Long-Term and Post-Acute Care Providers Engaged in Health Information Exchange: Final Report. Appendix G. Health Information Exchange Interventions and Activities Identified That SUPPORT CARE Coordination for Persons Receiving LTPAC/LTSS

10/29/2013

TABLE G-1. HIE Interventions and Activities Identified that Support Care Coordination for Persons Receiving LTPAC/LTSS

  Entitles Engaged in HIE to Support Care Coordination for LTPAC/LTSS     HIEO and Any Relevant Initiatives     Types of Exchange Partners with the Entities     LTPAC/LTSS Exchanges Data (y/n) and How     Links  
RI NHs, 13 trained NHs, more to be trained* Currentcare 

Beacon Community

Hospitals, laboratories, outpatient Not yet or limited use. http://www.currentcareri.com/matriarch/default.asp
Briody NH & Brothers of Mercy, SNFs, Western NY HEALTHeLINK/ HealtheNet 

Western NY Beacon Community

Hospitals, primary care, laboratories, SNFs Yes, both have LTPAC EHR software, likely with interfaces to HIE, no additional information available, assume similar to Beechwood, 1 of 3 SNFs participating in HIE in Western NY. http://wnyhealthelink.com 

http://www.briody.org/ 

http://www.brothersofmercy.org/skillednursing.htm

Beechwood Homes, a SNF, part of Beechwood Continuing Care, Getzville, NY (also study site visit) HEALTHeLINK/ HealtheNet 

Western NY Beacon Community

Hospitals, primary care, laboratories, other SNFs, HHA Yes, AOD EHR has interfaces to send an ADT through secure HL7 messaging. Can access data via HEALTHeLINK from portal. http://www.beechwoodcare.org 

http://wnyhealthelink.com 

http://www.wnyhealthenet.org/

Eastern Maine Health Care (EMHC),* a HHA (also study site visit) HIN 

Bangor Beacon Community ACO

Hospitals, primary care, laboratories, CCRC Yes, HHA have Allscripts & telehealth. Can send self-management information in relation to COPD, heart disease, diabetes, & asthma to HIN. Can access data from HIN via portal. http://easternmainehomecare.org/home-health-services.aspx?id=68257 

http://www.hinfonet.org/ 

http://www.hinfonet.org/resources/health-information-exchange/hie-participant-list

Brookdale Senior Living (BSL) communities (throughout US, including TX & FL) HIEO depends on community 

INTERACT, CMS Innovations Grant, Transitions of Care Program in TX & FL

Hospitals Yes, for CMS Innovations project some other BSL facilities outside the INTERACT project, a small number of BSL post-acute providers are exchanging with local private or regional HIEOs using Direct. http://seniorhousingnews.com/2012/08/13/assisted-living-program-for-reducing-rehospitalizations-could-have- national-impact 

http://www.brookdaleliving.com

Cedar Creek Living Center, a SNF, Norman, OK SMRTNET 

Challenge Grant

Hospitals, primary care, laboratories, NHs, Norman, OK Regional Health System Yes, Direct secure e-mail sends SBAR, UTF using INTERACT for transitions. Staff can access VHR. http://www.smrtnet.org/home 

http://www.resourcesystems.net/LongTermCare/CareTracker.aspx

Cathedral Square Corporation, housing, services & long-term care (LTSS) needs, VT VHIE 

SASH model

HCBS, LTSS, hospitals, primary care physicians Scheduled to exchange through VHIE by Fall 2013 so that program will be interoperable with community health teams & the VT hospitals' EHRs. The primary care providers & hospitals that are part of the medical homes are already connected through the Blueprint for Health & a clinical registry. Physicians participating in the Blueprint for Health record data about their patients in a registry or an EHR. Housing services enters data directly into a clinical registry. Health status information that will be sent among the community's SASH exchange partners includes nutrition, fall risk, physical inactivity rates, ADLs, IADLs, fall history, & basic health information. Hospitals use the ADT messages & this will be facilitated with HIE. http://cathedralsquare.org/future-sash.php 

http://www.vitl.net/health-information-exchange/blueprint-for-health

Montefiore Medical Center,* Integrated Delivery System (IDS), New York, NY Bronx RHIO, a borough-wide system that supports exchange between Bronx hospitals, health centers, NHs, HHAs, community-based physician practices for patients who have signed consent forms 

ACO

Hospitals, primary care, health centers, laboratories, NHs, HHA Yes, HHA, SNF have integrated EHR links to community-wide system within the IDS, inpatient & outpatient EHRs. They also have access to patient data through Bronx RHIO. http://www.prnewswire.com/news-releases/montefiores-bronx-accountable-healthcare-network-to-participate-as- medicare-pioneer- accountable-care-organization-135871133.html 

http://www.innovations.ahrq.gov/content.aspx?id=3651

CO LTPAC providers: 65 SNFs, 3 ALFs, 30 HHAs, 14 hospice organizations, 1 LTPAC CORHIO 

Challenge Grant, ACO

Hospitals, laboratories, primary care physicians, other LTPAC providers Yes, Viewing community health record from hospitals LIVE on CORHIO. Includes ADT's, Lab Results, Pathology results, Transcription reports, H&P. http://www.corhio.org/ 

http://statehieresources.org/wp-content/uploads/2012/05/CORHIO-Challenge-Grant-Summary-Report-April-2012.pdf

Complete Home Care, HHA, CO CORHIO 

Challenge Grant, ACO

Hospitals, primary care, laboratories, NHs No. http://www.completehhc.com 

http://www.corhio.org 

http://www.corhio.org/news/corhio-e-newsletter/patient-care-coordination-improves-after-home-health-providers- connect-to-hie-%281%29.aspx

MA IMPACT:* 8 NHs, 2 HHA, 1 Long-term acute care facility, 1 IRF participating MeHI HIE 

Challenge Grant

Hospitals, community health care centers, medical homes, ambulatory care providers, HHA, SNFs Yes, wide variety of information including functional status. http://mehi.masstech.org/what-we-do/press-releases/massachusetts-awarded-two-hie-challenge-grant 

http://wiki.siframework.org/LCC+Long-Term+Post-Acute+Care+(LTPAC)+Transition+SWG

Golden Living SNF s & Maria Joseph Continuing Care Community, PA Keystone HIE 

ONC Grant to Geisinger, Beacon Community

Hospitals, physicians, HHA Yes, Golden Living has EHR with interfaces to HIE. Maria Joseph Continuing Care is an early adopter of the MDS-to-CCD tool & is sending this assessment data to hospitals & other providers. https://www.keystonebeaconcommunity.org 

http://www.healthit.gov/policy-researchers-implementers/keystone-beacon-community

NY Presbyterian System affiliated LTPAC providers, New York, NY (Beth Israel Medical Center [hospice], Hebrew Home for the Aged [SNF], Village Center for Care [SNF], North Shore Long Island Jewish Health System [SNF], & VNSNY [HHA, see below for separate description] are the LTPAC providers in the NYCLIX) NYCLIX (RHIO) HRSA Special Projects of National Significance Information Technology Networks of Care Initiative, Supports Select Health--a NYCLIX Medicaid Managed Special Needs Plan for Persons Living with HIV & AIDS   Yes, most providers send & receive information via NYCLIX such as ADT, diagnoses, medications, lab results, radiology reports, allergies, discharge summaries, & other clinical data, query NYCLIX to retrieve information. http://www.healthix.org
UT: 98 SNFs UHIN All SNFs connected for Medicaid eligibility use case Special use of UHIN for Medicaid authorization for NH services process, now all electronic system, being pilot for HHA. http://uhin.org
Avalon Healthcare throughout UT UHIN cHIE   Yes, 14 Avalon SNFs in on system have EHR, can push information to HIE. http://www.avalonhci.com/communities/utah/
Maimonides Medical Center (Mental Health Home), Brooklyn, NY BHIX 

NY State HEAL grant to demonstrate enhanced care coordination

Mental health providers, hospitals, outpatient care clinics, 13 organizations with which Maimonides works Yes, BHIX provider portal & messaging system to send & receive information including real-time alerts when patient has inpatient, ED, psychiatric admission or discharge, care coordinators monitor these events. http://www.bhix.org 

http://www.maimonidesmed.org/Main/ClinicalServices/Psychiatry_45.aspx 

http://ehrintelligence.com/2013/04/03/brooklyn-hie-supports-mental-health-patients-coordinates-care/ 

http://statehieresources.org/wp-content/uploads/2013/01/Bright-Spots-Synthesis_Care-Coordination-Part-I_Final _012813.pdf

Kindred Health care, US (Post-acute care hospitals, nursing centers, rehab services) Varies by location, facilities in IN are exchanging through the IHIE 

ACO, InteractII Program, MA Challenge Grant

In a few communities, hospitals in their care markets, & physicians with plans to expand significantly with EHR implementation Yes, varies by location, 1 provider uses Direct to send UTF** through VPN for transition, Kindred is rolling out PCC EHR, planning for interoperable exchange in all care markets, starting with sending the CCD. http://www.kindredhealthcare.com
Senior Home Health, 22 HHAs, FL FL HIE 

Partners with ACOs across FL

Hospitals, physicians, other providers HHAs have EHR & can access HIE information including, medications & test results from other physicians, facilities. http://www.seniorhomecare.net 

http://www.florida-hie.net/

MD: 4 SNFs awarded funds for adoption of HIT to support improved transitions of care for patients as they transition between hospitals & their facility CRISP

Challenge Grant

Hospitals, other LTPAC providers Yes, providers query patients they are treating for information in the HIE. Information obtained through the portal can be printed & incorporated into records. 

Types of data available: patient demographics, lab results, radiology reports, medication fill history, discharge summaries, H&Ps, operative notes, & consults. 

ENS notifies providers when 1 of their patients has an encounter at a MD hospital. Alerts are sent via a Direct secure message or HL7 into an EHR system.

http://crisphealth.org/ 

http://www.times-news.com/local/x730873032/Nursing-homes-win-tech-grant 

http://crisphealth.org/FOR-PROVIDERS/Serivces-for-Long-Term-Care

Erickson Living Retirement Community, MD CRISP Challenge Grant Program Hospitals, physicians & CRISP partners   http://www.crisphealth.org
Golden Living Post-Acute Recovery Centers, Central IN IN HIE 

Central IN Beacon Community

Hospitals, LTPAC providers, community health & behavioral health centers Yes. http://www.ihie.org/ 

http://m.govhealthit.com/news/major-long-term-care-provider-signs-hie-deal 

http://www.goldenlivingcenters.com/home.aspx

Visiting Nurse Service of NY (VNSNY) NYCLIX (RHIO), Bronx RHIO, BHIX, NYCHHIP, LIPIX Hospitals, EDs, community health centers, SNFs, pharmacies, clinical labs, diagnostic imaging centers, etc. VNSNY enrolls physicians to use web portal to: manage their patient list with VNSNY; see current clinical information on their medications & other data; & review, sign or change the POC & modifications. The Web Portal is useful for physicians who have patients in home care, but whose EMRs cannot yet support electronic exchange of data with VNSNY or through RHIOs. VNSNY: accepts eReferrals & face-to-face attestations; display wound images & other data forms; & adapt more tightly to smartphones. 

A VNSNY allows the physician to: Refer patients electronically from the EMR, automatically drawing patient data from the EMR & adding instructions for home care. 

Receive the POC electronically, review & approve or change it, return it to VNSNY & file it in the EMR. 

Send & receive clinical messages electronically to & from VNSNY, & file a copy of the exchange in the EMR.

http://healthix.org 

http://www.vnsny.org/why-vnsny/getting-started/health-information-exchange 

http://www.vnsny.org/system/assets/0000/0548/HIEFactSheet102507-English.original.pdf?1226441761/

Rush University Medical Center (RUMC), Chicago, IL care transitions program, & HRS Home Care & partner SNFs (also study site visit) Currently no HIE, MetroChicago planned 

The Bridge Model--EDPP, Project BOOST, HRS has received a CMS/CMMI 3026 (CCTP) Grant, RUMC plans to connect with Chicago MetroChigago HIE Fall 2013 ACO in planning phase

HHA, SNFs, CBOs, aging services Rush has an EHR system (EPIC) & provides access to select EHR information to facilitate information sharing particularly during the pre-discharge phase when transition plans are being established. Uses multiple methods of HIE with LTSS, LTPAC providers & other community partners, ranging from phone, fax, mail & e-mail to a referral management system by Allscripts called ECIN which allows messages & attachments to be exchanged in a secure manner. For providers with Allscripts EHR, the information can be pulled into their EHR application. HIE primarily occurs in the transition of care process in the following areas:
  • Referral & assessment for placement and/or services.
  • Transfer of care.
  • Followup phone calls within 24-48 hours after transfer to ensure services are set up.
  • Clinical, demographic & service information is communicated by hospital case managers & care coordinators to community providers (HHA, other HCBS).
http://www.transitionalcare.org/the-bridge-model/ 

http://www.ehcca.com/presentations/readsummit2/golden_pc.pdf

Cleveland Clinic, HHA, Cleveland, OH 

Also small number of HIE initiatives for interfaces with specific LTPAC providers in OH

Private HIE for EPIC users, plans to join Clinisyc Clinical HIE 

PCMH pilot

Other EPIC users affiliated HHAs using Allscripts, & affiliated hospitals, outpatient 

In 1 Cleveland clinic facility, built interfaces with local SNF using PCC

SNF PCC Interfaces with EPIC; HHA Allscripts interfaces with EPIC. Will be moving to EPIC home health module soon. http://www.clinisync.org/ 

http://www.darkdaily.com/cleveland-clinic-and-university-hosptials-to-join-clinisync-ohios-statewide-health-information- exchange-329#axzz2tAnIEB6Z

DE: 48 SNFs connected DHIN NA NA, more information needed. http://www.dhin.org/
MN LTPAC providers, primarily SNFs CHIC through HIE-Bridge NA No, early in process of getting connected & participating. http://www.hiebridge.org/ 

http://www.medinfosystems.org/web_documents/part_c_release_for_website_posting.pdf

Litchfield Woods Health Care Center, SNF, CT Charlotte Hungerford Hospital Connect, Community HIE (Siemens Mobile MD HIE) Hospitals, HHA Yes, more information needed. http://www.athenahealthcare.com/CT_Litchfield_Woods.aspx
KS HHAs (3 identified) KHIN NA NA. http://www.khinonline.org/files/KHIN_Participants_Map/013114_map.pdf
Council on Aging of Southwestern OH, an AAA HealthBridge HIE 

Greater Cincinnati Beacon Community, ACO

NA Receive ADTs through Direct, admission alerts from hospitals, ED, More information NA. http://www.healthbridge.org/WhoWeServe/OtherProviders.aspx
Visiting Nurse Service of Greater Cincinnati, OH & Northern KY HealthBridge HIE 

Greater Cincinnati Beacon Community, ACO

Hospitals, primary care, health centers Receive ADTs through Direct, admission alerts from hospitals & ED. More information NA. http://www.healthbridge.org/Portals/0/GC%20Beacon%20Overview%20new%20v2%20final.pdf

http://www.healthbridge.org/WhoWeServe/OtherProviders.aspx

Central IL Health Information Exchange (CIHIE), connecting 30 LTPAC providers   Hospitals, ambulatory clinics, physician groups LTPAC providers MDS data converted to CCD format, & pulled into CIHIE, where it becomes part of the patient's longitudinal record that can be accessed by any provider in CIHIE through clinician portal. Organizations with EHR that can consume CCD can pull this MDS information into their system. http://cihie.org/ 

http://cihie.org/#/news/4553179412

NOTES: This table reflects HIE interventions identified from an environmental scan and literature review and is not intended to represent all HIE interventions and activities. Information regarding these interventions was gathered from a variety of sources, including telephone and e-mail inquiries; web sites, public or requested reports; presentations; webinars; and meeting summaries. All of these interventions have some type of electronic HIE. NA means more information was not readily available at the time of this report.

* AOD is Answers on Demand EHR software; PCC is Point Click Care EHR software.
** The UTF contains medication lists, advance directives, the patient's functional status such as activities of daily living (ADL) and instrumental ADL, treatment plans, and other data elements required by the next provider of care in order to seamless assume responsibility for the patient. 

CO=Colorado; CT=Connecticut; DE=Delaware; FL=Florida; IL=Illinois; IN=Indiana; KS=Kansas; KY=Kentucky; MA=Massachusetts; MD=Maryland; ME=Maine; MN=Minnesota; NY=New York; OH=Ohio; OK=Oklahoma; PA=Pennsylvania; RI=Rhode Island; TX=Texas; US=United States; UT=Utah; VT=Vermont.

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