Site visits were conducted with three strategically identified providers engaged in cutting edge information exchange to support care coordination for persons receiving LTPAC/LTSS:
Chicago's Rush University Medical Center's Bridge Model Care Transition Program, improves care transitions through a patient-centered approach that engages a multidisciplinary health care team to help older adults safely transition back to the community through intensive care coordination that includes HCBS providers and others in the health delivery system.
Beechwood Homes, a 272-bed skilled SNF in Western New York, provides a continuum of LTPAC services. Beechwood Homes is one of the first LTPAC providers to participate in HIE through a regional HIEO.
Eastern Maine HomeCare (EMHC), part of Eastern Maine Health System (EMHS), an integrated delivery system (IDS), is using HIE to support continuity and cost-effective care across the delivery system, implementing care management practices to support complex/fragile patients, and using telehealth to support service delivery in remote areas.
Interview guides and observation protocols guided the site visits. In-person visits were conducted with the sites and their exchange partners and stakeholders, including clinicians, case and care managers, administration, discharge planners, quality assurance (QA)/Performance Improvement staff, IT staff, and HIEO staff. The site visits provided rich case studies of the state of HIE to support LTPAC/LTSS and opportunities to advance HIE, including interoperable HIE.
"HIEengage.pdf" (pdf, 976.86Kb)
"HIEengageA.pdf" (pdf, 122.65Kb)
"HIEengageB.pdf" (pdf, 132.47Kb)
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"HIEengageI.pdf" (pdf, 264.75Kb)
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