Preliminary Findings From IMPACT (Improving Massachusetts Post Acute Care Transitions) Leveraging...

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 8DATA ELEMENTSDate of TransferDemographic information- Patient

Last name, First name, Middle InitialDate of birthNext of KinAddressPhoneGenderMarital StatusReligionRaceEthnicityPrimary Language: English Y/N Primary Language if not English_______Links to patient or other computer applications for patient results, summaries, etc.Email of PatientContact Name, Contact Number Last name, First name, Middle InitialTelephoneRelationship (relative, guardian, durable power of attorney)Is this the health care proxy? If health care proxy is different: Name, TelephoneHas health care proxy been invoked? Y/NInsurance Name, Phone #, Group #, Type, Member #, Subscriber Name, Financial responsibility Insurance NameInsurance Phone #Insurance Group #Insurance TypeMember #Subscriber NameFinancial responsibility

Data Set: Slide 2 of 8Origin of Transfer (Sent From)

Name of Sending SiteRole/Title of individual providing transfer informationAddress of "Sending" sitePhone number of "Sending" siteType (HHA, SNF, etc)Date patient first arrived at the "Sending" siteWhere patient was before arrival at the "Sending" sitePagerEmailLinks 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 patientNameTelephonePagerEmailCell phoneClinician(s) if different from above to call for each active problem (with contact info)

Receiving SiteName of "Receiving" siteUnit:

Receiving Clinician (Receiver)Clinician Assuming Responsibility for Care at "Receiving" siteNameTelephonePagerEmailName of clinician accepting transfer if different than aboveHas either clinician received a verbal hand-off Y/N

Data Set: Slide 3 of 8Patient Specific Medical Information

Allergies (name of inciting agent, type of reaction, severity)MedicationsFoodOther

Date:Adverse medication reactions (name of medication, type of reaction, severity)Current Active Clinical ConditionsStatusPast Medical HistorySocial HistoryChief ComplaintReason Patient is being referred Reason for TransferHistory of Present IllnessHistory of Major Surgeries with datesHospital admissions in the past 12 monthsIssues requiring ongoing management

MedicationsCurrent Active Medications on Transfer or Discharge

IndicationRouteDoseFrequencyDate 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 MedicationsMedication 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 changeNew medications (not on pre-admission medication list)

Reason for additionMedications removed from the Pre-admission Medication List

Reason for deletionPertinent medications administered during the course of this episode of care not on Discharge medication list

Data Set: Slide 4 of 8Summary of expectations for care

Code StatusDo not resuscitateDo not hospitalizeFullIf 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

ImmunizationsImmunizations namedoseroutedate administered to the patient

Physical Findings (with time recorded)Heart rateResp RatePulseOxygen SaturationTemperatureBlood PressurePain scaleWeightMental status at discharge/transfer

Treatment Course by Active ProblemPertinent Findings by Active ProblemResults and dates of Diagnostic Procedures Pertinent test results with datesAssessment of patient's active issues at discharge/transferProposed interventions and procedures for patient after transfer/dischargeFollow-up plansTests pending at Discharge/transferWho is responsible for following upNumber(s) to call for results

Pressure ulcers at Discharge/TransferLocation(s)StageAppearanceTreatmentsOther woundsWound care sheet attached Y/NVAC Dressing

SettingWho will change dressingFrequencyTeaching materials used for patient/family

Data Set: Slide 5 of 8Functional Status at Discharge/Transfer

Activities of Daily Living (ADLs) BathingDressingToiletingTransfersAmbulationEatingCan ambulate _______distance with device or independentContinent of bowels Y/NContinent of bladder Y/NLast Bowel MovementCatheter last changed or removed

Known risks or unidentified problems Devices, drains

pacemakerfoleyIR drainsInternal defibrilator (AICD)drains

High risk linesHemodialysisPortsEpidural cathetersTotal Parenteral Nutrition (TPN) LinePICC

Placement documentation (chest xray, line length)Special treatments/interventions

dialysischemotherapyradiationTotal Parenteral Nutrition (TPN) fluid restrictionfingersitcksweight checksNebulizersTracheostomyOxygen #liters via___SuctioningContinuous Positive Airway Pressure (CPAP)/ Bilevel Positive Airway Pressure (BiPAP)Bariatric equipmentIV medications (dose, frequency, duration, who supplies)

Method of administration (push, cassette)Type of PumpWho is managing IV in home

Other

Data Set: Slide 6 of 8Alerts, Restrictions

ElopementPainRestraintsTrouble swallowing Y/NSpecial diet or consistency Y/N Needs assist with feeding Y/NTube feeing Y/N Fall Risk Y/N interventionsAspirationLimited/non-weightbearing left/right, Upper/LowerSeizure PrecautionsHigh risk for pressure ulcerWandererOtherViolent behaviorInfection precautions

methicillin-resistant Staphylococcus aureus (MRSA), VISAvancomycin-resistant enterococci (VRE)Clostridium difficileESBLOther

Pregnant, Y/Nspecial circumstances or potential complications

Know Limitations and DisabilitiesCognitiveSpeechHearingVisionSensationAbility to consent to treatmentAmputationParalysisContracturesAdaptive devices sent with patient (Y/N)clearance to drive

Pain Assessement and TreatmentPain score (x out of 10) at transfer (time recorded)Location(s)Medications. Y/N Scripts/Meds sent Y/NOther modalitiesTime last medicated prior to transfer (time recorded)

medication administereddose

Clinician providing consultation or follow-up (name, contact information)Pain narrative

Data Set: Slide 7 of 8Home Care Specific Elements

Address where care is to be providedname of referring physicianname of primary care physicianWere supplies ordered Y/N

If yes, were they sent Y/NWhat was orderedQuantityWhere ordered from (contact information)Anticipated delivery date/time

Name of Identified Learner for educationFace to Face Certification

Name of certifying physicianHomeboundSpecific conditions requiring treatmentAttestation of face to face encounter

Condition Specific ElementsAnticoagulation

WarfarinPrescribed byIndicationTarget International Normalized Ratio DurationWho will prescribe dose changesLast 3 International Normalized RatiosLast 3 dosesNext recommended dose and International Normalized Ratio

Low Molecular Weight Heparin/Direct Thrombin Inhibitors Prescribed byMedication

DoseFrequencyRoute

IndicationDurationRequired lab workContact information of prescriber

Data Set: Slide 8 of 8Congestive Heart Failure

Ejection Fraction Goal weightCurrent weightAtrial Fibrillation or notAnticoagulation

if not why notBeta blocker

if not why notAngiotension Converting Enzyme Inhibitor/ Angiotension Receptor Blocker

if not why notLast Hematocrit, Blood Urea Nitrogen, Creatinine, Potassium, Sodium

Major Psychiatric ConditonsPsychosisSevere depressionBipolar

Potential New Elements for addition to data setPatient likes and dislikesAlternative 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 datesList of Hospital Diagnosis and dates Admission DiagnosesConditions/Diseases identified during hospital stay and dates Problem listMedications names, doses, frequency, route ordered for the patient for after discharge Assessment of patients conditions and expectations/goals of care

HeadersElements 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”

Transitions to (Receivers)In Patient ED Out patient LTAC IRF SNF/ECF HHA Hospice Amb Care CBOs Patient/

Transitions From (Senders) Services (PCP) Family

In patient

ED

Out patient services

LTAC

IRF

SNF/ECF

HHA

Hospice

Ambulatory Care (PCP)

CBOs

Patient/Family

11x11 Sender (left column) to Receiver (top) Grid

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 floor2. ED3. Outpatient testing and treatment sites

4. Exchange information from Acute Care Hospital units to LTPAC providers and patient/family

New

New



In patient

ED


LTAC

IRF

SNF/ECF

HHA

Hospice


CBOs

Patient/Family

1 23

4

Four Relevant Scenarios: Transitions by Origin and Destination

Scenario 1: Exchange between LTPAC sites

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

New

New

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


Transitions From (Senders) Services (PCP) FamilyV = H V = H V = H V = H V = H V = H V = H V = H

In patient CI = H CI = H CI = M CI = M CI = L CI = M CI = L CI = MTV = H TV = H TV = H TV = H TV = H TV = H TV = H TV = HV = H V = H V = H V = H V = M V = H V = M V = H

ED CI = H CI = H CI = H CI = M CI = M CI = L CI = L CI = MTV = H TV = H TV = H TV = H TV = H TV = H TV = H TV = HV = H V = H V = H V = H V = L V = H V = H

Out patient services CI = H CI = M CI = M CI = M CI = L CI = L CI = LTV = H TV = H TV = H TV = H TV = H TV = H TV = L

V = H V = H V = H V = M V = H V = H V = M V = H V = H V = HLTAC CI = H CI = H CI = H CI = M CI = M CI = M CI = M CI = M CI = M CI = M

TV = H TV = H TV = H TV = H TV = H TV = H TV = H TV = H TV = H TV = HV = H V = H V = H V = L V = H V = H V = L V = H V = H V = H

IRF CI = H CI = H CI = M CI = H CI = L CI = L CI = M CI = L CI = L CI = LTV = H TV = H TV = H TV = H TV = H TV = H TV = H TV = H TV = H TV = HV = H V = H V = H V = M V = L V = L V = H V = M V = H V = H V = H

SNF/ECF CI = H CI = H CI = M CI = H CI = M CI = M CI = M CI = M CI = L CI = M CI = LTV = H TV = H TV = H TV = M TV = M TV = M TV = H TV = M TV = M TV = H TV = HV = H V = H V = L V = M V = H V = H V = H

HHA CI = H CI = H CI = L CI = L CI = L CI = L CI = LTV = H TV = H TV = L TV = L TV = L TV = L TV = LV = L V = M V = M V = L V = L V = L V = M V = L

Hospice CI = H CI = H CI = M CI = L CI = L CI = M CI = L CI = MTV = H TV = H TV = M TV = M TV = M TV = L TV = L TV = MV = M V = H V = L V = M V = L V = L V = M V = L

Ambulatory Care (PCP) CI = H CI = H CI = M CI = M CI = L CI = L CI = L CI = LTV = H TV = H TV = H TV = M TV = H TV = M TV = M TV = L

CBOs

Patient/Family

Prioritizing Transitions by Volume, Clinical Instability and Time-Value of Information

Black circles = highest priority Green circles = high priority



In patient

ED


LTAC

IRF

SNF?ECF

HHA

Hospice


CBOs

Patient/Family

Prioritizing Transitions by Volume, Clinical Instability and Time-Value of Information

Black circles = highest priorityGreen circles = high priority

Transitions to (Receivers)In Patient ED Out patient LTAC IRF SNF ECF HHA Hospice Amb Care CBOs Patient/


In patient

ED


LTAC

IRF

SNF

ECF

HHA

Hospice


CBOs

Patient/Family

Scenario #1: LTPAC TO LTPAC Priority Transitions



In patient

ED


LTAC

IRF

SNF/ECF

HHA

Hospice


CBOs

Patient/Family

Scenario #2: LTPAC To Patient/Family Priority Transitions



In patient

ED


LTAC

IRF

SNF/ECF

HHA

Hospice


CBOs

Patient/Family

Scenario #3: LTPAC To Acute Care Hospital Units Priority Transitions



In patient

ED


LTAC

IRF

SNF/ECF

HHA

Hospice


CBOs

Patient/Family

Scenario #4: Acute Care Hospital Units to LTPAC Sites Priority Transitions



In patient

ED


LTAC

IRF

SNF/ECF

HHA

Hospice


CBOs

Patient/Family

Priority Transitions by Relevant Scenario

Scenario 1: Exchange between LTPAC sites

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

New

New

1 23

4

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

Transitions to (Receivers)Total In Patient ED Out patient LTAC IRF SNF/ECF HHA Hospice Amb Care CBOs Patient/


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

CBOs 0 0 0 0 0 0 0 0 0 Elective Urgent

Permanent

Patient/Family 0 0 0 0 0 0 0 0 0

Temporary

Transition Categories

Scenarios, Priorities and Transition Types

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 SiteTransitions to (Receivers)

Total In Patient ED Out pt LTAC IRF SNF/ECF HHA Hospice Amb Care CBOs Patient/Unit Services (PCP) Family

Priority Transitions 49 6 6 3 4 3 5 6 1 6 4 5

Role Groups Responding 5 4 4 5 5 9 7 3 8 4 2Respondants by Role

Admin X X X X X X X X

Care Transition Coach X

Case Manager X X X X X

EMT X

MD X X X X X X

OT X X X X

Patient X

PT X X X X X

RN X X X X X X X X X X

Social Work X

Speech X X X X

Technician X X

Transitions to (Receivers)Total In Patient ED Out patient LTAC IRF SNF/ECF HHA Hospice Amb Care CBOs Patient/


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

Surveys received for each Priority Transition

Survey Responses by Role-group by Site

Transitions to (Receivers)Total In Patient ED Out pt LTAC IRF SNF/ECF HHA Hospice Amb Care CBOs Patient/

Unit Services (PCP) FamilyPriority Transitions 49 6 6 3 4 3 5 6 1 6 4 5Priority Transitions with Data 49 6 6 3 4 3 5 6 1 6 4 5Number of Responding Sites 46 1 2 1 1 2 26 4 1 2 2 4Role Groups Responding 5 4 4 5 5 9 7 3 8 4 2Respondants by Role 201

Admin 32 0 1 1 0 1 20 3 3 1 2 0

Care Transition Coach 2 0 0 0 0 0 0 0 0 0 2 0

Case Manager 20 1 0 0 1 0 16 1 0 1 0 0

EMT 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

Patient 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

Technician 6 0 0 2 0 0 0 0 0 0 0 4

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

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

10/14/11Identify,

define, and ballot CDA

modifications & extensions

Preliminary Findings From IMPACT (Improving Massachusetts Post Acute Care Transitions) Leveraging...

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