, MD. 2014. 2. Ostrovsky A, O’Connor L, Marshal O, et al. Predicting 30-120 day readmission risk among Medicare FFS patients using non-clinical workers and mobile technology. Perspectives in Health Information Management. 2015. In press. 3. Munevar D, Drozd E, & Ostrovsky A. Correlation between Medicare A spending and hospitalization risk score using mobile technology. Avalere Independent Analysis. 2015.

39.6%1 30-day readmissions

257%1 ROI from prevented readmissions

$4,5913 Reduction in Medicare A & B spending per beneficiary per year

Predict admissions up to

120 days2

Overcoming objections in MD

How do you define success

• Run chart demonstrating improve outcomes associated temporally with incremental increase in interoperability

• Improve outcomes in terms of “payer/provider” and “consumer”– ED utilization– 30 day readmission rates– SNF LOS– NCI– Percent of goals of care met– Consumer confidence (activation subcomponent)

Care at Hand’s vision

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Beneficiary System

LTSS/Service Provider System

EHR System Case Management System

Payer System