The changes on the horizon for delivery and payment of health care services including LTPAC necessitate changes in how information is shared across the health care spectrum. A number of efforts are underway to support states' ability to engage LTPAC in exchange activities and address the challenges discussed above. A number of state grant programs highlight the need to address LTPAC or focus funding.
ONC State HIE Cooperative Agreement Program: Through ONC, states were eligible for grants to facilitate the secure movement of health information using nationally recognized standards. The grants supported the development and implementation of a state HIT plan to support the exchange and use of health information in the state and focus efforts primarily on those provides eligible for meaningful use incentive payments. Fifty-six states and territories were eligible and received grants.34
ONC Challenge Grants: As described in section III: HITECH Focuses on Key Priorities for HIT, ONC issued four Challenge Grants to states to focus on improving LTPAC transitions. These efforts can provide a model to other states for engaging LTPAC in HIE.35
ONC Beacon Community Cooperative Agreement Program: As described in section III: HITECH Focuses on Key Priorities for HIT, ONC awarded 17 grants to several communities to use HIT and HIE capabilities to improve care coordination, quality of care and slow growth of care spending. A few Beacon Community Programs -- Rhode Island, Maine and Pennsylvania -- include a focus on LTPAC providers. Pennsylvania's Geisinger Keystone Beacon is focusing on connecting their community including nursing homes and home health agencies to improve care coordination, quality and efficiency by using the Patient Assessment Summary discussed in section V: Exchanging Standardized Assessment Content for Patient Assessment Summary Documents.36
CMS State Medicaid HIT Plans (SMHPs): As part of the HITECH Medicaid Incentive Program, state Medicaid agencies were directed to begin conversations with a range of stakeholders to develop solutions for how the Medicaid EHR Incentive Program will operate in the context of larger health systems and statewide efforts. States were asked to develop an SMHP which serves as the Medicaid HIT vision document. The SMHP integrates the statewide HIT plan developed under the ONC grant program and contains at least four components: A current landscape assessment, a vision of the state's HIT future, specific actions necessary to implement the EHR incentive program, and an HIT roadmap. To accomplish this plan, states will initiate discussions and activities with a diverse group of individuals, organizations and institutions from within the state government (including long-term care) and with persons outside the state government.37
Other tools and resources have been developed or are under development to assist states with addressing how to engage LTPAC in HIT plans and HIE activities. ONC posted a "Vulnerable Population Report" on the State HIE Resources web site.38 The Vulnerable Population Report, produced by ASPE and private sector representatives, describes LTPAC (and behavioral health) population and providers, how states could engage these providers and support the meaningful use program and eligible providers and eligible hospitals.
Further, ONC sponsored a five-year study with the NGA Center for Best Practices to better understand the states' HIE needs with respect to long-term care. NGA conducted a technical expert panel meeting and coordinated meetings with state HIT officials in conjunction with ONC Regional Extension Center and Beacon Communities meetings. NGA published an issue brief summarizing the findings and concluded that there is great promise for electronic exchange of health information for improving quality and potentially reducing health care costs once LTCFs begin connecting to broader state HIE activities.39 The NGA issue brief highlighted the following common challenges identified by states to integrate long-term care into HIE efforts:40, 41
Lack of funding/payment incentives to adopt HIT and EHRs: States have generally prioritized their focus on incentivized providers. Although they understand the value of engaging LTPAC providers, the path to greater integration is largely unclear and not uniform among states.
Inaccessibility of data: Inadequate information in an inconsistent structure is a significant barrier. Clinical data in LTPAC is often fragmented due to antiquated record systems that collect only a portion of a patient's health information. Information such as the MDS is reported to CMS in real-time, but that data cannot be shared across care providers and may not include all relevant information.
Workforce issues: To effectively use and deploy HIT, staff in LTPAC settings need to be skilled and well trained. The ability to attract skilled information technology workers is a challenge. The information technology workforce in LTPAC frequently has high turnover rates and typically lower education and health care training.
Lack of standardization of EHRs: There is a lack of standardized data collection methods in the various LTPAC settings that leads to challenges in care coordination functions such as treatment history, referrals and transfers. CCHIT has certified EHR programs unique to LTPAC but adoption by LTPAC vendors has been low.
Multiple and competing state health initiatives running in parallel: States are coordinating multiple initiatives including sustaining Medicaid, implementing health care reform, and controlling health care costs. As a result, state HIT efforts have largely focused on the meaningful use incentive program for eligible providers and hospitals. The result has been fewer resources for ineligible providers such as LTPAC.
As part of its study on integrating long-term care in HIT, the NGA noted that despite the challenges, states are taking steps to engage LTPAC providers and made the following recommendations to states:42
Understand the LTPAC Environment and Engage Stakeholders: NGA recommended that states conduct an environmental scan of LTC facilities, providers, care centers and others to understand their landscape and key challenges. For example, some states have conducted a survey of the LTPAC providers and their readiness/interest in HIE activities. States could bring LTPAC stakeholders into workgroups and planning efforts to identify specific actions for change.
Incorporate Long-Term Care into Ongoing State Strategic HIT Plans: States could look for opportunities to establish goals and bring LTPAC into their state strategic and operational plans as well as their HIE outreach plans.
Utilize Regulatory and Policy Levers: States could use their regulatory process to develop and advance HIE across the state including LTPAC; attempt to drive the market using purchasing from state programs and Medicaid; and convene payers to make a case for better integration of long-term care and HIE to help push the market toward adoption.
In addition, ONC has convened meetings to raise awareness about the need to exchange health information across the health care enterprise, including the LTPAC sector. ONC convened a town hall meeting at the 2011 LTPAC HIT Summit43 to make available information regarding state HIE activities that include LTPAC providers. In October 2011, ONC and private sector foundations hosted a working meeting -- Putting the IT in TransITions44 -- of innovators, policymakers, and HIT experts, providers, and others to identify how HIT could be used to support some of the challenges in transitions in care. In addition, in November 2011, ONC hosted a meeting for State Health IT Coordinators, Beacon Communities, and other entities. A session during this meeting was focused on increasing awareness of and opportunities and methods for engaging LTPAC providers in HIE activities.
The work developed under this study and described in this report provides important information, resources and tools that states could leverage to address some of the challenges identified by the NGA and advance HIE on behalf of LTPAC patients and providers. As described, the MDS 3.0 and OASIS are electronic data sets collected on persons served by most nursing homes and home health agencies. When content and exchange standards are applied to the MDS 3.0 and OASIS assessments, the data can be re-used and shared with other health care providers in an efficient and cost-effective manner. The ability to exchange other clinical information (such as medication information) beyond the MDS and OASIS is a critical step, and can be linked with widely available assessment information to support more robust HIE opportunities.
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