Critical Conversations in Transitions of Care – Part 1

Transferring Patient Data from the Hospital to LTPAC

Wednesday, March 2, 2016

Gregory L. Alexander, PhD, RN, FAAN Professor

Sinclair School of Nursing, University of Missouri

John F. Derr, RPh.

CEO

JD & Associates Enterprises, Inc.

Conflict of Interest Gregory L. Alexander, PhD, RN, FAAN, Professor, Sinclair School of Nursing, University of Missouri

and John F. Derr, RPh, CEO, JD & Associates Enterprises, Inc.

Have no real or apparent conflicts of interest to report.

• Data exchange MOTIVATIONS

• Data exchange CHALLENGES

• Data exchange APPROACHES and QUESTIONS

Agenda

Learning Objectives Objective 1: • Summarize the motivations driving the data exchange needs of acute

providers

Objective 2: • Summarize the challenges facing the data exchange efforts of acute

providers

Objective 3: • Describe at least one approach an acute care provider has leveraged in

sending patient data to an LTPAC provider organization

Objective 4: • Compose at least one data exchange question acute care providers

should ask LTPAC providers

http://www.himss.org/ValueSuite

STEPS: Electronic Secure Data

• Data exchange MOTIVATIONS

• Data exchange CHALLENGES

• Data exchange APPROACHES and QUESTIONS

Agenda

Situation Motivation

MARKET FORCES Meet Requirements Of The HITECH Act and Meaningful

Use

Reduce

Re-hospitalizations

Provide Electronic Transition of Care to LTPAC Providers

Quality LTPAC Partners in Pay Model Bundling

Ensure Continuity Quality of Care Management

Why Does Acute Care Require Electronic Interoperability with LTPAC ?

Situation Motivation

DISCHARGE CHALLENGES

Discharge and Transitioned to Another Provider Site or

to Person’s Home

Complete Electronic Health Record for Next Provider

Continuity of Care Within the Spectrum of Care

Quality Metrics Harmonized

Trusted Partnerships

Why Does Acute Care Require Electronic Interoperability with LTPAC ?

Situation Motivation

PATIENT CARE Integration Into the LTPAC Electronic Medical Record

Incorporation of the Hospital Care Plan Into the

Chronic Care Diagnosis and Longitudinal Care Plan

Assurance of Continuity of Care

Accurate Data for Risk Payment Systems

Re-hospitalization Data Integration Into the ER EMR

Why Does Acute Care Require Electronic Interoperability with LTPAC ?

• Data exchange MOTIVATIONS

• Data exchange CHALLENGES

• Data exchange APPROACHES and QUESTIONS

Agenda

Nearly all hospitals have the infrastructure to enable exchange.

Exchange with outside ambulatory care providers and outside hospitals is increasing.

Data Exchange CHALLENGES Three basic types of barriers to data exchange • Operational Barriers • Financial Barriers • Technical Barriers

Data Exchange CHALLENGES

Financial Barriers

Operational Barriers

Data Exchange CHALLENGES

Technical Barriers

• Data exchange MOTIVATIONS

• Data exchange CHALLENGES

• Data exchange APPROACHES and QUESTIONS

Agenda

• Electronic health information exchange created between providers

• Meets Meaningful Use documentation standards

• Documentation completed prior to discharge for electronic submissions

• Information completed for follow-up care

• Discharge documentation completed in EMR Discharge Navigator:

– Selecting providers/locations – Entering data and searching for CORRECT entry – Choose entry that begins with TOC only

Data Exchange APPROACHES

Data Exchange APPROACHES Case Study: Scheduling appointments

• Determine which interdepartmental communication forms are

required

• Establish communication workflows that incorporate communication forms

• Identify all stakeholders who require information about appointments

• Determine IT readiness for stakeholders

• Educate and conduct pilot test of exchange

Data Exchange APPROACHES Case Study 1: Scheduling appointments

0

Discharge Paperwork Used for Post Acute Report

1. Face sheet (EMS needs) 2. Med rec 3. Rounding report (HC) 4. 3 days MD notes 5. Patient summary report (HC) 6. Advance directives/living will, if applicable 7. H&P (only for long distance transfers over 25 miles) 8. DA-124C (mandated for new patients) 9. DA-124A/B, if applicable 10. Patient transfer form (MD orders/nursing pt functional assessment) 11. Physician certification statement (for ambulance transfer only) (EMS needs) 12. Transfer and authorization form (for hospital-based NH or ED transfer to

another hospital

Data Exchange QUESTIONS

Questions

Gregory L. Alexander, PhD, RN, FAAN Professor Sinclair School of Nursing, University of Missouri E-mail: alexanderg@missouri.edu LinkedIn: https://www.linkedin.com/pub/gregory-l-alexander/20/a2a/9b2

John F. Derr, RPh. CEO JD & Associates Enterprises, Inc.

E-mail: jfderr@mac.com LinkedIn: https://www.linkedin.com/pub/john-derr-r-ph/8/4b7/245