Long-Term and Post-Acute Care Providers Engaged in Health Information Exchange: Final Report. 4.1.1. Rush University Medical Center, Transition of Care Programs

10/29/2013

Background

Rush University Medical Center (Rush) is part of the Rush System for Health, an IDS with hospitals and ambulatory care practices. Rush is an urban hospital located in downtown Chicago, Illinois with multiple programs focused on improving care transitions including improving transitions with SNFs and HHAs, and programs focused on reducing hospital readmissions and care coordination with community-based services.

A key components of Rush's Facility Transitions in Care and Bridge Programs is coordination with community-based LTSS. Through a patient-centered approach, Rush works to improve care transitions through intensive care coordination that starts in the hospital and continues into the community. The multidisciplinary health care team is extended beyond the hospital's physicians, nurses, pharmacists, and case managers to include the community resource team (therapists and community providers such as home health, SNFs, and other services). The team identifies and addresses the services and resources needed by the patient and works to eliminate barriers that will prevent them from safely transitioning back to the community and meeting their health care goals.

Grants, Policy Drivers and Other Funding Models Advancing HIE

The transition of care programs at Rush have focused on Medicare beneficiaries only. However, Rush has emerging programs that will extend their transition programs to adults of all ages who have chronic conditions. Rush has worked to improve the care transition process for more than 5 years. More recently, two programs -- the CMS Hospital Readmission Reduction Program and CMS CCTP have spurred initiatives to improve processes, communication and information sharing between the hospital and community partners.

  • CMS Hospital Readmission Reduction Programs: In response to the CMS program, Rush implemented the Readmission Reduction Project RED Pilot to reduce the number of readmissions and maintain an overall readmission rate of less than 12.3%. At the time of the site visit in April 2013, they had identified interventions and started their pilot project. Interventions related to LTPAC to reduce hospital readmissions include improved coordination and communication prior to hospital discharge (such as participation of LTPAC providers in discharge planning rounds), better access to hospital EHR data to facilitate transitions, and development of post-discharge protocols. Protocols or processes developed include:
    • A home care nurse visit within 24 hours after discharge (same day if possible).
    • A physician visit to the SNF within 48 hours after discharge.
    • Social work followup with community services within 24-48 hours to ensure services were started.
  • CMS CCTP (3026 Program): Rush is a partner in the Illinois Transitional Care Consortium (ITCC) which is currently participating in the CMS funded CCTP.

The ITCC is deploying the Bridge Program to help manage community-based care transitions. With this program Medicare beneficiaries who have at least one chronic condition requiring followup care and are at risk for rehospitalization are assigned a Bridge care coordinator (BCC). Upon discharge from the hospital, the BCC assists the patient with engaging community services and resources for a 30-day period. Figure 4-1depicts the providers and services targeted for coordination. The BCCs frequently access, share, and exchange health information to coordinate community services to assess the patient's needs, communicate with care managers, and coordinate community services.

FIGURE 4-1. Bridge Program Systems Targeted for Coordination

FIGURE 4-1. Bridge Program Systems Targeted for Coordination

At the time of the site visit, Rush was not involved in any of the new payment models (such as an ACO or bundled payment), however they are exploring future accountable care arrangements.

Community HIE Organization

The State of Illinois is developing a federated model for their HIEO using a record locator service that will reach out to regions and bundle and route information. The Chicago-area region does not currently have an operational HIEO to facilitate automated, electronic exchange of information. However, Rush staff indicated one is under development with an organizational structure in place and software selected.

Summary of EHR and HIT Systems and Development Plans Related to HIE

Rush University Medical System uses the EPIC EHR system for all patient care documentation in the hospital and ambulatory care sites. EPIC has achieved MU Stage 2 certification for its ambulatory and inpatient applications.i

HIE from hospital to LTPAC/LTSS providers relies on multiple methods to communicate and exchange information including telephone, fax/e-fax, secure e-mail, and the use a proprietary electronic referral application (e.g., Allscripts Care Management application). Some Chicago-area hospitals allow LTPAC providers to access their EHR to facilitate communication and information sharing; however, Rush's policy limits EHR access to only staff and physicians and does not allow access to non-affiliated providers such as LTPAC and LTSS providers.

The Allscripts Care Management application facilitates the electronic exchange of some health information (e.g., unstructured narrative messages as well as medical record document attachments) between Rush and their community partners including LTPAC organizations. The community partners who pay a subscription fee and use the Allscripts application can receive messages and attachments from Rush and pull some of the information into their EHR.

Health Information Routinely Exchanged

Clinical, demographic and service information is communicated by hospital case managers and care coordinators to community providers such as HHAs, SNFs, and/or HCBS providers. They use a number of methods to communicate and share information including face-to-face, telephone, fax/e-fax, e-mail, secure messaging, and Allscripts care management application. The lack of HIE tools and an HIEO are a challenge for Rush and their partners. Rush's exchange of health information with LTPAC providers and other community partners typically occurs during the transition of care and followup process. Section 4.2 in this report and Appendix K provide additional information on information routinely exchanged.

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