LTPAC13: The shared task of care transitions and quality measurements

Long-term and post-acute care (LTPAC) organizations may think Meaningful Use (MU) incentives are really about hospitals, but they’re not anymore, says Larry Wolf, health IT strategist at Kindred Healthcare, in a presentation at the 2013 Long-Term and Post-Acute Care Health IT Summit in Baltimore.

As of May 2013, 81 percent of acute care providers are participating in the MU programs under the HITECH Act. By 2014, the earliest adopters of the MU incentives will be at Stage 2, which includes requirements for transitions of care, medical record sharing and discharge summaries.

The LTPAC organizations that have thought ahead on how to support transitions of care and discharge summaries may be reaping a business advantage in the near future. “MU stage 2 includes transitions of care, and 40 percent of those discharges will come to us [in LTPAC],” Wolf says. “Will we be able to receive them?”

Tracking the data

Linking your organization’s IT system to partners’ systems is a journey, says Larry Wolf, Health IT strategist, Kindred Healthcare. How much data does your IT system need to be capable of gathering and sharing? Here’s what’s involved already:

  • 175 CCD elements
  • 325 IMPACT data elements for basic TOC
  • 483 data elements for longitudinal coordination of care
  • QAPI and [add your organization’s own quality initiative data here]

“That’s just the tip of the iceberg,” Wolf says.

What is at the fore now is patient-centered care, and that requires a care team, Wolf says. “This is not about solo practitioners anymore. It’s a culture change. The accountabilities and processes are very different.”

The old cross-town attitude of ‘you hospitals do your job and we’ll do ours’ is long gone, Wolf explains. “We can’t do the things we’re charged with doing if we’re not active in the acute-care cycle.”

One of the challenges in any culture change is getting all sectors of staff and on board with un-siloed care models, he says. Kindred uses interdisciplinary care teams for all services, including transition-of-care nurses and clinical liaisons to keep the organization’s communications and processes with hopsitals at an optimum.

No organization can blaze this trail without accepting the shared responsibility of processes and outcome measurements—including when things go wrong. But shared accountabilities is also a powerful business driver, Wolf adds.

Kindred, for example, is participating in the CMS bundled payment program, using model #3. That means the organization is responsible for a 60-day span of care surrounding each patient admission, and charged with reducing Medicare costs by three percent. So, if a resident gets readmitted to a hospital within 60 days, the acute care costs are part of Kindred’s responsibility.

Once partners share penalties as well as goals, the way the partner organizations communicate and work together becomes paramount. Kindred maintains a joint quality committee with its partners to discuss processes, cost drivers and new opportunities for efficiency and quality measures. “We meet monthly and talk about processes. We don’t just meet for dinner once a year and thank each other for being good partners,” he says. “Outcomes measurement isn’t a 50,000-foot conversation. It’s an upfront and personal conversation.”

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