Long-Term and Post-Acute Care Providers Engaged in Health Information Exchange: Final Report. Health Information Exchange Related Measures

10/29/2013

TABLE J-7. HIE by Care Coordination Function and Partners, Eastern Maine HomeCare

EMHC does not report or identify any specific HIE measures. They report the 33 required quality measures as a Pioneer ACO. These measures are detailed in Attac hment J-1.

Transitions of Care
Care Coordination Function Across Members of the Care Team Within Affiliated Organization Between Staff in an Organization and Other Non-Affiliated Care Providers Including Community Services Between Staff in an Organization and Patient/Family Members Type of Exchange Data Sender and Receiver
Assessment/Referral
Preadmission Assessment Hospital care manager to post-acute care provider liaison for assessment & discharge planning    
  • Telephone
  • In-person
  • Participation in rounding
  • Hospital EHR
  • Demographics
  • Problem list
  • Medication list
  • Progress Notes
  • H&P
  • Information available on HIN
Hospital care manager to post-acute care liaison & central intake
Home Care intake gathers relevant information from multiple sources for use by EMHC    
  • Phone
  • Hospital
  • EHR
  • HIN
  • Discharge summary
  • Operative report
  • Diagnosis
  • Consults
  • Recent labs
Hospital, physician office & home care intake
Referral for Community Services Hospital care manager to community services when patient does not qualify for home health or SNF services    
  • Telephone
  • Demographics
  • Problem list
  • Medication list
  • Progress Notes
  • H&P
  • Information available on HIN
Hospital care manager to community coordinator
Patient input on Community Services     Hospital Care Managers with Patient & Family to build the discharge POC.
  • In-person interview
  • Patient Goals
  • Choices offered
  • Choices accepted
Patient care manager & patient/family
Transition of Care (transfer or discharge)
Transfer/Admission to LTPAC Order for Home Care    
  • Verbal Order for Home Care & paper copy
  • Physician's discharge order to home care
Hospital to EMHC Central Intake
Discharge Information from LTPAC Provider to Patient     Discharge POC developed by home care for patient.
  • Paper
  • Discharge POC & instructions
Home care to patient and/or caregiver
ADT Event Data to HIE Network   Home Care ADT feeds to HIN (2 way).  
  • ADT messages
  • ADT message
Home care EHR to HIE

TABLE J-8. Shared Care Information Exchange Activities

Shared Care
Care Coordination Function Across Members of the Care Team Within Affiliated Organization Between Staff in an Organization and Other Non-Affiliated Care Providers Including Community Services Between Staff in an Organization and Patient/Family Members Type of Exchange Data Sender and Receiver
Assess Needs and Goals
Initial Assessment & Development of Admission Plan Nurse and/or therapist assesses patient & develops POC.    
  • HIN
  • PowerChart
  • Access
  • EMHC Local Network (W Drive) where intake staff save a patient's medical record documentation received during preadmission
  • Discharge summary
  • Op report
  • Diagnosis
  • Consults, recent labs
  • History data from HIN
Central Intake & Nurse Manager and/or Therapist
Coordination with physician at Start of Care including Medication Reconciliation & Orders, Evaluation/ Certification & Plan of Care Medication reconciliation upon admission to home health care with Primary Care Manager.    
  • Phone
  • 485 POC
  • Medications & other order changes
Home care nurse & Patient Care Manager in PCMH
Start of care, orders & plan coordinated with physician. (Nurse calls the physician from the patient's home)    
  • Phone
  • 485 POC
  • Medications
  • Treatment orders
  • Discharge Summary
Home care nurse calls the attending physician
Pilot Pharmacy Student for Medication Reconciliation: Start of care, orders & plan--when therapist completes the start of care in a patient's home, a pharmacy student assists with medication reconciliation      
  • Medication history information
  • Hospital discharge summary
  • HIN
  • PowerChart
Pharmacy Student & Therapist & Physician
Physician reviews & signs 485 POC    
  • Home Care EHR Physician Portal
  • Fax
  • Home Care POC
Home care to Physician
Data to HIE Network   Physician POC sent to HIN for inclusion on HIE.  
  • Electronic from home care EHR to HIN
  • Home Care POC
Home care EHR to HIN
Create and Maintain Plan of Care
Care Management/ Community Care Team Meetings Coordinate care management functions with Patient Care Manager in the PCMH    
  • Telephone
  • PowerChart
  • HIN
  • POC
  • Order Changes
Home Care Nurse Manager & PCMH Patient Care Manager
Monitor, Followup, and Respond to Change
Transmission of telehealth data from patient     Patient submits telehealth data via devices for monitoring by EMHC telehealth nurse.
  • Telehealth Devices
  • Web-based EHR
  • Telehealth clinical measure data
Patient to telehealth home care nurse
Change in condition/ status update and/or order change request to attending physician Physician order changes & signature on new orders    
  • Phone to obtain new order
  • Physician portal
  • Fax
  • Order
Home care to Physician
Referral to Community Care Team Referral to CCT if patient is not meeting goals & additional services are needed    
  • Phone
  • Progress notes
  • POC
Home care nurse to manager to CCT care manager
  Participate in CCT meetings when patient is also in PCMH and/or utilizing services of CCT    
  • In-person
  • Progress notes
  • New orders
  • Care plan
Home care to CCT
Coordination with physician for ongoing Orders, Evaluation/ Certification & Plan of Care Physician recertification    
  • EHR Portal for physicians to log in, review & sign
  • Fax
  • Home care POC
  • HIN
Home care to Physician

TABLE J-9. Other Information Exchange Activities

Other Exchange Activities
Care Coordination Function Across Members of the Care Team Within Affiliated Organization Between Staff in an Organization and Other Non-Affiliated Care Providers Including Community Services Between Staff in an Organization and Patient/Family Members Type of Exchange Data Sender and Receiver
Quality Measure
Electronic submission of mandatory data sets which includes quality measures   Submission of OASIS data which includes CMS required quality measure data.  
  • Electronic
  • OASIS data
Home care to CMS
  Submission of Hospice quality measures.  
  • Electronic
  • Required Hospice quality measure data
Hospice to CMS
ACO Measures Pioneer ACO Measures (EMHS) Pioneer ACO Measures (EMHS ACO Partners).  
  • EHR and/or -
  • Excel Spreadsheet
  • 33 Pioneer ACO Measures
Home care to ACO data repository
Public Health
  Unknown          
Payment
Payer Medical Records Requests   Remittance, medical review, or RAC request for medical records.  
  • Billing system
  • Photocopies
  • Mail
  • Relevant medical record documentation
HIM & Billing to Payer

 

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