John F. Derr, RPh

John F. Derr, RPh is CEO of JD & Associates Enterprises specializing in Strategic Clinical Technology with a focus on person centric electronic longitudinal medication management and LTPAC. He has over fifty years of top executive level experience Squibb, Siemens, Tenet (NME), Kyocera, MediSpan and EVP of AHCA. He was SVP, CIO and CTO for Golden Living, LLC. He is a member of Corporate Boards providing guidance on clinical Health IT and medication management. He represents LTPAC and Pharmacy as a member of HHS HITECH Committee on Standards. Derr is a graduate of Purdue School of Pharmacy and a 2006 Distinguished Purdue Alumnus.

This article, the final in a series, summarizes the May 2015 Office of the National Coordinator for Health IT (ONC)brief prepared for Karen DeSalvo, M.D. on the Health Information Technology Use & Value Delivered by the Long Term & Post Acute Care (LTPAC) Sector. Previous articles outlined the five major valued quality coordinated care (VQCC) differentials of long-term post-acute care when compared to hospitals and physician offices.

The definitions of the five VQCCs listed below tell a unique story in the value proposition and quality of care and quality of life required in the new care and payment models in the spectrum of care.

1. Duration of Care Differential
  • Prolonged care duration over a hospital length of stay for continued diagnosis, care, and clinical outcomes
  • Person-centric clinical care, activities of daily living, and social observations over a long course of care
  • The development of a person-centric electronic longitudinal care plan
  • The trending of clinical information to establish alerts, early potential intervention and prevention care as well as a beginning of care maintenance and wellness goals.
2. Electronic Assessments Differential
  • A comprehensive clinical and functional total patient electronic assessment (e-assessment)
  • An e-assessment under the Centers for Medicare & Medicaid Services’ (CMS) regulations and approved standards that is updated to a schedule and as necessary
  • An e-assessment conducted by a coordinated team of licensed personnel in accordance with CMS regulations
  • Clinical knowledge over a long duration of time to allow an electronic medical record (EMR) software application to develop trending and alerts to potential incidents and prevent possible rehospitalizations, regardless of the site of care.
3. Chronic Care Comorbidity Care Differential
  • LTPAC providers as one of the first providers after hospital discharge to coordinate care, have coordinated staff, and use health information technology (HIT) capability to conduct chronic care comorbidity e-assessments
  • A complete clinical profile of the patient identifying the diagnostic care, treatment and/or maintenance plan, and observation requirements for chronic care and comorbidities
  • A person-centric longitudinal care record based on coordinated team care in a controlled environment
  • A plan that prepares the person (and family) for the next level of care or the home of their choice.
4. Medication Management Differential
  • Provides a comprehensive review of the whole person’s medication management and reconciliation by a licensed consultant pharmacist as it relates to all factors that affect the clinical outcomes of medications including laboratory, diet, and therapy. Clinical information reconciliation (CIR) includes medication reconciliation and medication indication for use, allergies, allergy intolerance or reactions
  • Reviews the hospital transition of care reconciled medication results as they pertain to medications taken before hospitalization and the potential drug interactions and manages polypharmacy, ensuring that each medication has an indication
  • Includes a nursing center with a medication team of the nurse, medical director, primary care provider, institutional pharmacy, and consultant pharmacist who conducts a comprehensive integrated person-centric management of medications in the electronic health record (EHR), electronic medication administration record, and in some nursing homesan automated medication-dispensing instrument
  • Provides medication counseling when transitioning to another provider or home.
5. Technology Differential
  • Provides a person-centric electronic longitudinal care EHR that covers a long duration of care
  • Aggregates all medical data functions over a long duration of care allowing trending and alerts to prevent incidents
  • Uses devices to track activities of daily living
  • Provides a controlled clinical environment where advanced clinical technology can be tested and utilized by hundreds of persons to assist in public health technology. 

In spite of this impressive list, the story of the value proposition of LTPAC is not over. There are two very important requirements that all members of the person-centric electronic longitudinal care with a focus on prevention and wellness will have to have to achieve success in the new value spectrum of care. They are:

  • Transitions of care (ToC) (interoperability) through certified standards
  • Secure, privacy, HIPAA, hack- and ransom-proof trusted systems.

Although LTPAC providers did not receive HIT incentive funds to upgrade their infrastructure, the technology vendors have responded to the need for operational efficiency and better care coordination at a cost that is scaled to LTPAC. The top LTPAC HIT vendors have upgraded their applications and are certified. Additionally there are cost-effective electronic document exchange applications, like Kno2, that are available for LTPAC that meet the requirements of ToC, replacing manual fax workflows with more efficient methods and standards in healthcare, like Direct, Carequality, Commonwell and IHE profiles.

There are corporations that can provide a comprehensive assessment of a provider and health IT vendor secure, privacy, HIPAA, hack-and-ransom proof like BlueOrange Compliance. Their systems were designed for LTPAC and hospitals. The business model is to be a partner in compliance and not just provide a report that sits on the shelf.

The value of LTPAC is slowly being understood and realized, as CMS proceeds at full speed to provide the regulations that have to be put in place to assure the new models of care and payment are successful. If the five VQCCs are understood by the partnerships in healthcare, those requiring care will receive a greater benefit from post-acute-care providers and their vendor supporters. More about ToC and compliance to come in upcoming articles.

About the Author

John F. Derr, RPh is CEO of JD & Associates Enterprises specializing in strategic clinical technology with a focus on person-centric electronic longitudinal medication management and LTPAC. He has more than 50 years of top executive level experience Squibb, Siemens, Tenet (NME), Kyocera, MediSpan and EVP of AHCA. He was SVP, CIO and CTO for Golden Living, LLC. He is a member of Corporate Boards providing guidance on clinical Health IT and medication management. He represents LTPAC and Pharmacy as a member of HHS HITECH Committee on Standards. Derr is a graduate of Purdue School of Pharmacy and a 2006 Distinguished Purdue Alumnus.

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This is the seventh article in a series addressing the value proposition of long-term, post-acute care (LTPAC) providers and health IT vendors. The articles focus on five major valued quality of care coordination (VQCC) differentials between LTPAC providers and acute/ambulatory care providers. This series is based on the LTPAC health IT collaborative ONC brief written in May 2015 for Karen B. DeSalvo, national coordinator for health informationtechnology and acting assistant secretary for health with the U.S. Department of Health and Human Services (HHS), titled Health Information Technology Use & Value Delivered by The Long-Term and Post-Acute Care (LTPAC) Sector. Readers can find the ONC Brief on the LTPAC Health IT Collaborative website.

Technology is a broad subject, and it includes much more than health information technology (IT). First we must expand on the word “technology.” Specifically, we must begin to talk about “clinical technology.” In today’s world and in the future, the two functions cannot exist separately. Clinical initiatives such as  quality measures, clinical outcomes, new pay and care models, and clinical partnerships are all in the mix. I have tried to get providers to understand that they have to be partners with their health IT vendor, and in the case of small, independent skilled nursing facilities (SNFs) and home health agencies (HHAs), I have suggested that the vendor sit in on strategic clinical meetings. The IT vendors have to think clinical technology, but the providers continually separate the two functions.

This is a slide I have used for years to illustrate that the past and current thinking is not the future. 

Since the release of the 2009 HITECH Act and the development of the meaningful use incentive program, when the LTPAC as well as behavorial health segments were left out, LTPAC health IT has been under secunity. I feel that it is the adoption of Health IT that is lagging behind; after all, the applications are available. If LTPAC were provided with financial assistance, the adoption rate would be much higher. ONC has done its very best to provide grant fundng, and the new Medicaid financing helps with interoperability, but it does not the assist the SNFs or HHAs in upgrading their electronic medical records (EMRs).

The important point in the  technology VQCC is that the technology in LTPAC is different than that of hospitals and physician offices. As we move to transitions of care, some technologies like telehealth and telemedicine, as well as interoperability technology, will bring the clinical technology of the three segments of care closer.

Hospital instrumentation includes areas such as computerized axial tomogaphy (CAT), magnetic resonance imaging (MRI), positron emission tomagraphy (PET), surgical, cardiac monitoring, etc. Health IT is an aggregation of departments to central billing by a person. There is not really enough time in a person’s LOS to develop a longitudinal record. Physician office technology has a person-centric focus to cover what the person is seeing the physician to fix. Health IT is being upgraded to develop a person-centric longitudinal care plan, but it’s going to be made up of personal input and long periods of time between visits – and a number of specialists becoming involved that are not part of the office practice (i.e. therapists).

The ONC brief states that the technology VQCC:

  • Provides a “person-centric electronic care EMR that covers a long duration of care;”
  • Aggregates all personal medical data functions over a long duration, allowing for trending and alerts to prevent incidents;
  • Uses devices to track activities of daily living; and
  • Provides a controlled clinical environment where advanced clinical technology can be tested and utilized by hundreds of persons to assist in public health technology.

The following is a quote from the ONC brief’s Appendix L:

“As previously stated, there are VQCC differentials between the care given in LTPAC and acute care. These VQCC differentials cannot be realized without state-of-the-art technology.


 

Various new technologies have been used in LTPAC and are being expanded by LTPAC providers, as this healthcare segment invests millions of dollars in the future healthcare system. The LTPAC provider has to aggregate clinical data from many sources of clinical services that are provided in longitudinal chronic care. These different clinical data sources are important over long periods of time, as they are interrelated to each other in longitudinal chronic care. Social and therapy care are interrelated to adjustments to daily living; comprehensive medication management are interrelated with diet and therapy; and the interrelationship between changes in condition, quality measure, and continuous eAssessments.”

As reported earlier in this series, persons with chronic conditions have to receive holistic longitudinal care during their stay in LTPAC, especially in SNFs and long-term acute-care hospitals (LTACHs). This requires clinical technology to be in harmony with the diagnosis, treatment, care plan, and discharge plan when going through the transition of care to another provider setting or to the home. This is longitudinal care and planning, not static episodic care. As an example, dieticians and social workers are very important to chronic care patients, as well as those in LTPAC who are in rehabilitation. As reported on a o-Net OnLine 2016 summary report, dieticians and nutritionists use various electronic devices to measure body weight and other metrics, including metabolic carts, glucose monitors, bioelectric impedance machines, and wearable fitness monitors for physiological as well as various analytical or scientific purposes. Numerous new device applications are being released to aid monitoring persons in LTPAC.

The leading LTPAC health IT vendors have spent millions of dollars on upgrading their EMRs to include longitudinal plans, clinical decision software, interoperability applications, integration of assisted living/home care/hospice software, activities of daily life monitoring, and integration of therapy/medication/social/diet needs.

At the April meeting of the Society for Post-Acute and Long-Term Care Medicine (formerly the American Medical Directors Association, or AMDA), one of the leading health IT vendors presented a roadmap of their current capabilities in the support of the new LTPAC EMR.

            


 

 

The other leading health IT vendors also have similar capability. So the answer to health IT in the LTPAC sector is the have all the providers on the most current EMR software technology.

SNFs, LTACHs, independent rehabilitation facilities (IRF), and other providers have sophisticated therapy technology, and it is being improved daily with new API applications that monitor therapy outcomes. ALFs are also starting to incorporate therapy instrumentation so the residents can maintain their rehabilitation plans and prevent re-hospitalization. With the increase in sensors and wearables, therapy is going to be a more sophisticated clinical technology.

One of the least known technologies in SNFs is their mockup home environment facilities. Most SNFs have an area set aside that is a mockup of a person’s home. The nurses and therapists teach patients on rehabilitation, plus how they can live with their disability. Examples are toilet training, cooking, and just getting around the home while rehabilitating or living their new life with a disability. Home care nurses then can build on this training when they visit persons in their home. SNFs also involve family members, loved ones, and caregivers so they can assist the patient when they return home.

 

In another area, first, there is some confusion as to the difference between telehealth and telemedicine. This confusion has continued as Congress and other agencies have begun to comprehend the advantage of these two clinical technologies in the new care models. For the purposes of this article, telehealth is the monitoring of a patient’s health and environment, usually in their home. It is used to acquire vital signs and to provide an early warning to the HHA nurse or the caregiver should issues arise. The accountable care organizations (ACOs) are looking to adopt telehealth monitoring to give alerts between visits of a caregiver or warning of an impending re-hospitalization. Telemedicine on the other hand is real-time electronic visual and audio communication between two or more healthcare professionals concerning a person’s medical condition. New technology such as the iPhone and iPad has replaced large costly video instrumentation that was mostly unaffordable.

Home health agencies and the VA have been using telehealth monitoring devices for years. It has been reported by the VA that they have over 5,000 veterans using a telehealth monitoring device report their daily activities and other measurements to a care coordinator so the VA can take action to prevent an incident causing a hospitalization.


 

This next form of clinical technology is going to cause the biggest changes in longitudinal care. The ability to clinically and wirelessly monitor a person as they and their caregiver team take them through rehabilitation and maintenance of their chronic conditions will lead us into the preventative stage of healthcare. In SNFs you can visualize patients with an iWatch to measure vital signs integrated into the longitudinal EMR. Or sensors measuring rehabilitation outcome improvements integrated with clinical decision software to monitor changes and provide alerts when the plan is not going in the right direction as programed for the best clinical outcome.

Clinical technology will continue to advance and be available to LTPAC to use in their capability of initiating the person-centric electronic longitudinal care record while the patient is in the care of a LTPAC provider.

The major barriers to success are:

  • Widespread recognition of the VQCC differentials and their value to the spectrum of care providers;
  • Recognition of the need and value by non-LTPAC providers;
  • Reimbursement of the costs of clinical technology in payment risk models; and
  • Understanding of the value to long-range clinical outcomes of a comprehensive longitudinal record with analytic integration of all clinical elements, trending, and preventative alerts.

About the Author

John F. Derr, RPh is CEO of JD & Associates Enterprises, specializing in strategic clinical technology with a focus on person-centric electronic longitudinal medication management and LTPAC. He has over 50 years of top executive-level experience with Squibb, Siemens, Tenet (NME), Kyocera, MediSpan and EVP of AHCA. He was SVP, CIO and CTO for Golden Living, LLC. He is a member of corporate boards providing guidance on clinical Health IT and medication management. He represents LTPAC and pharmacy as a member of the HHS HITECH Committee on Standards. Derr is a graduate of Purdue School of Pharmacy and a 2006 Distinguished Purdue Alumnus.

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Comment on this Article

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john derrThis is the sixth article in a series addressing the value proposition of long-term, post-acute care (LTPAC) providers and LTPAC health IT vendors. The articles focus on five major valued quality of care coordination (VQCC) differentials between LTPAC providers and acute/ambulatory care providers. This series of articles is based on the LTPAC health IT collaborative ONC brief written in May 2015 for Karen B. DeSalvo, national coordinator for health information technology and acting assistant secretary for health with the U.S. Department of Health and Human Services (HHS), titled Health Information Technology Use & Value Delivered by The Long-Term and Post-Acute Care (LTPAC) Sector.

Readers can find the complete ONC brief on the LTPAC HIT Collaborative website (http://www.ltpachealthit.org/sites/default/files/ONC%20Brief%20LTPAC%20HIT%20Value%20and%20Use_May%201%202015.pdf).

The first three VQCC value proposition differentials were duration; eAssessments; and chronic care. The fourth VQCC is medication management. The VQCC LTPAC medication management differential:

  • Provides for a comprehensive review of each patient’s medication management and reconciliation by a licensed consultant pharmacist as it relates to all factors that affect the clinical outcomes of medications, including laboratory, diet, and therapy. Clinical information reconciliation (CIR) addresses medication reconciliation, medication indication for use, allergies, allergy intolerance, and reactions.
  • Provides for a review of the hospital transition-of-care reconciled medication results as it pertains to medications taken before hospitalization, potential drug interactions, and polypharmacy. It ensures that each medication has an indication.
  • Ensures that skilled nursing facilities (SNFs) have a medication team comprised of the nurse, medical director, primary care provider, institutional pharmacy, and consultant pharmacist to conduct comprehensive, integrated, person-centric management of medications. This also involves the electronic health record (EHR), electronic medication administration record, and in some nursing homes,an automated medication dispensing instrument.  
  • Provides for medication counseling when a patient transitions to another provider or home.

Medication management is very important to every patient, but it’s more important when a patient is being transitioned from an acute-care setting to a SNF or home healthcare agency (HHA) and then to their home. This is especially critical when the patient requires chronic care and has comorbidities. The second VCQQ, chronic care, notes how important LTPAC diagnosis, care provision, and maintenance are to patients requiring chronic care, and how these persons make up a large percentage of Medicare costs. One of the important aims in chronic care is to establish each patient’s medications and then provide medication management in order to meet the indicators established by the prescribing physician and to prevent polypharmacy. As pointed out in the previous VQCC bullet points, the ideal provider location to establish a patient’s medication regimen is an SNF.

In 2016, Rand Corporation performed a literature review of medication reconciliation and summarized that:

  • Medication reconciliation (MR) is a national patient safety goal.
  • Approximately half of hospital-related medication errors and 20 percent of adverse drug events (ADEs) occur during transitions, admission, transfer, or discharge from a hospital.
  • Seventy-five percent of medication errors are preventable.
  • The economic impact of medication errors is substantial.
  • MR is the most common type of health system error.
  • Preventable ADEs are associated with one in five injuries or deaths from errors.
  • Drug-related morbidity and mortality estimates were approximately $177 billion in 2000.

What is medication management? There are many different definitions describing the processes and regulations. To list only a few, there is medication therapy management (MTM), medication management (MM), medication reconciliation (MR), and drug regimen review (DRR). It is my belief that this involves not just one clinical element, process, or form, but a management of a person’s medications throughout their life and across their spectrum of care (if they are under professional care). In my research I found a very comprehensive definition in the 2012 Patient-Centered Primary Care Collaborative (PCPCC) Resource Guide on “The Patient-Centered Home: Integrating Comprehensive Medication Management to Optimize Patient Outcomes” (https://www.pcpcc.org/sites/default/files/media/medmanagement.pdf):

“Comprehensive medication management is defined as the standard of care that ensures each patient’s medications (whether they are prescription, nonprescription, alternative, traditional, vitamins, or nutritional supplements) are individually assessed to determine that each medication is appropriate for the patient, effective for the medical condition, safe given the comorbidities and other medications being taken, and able to be taken by the patient as intended. Comprehensive medication management includes an individualized care plan that achieves the intended goals of therapy with appropriate follow-up to determine actual patient outcomes. This all occurs because the patient understands, agrees with, and actively participates in the treatment regimen, thus optimizing each patient’s medication experience and clinical outcomes.”

I realize that this definition is referring to a person in their home, but in transitions of care from an episodic incident, over 40 percent of the time the person is transitioned to a SNF, which becomes their home for a short period of time for rehabilitation. The SNF has the time, professional staff, and capability to develop and include medication management in a person-centric, electronic longitudinal plan before the person is transitioned to their home of choice or to a HHA.

Medication source is a barrier to true medication management. There is a big push on medication reconciliation (MR) lists, especially when it comes to rehospitalization. But a list is just a list, and whoever is filling out the MR list should ensure that it is accurate.

In today’s world medications can be acquired from various sources, including the retail pharmacist, hospital clinical pharmacist, senior pharmacist, and consultant pharmacist. The medications can be obtained from various pharmacies as prescriptions or over-the-counter medications. The trend of relabeling prescription medications to over-the-counter continues, and these medications can cause adverse drug reactions. MR requires the collection of data from various sources, not just what the hospital provided before the transition of care.

An SNF represents a tightly controlled, closed environment that uses an institution pharmacy to provide medications. Today’s leading LTPAC clinical technology vendors have incorporated an electronic medication administration record (eMAR) to assist nurses in their medication administration. An eMAR, as defined by CMS, automatically tracks medications from order to administration using assistive technologies.

The MR also incorporates the act of reconciling any discrepancies between lists. The Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014 also requires a standardized MR. In the SNF, the process is assisted by a licensed consultant pharmacist supported by the American Society of Consultant Pharmacists (ASCP). Many of these consultant pharmacists are also certified by the Commission for Certification in Geriatric Pharmacy (CCGP) and are very valuable in chronic care and polypharmacy.

Gaps in True Medication Management

True, comprehensive medication management has to be a closed, continuous process throughout the spectrum of care, especially for persons requiring chronic care. The major gap is in the transition of care, when a comprehensive MR has to be conducted and transmitted electronically to the next care setting. The following is an example graphic of a transition of a person from their episodic incident to their home. At each transition of care (ToC) point, there is a possible discrepancy in the MR.

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There are also gaps within the SNF medication management process that would improve what already is the best provider site to establish medication within a comprehensive EMR. First, within the SNF’s EMR, there has to be an integrated system incorporating all clinical technology that affects the patient’s medication management, as well as an integration of the consultant pharmacist software application, which provides medication review.

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Another gap is in the administration of the medications. Today, in the majority of SNFs, there is a medication cart that is filled with the medication punch cards from the institutional pharmacy with a 30-day supply of a patient’s medications. This manual process causes problems when medications are changed or when the patient is transitioned from the facility. Unused medications that are already paid for are a cost problem for SNFs.

This long has been a manual process, but it can be automated. As an example, below are two graphics; the first demonstrates the traditional distribution on medications and the second depicts the use of a medication-dispensing instrument.

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There are a number of companies that provide instrumentation for medication runs within SNFs. One of these is the Talyst’s InSite System. This in-facility medication dispenser is designed for improving the medication supply chain into SNFs, and medication management within SNFs, thereby aligning them more closely with acute-care medication management practices. The InSite System is being expanded to make it the authoritative SNF informatics hub, wherein real-time data aggregation, data visualization, and even simulations occur among data a) from medication therapy and regimen management; b) from medication prescribing practices and other physicians’ orders; and c) from medication administration outcomes noted in nurses’ clinical notes, and from in-facility EHRs and eMAR. Having an in-facility medication dispenser will eliminate a gap in the process and also eliminate medication waste.

Another gap in true medication management involves polypharmacy. Polypharmacy is defined by one medical dictionary as “the practice of administering many different medicines, especially concurrently, for the treatment of the same disease (and) the concurrent use of multiple medications by a patient to treat usually coexisting conditions and which may result in adverse drug interactions.”

This can happen with various sources of medications, especially when a person is going through transitions between provider sites.

The emerging field of pharmacogenomics offers a very valuable tool in eliminating polypharmacy issues. It will help eliminate unnecessary medications and ensure that medication is correct for each individual patient as we move into personalized medicine. The National Institutes of Health (NIH) U.S. National Library of Medicine defines the field like so:

“Pharmacogenomics is the study of how genes affect a person’s response to drugs. This relatively new field combines pharmacology (the science of drugs) and genomics (the study of genes and their functions) to develop effective, safe medications and doses that will be tailored to a person’s genetic makeup.

Many drugs that are currently available are ‘one size fits all,’ but they don't work the same way for everyone. It can be difficult to predict who will benefit from a medication, who will not respond at all, and who will experience negative side effects (called adverse drug reactions). Adverse drug reactions are a significant cause of hospitalizations and deaths in the United States. With the knowledge gained from the Human Genome Project, researchers are learning how inherited differences in genes affect the body’s response to medications. These genetic differences will be used to predict whether a medication will be effective for a particular person and to help prevent adverse drug reactions.” (https://ghr.nlm.nih.gov/primer/genomicresearch/pharmacogenomics)

The medical, pharmacist, and LTPAC communities are just starting to realize the value of pharmacogenomics solving polypharmacy issues and improving quality of life for geriatric persons requiring chronic care. One of the major obstacles is the cost of the laboratory tests. In order to establish some quantifiable documentation on the cost savings, there was a study with the following conclusion:

“A recent study by the University of Utah on the comprehensive approach to medication management, based on the YouScript CDS system, demonstrated a 39-percent reduction in hospitalizations and a 71-percent reduction in emergency department visits among a cohort of elderly, polypharmacy-treated patients subjected to CYP genetic testing and comprehensive interaction management in the four months following testing. In total, more than 95 percent of prescribing physicians found the CDS-generated reports helpful and approximately a half implemented recommended changes in patient medication regimens.” (Brixner D, Biltaji E, Bress A et al. The effect of pharmacogenetic profiling with clinical decision support tool on healthcare resource utilization and estimated costs in the elderly exposed to polupharmacy. J. Med. Econ. 19, 1–40 (2015). http://www.futuremedicine.com/doi/abs/10.2217/pme.15.47)

Summary

The VQCC differential of medication management is very important in providing personally tailored healthcare and utilizing the advantages of an SNF. When the gaps noted above are closed, the SNF will be one of the best medication management sites in the spectrum of care because of the other VQCCs noted, especially the duration of stay and the professional environment.

About the Author

John F. Derr, RPh is CEO of JD & Associates Enterprises, specializing in strategic clinical technology with a focus on person-centric electronic longitudinal medication management and LTPAC. He has more than 50 years of top executive-level experience with Squibb, Siemens, Tenet (NME), Kyocera, MediSpan, and EVP of AHCA. He was SVP, CIO, and CTO for Golden Living, LLC. He is a member of corporate boards providing guidance on clinical healthcare IT and medication management. He represents LTPAC and pharmacy as a member of the U.S. Department of Health and Human Services (HHS) HITECH Committee on Standards. Derr is a graduate of the Purdue School of Pharmacy and a 2006 Distinguished Purdue Alumnus.

Contact the Author

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Comment on this Article

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This is the fifth article in a series addressing the value proposition of long-term, post-acute care (LTPAC) providers and health IT vendors. The articles focus on five major valued quality of care coordination (VQCC) differentials between LTPAC providers and acute/ambulatory care providers. This series of articles is based on the LTPAC health IT collaborative ONC brief written in May 2015 for Karen B. DeSalvo, national coordinator for health information technology and acting assistant secretary for health with the U.S. Department of Health and Human Services (HHS), titled Health Information Technology Use & Value Delivered by The Long-Term and Post-Acute Care (LTPAC) Sector.

Readers can find the complete ONC brief on the LTPAC HIT Collaborative website.

The following is a summary table of the five VQCC differentials cited in the ONC brief. Articles have been published on the first two differentials (duration and e-assessments).

This article is about what might be the most important VQCC differential: chronic care comorbidities. Why is chronic care the most important of the five differentials? The major reasons are:

An aging population: The fact that the Medicare program has experienced a large influx of new enrollees during recent years isn’t new news. What might be new is the anticipated rapid future growth of the program’s enrollees in their early to mid-80s. Mark Parkinson, MD, president and CEO of the American Health Care Association (AHCA), noted in a recent speech at the Direct Supply DSSI Forum in February that this age group had flat growth from 2012-2015. This caused a census issue in skilled nursing facilities (SNFs). As you can see from the graph, after 2015 and through 2030, the number of people over 80 is projected to increase at a rapid rate. This group includes the elderly, who are most prone to requiring chronic care.


 

 

 

Cost of care: There have been many papers written on the cost of care for the segment of the elderly population that have chronic conditions. Most of these patients have more than one chronic condition and are classified as complex chronic care patients with comorbidities.

 


 

Quality of care: As we shift from fee-for-service to value-based care, there are many programs that can be leveraged to harmonize quality measures across the spectrum of care. Most of these deal with single disease states and not quality measures associated with those with multiple chronic conditions with comorbidities. It will be difficult to really measure quality indicators on a complex chronic care patient, as the conditions are interactive, as well as the polypharmacy used in medication management. This means that developers of quality measures (QMs) will have a difficult time measuring metrics for one chronic care patient while referencing another or a segment of the population, especially across the spectrum of care.

Regulations: CMS has recognized the issue of the importance of caring for the chronic care patient with comorbidities, not only for their high costs of episodic care, but for their quality of life. Specifically, the agency noted:

“The Centers for Medicare & Medicaid Services (CMS) recognizes care management as one of the critical components of primary care that contributes to better health and care for individuals, as well as reduced spending.

Beginning Jan. 1, 2015, Medicare pays separately under the Medicare Physician Fee Schedule (PFS) under American Medical Association Current Procedural Terminology (CPT) code 99490 for non-face-to-face care coordination services furnished to Medicare beneficiaries with multiple chronic conditions. (Ref: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ChronicCareManagement.pdf ).

What does this mean to LTPAC and the VQCC differentials? In other care settings, there is often not enough time and professional support to diagnose, treat, stabilize, maintain, and set up a comprehensive, holistic chronic care plan. In the ONC brief, this is explained:

“VQCC No. 3, LTPAC Chronic Care – Co-Morbidity Care Differential LTPAC Providers, as (some) of the first providers after hospital discharge to coordinate care, have:

  • Coordination of staff and health IT capability to conduct chronic care co-morbidity as well as standard e-assessments;
  • A complete clinical profile of the patient, identifying the diagnostic, care, treatment, and/or maintenance plan; and observation requirements for chronic care and co-morbidities;
  • A person-centric longitudinal care record based on coordinated team care in a controlled environment; and
  • A plan that prepares the patient (and his or her family) for the next level of care or the home of their choice (see Appendix J of the ONC brief for more information).”

LTPAC value proposition: Mainly in skilled nursing facilities and home health agencies, there is an opportunity to develop the chronic care patient’s person-centric electronic longitudinal care record, and to be able to transition this care plan to the next care setting. Assisted living facilities using the clinical model and long-term acute-care hospitals also have an opportunity to develop the chronic care longitudinal care record, as do some of the new care models in which professionals make calls on chronic care patients in their homes. SNFs have been working with the complete chronic care model for years. It has remained in the paper clinical record and there has been very little trending and aggregating, except maybe in the minds of the caregivers. The SNF is the primary care facility that can develop the patient’s first person-centric electronic longitudinal chronic care record. They have the five VQCC differentials, which all build on the care of the patient (including No.1, duration, No. 2, e-assessments, No. 4, medication management, and No. 5, technology). The person-centric electronic longitudinal care plan was defined in a previous article in this series. Basically, it is the electronic aggregation of all the clinical elements of a patient collected over a period of time in order to develop trending, alerts, and the introduction of clinical decision software to get to preventative care and wellness.

The advantage of the chronic care patient with co-morbidities having his or her first transition of care from a hospital episodic incident to rehabilitation could be the development of the person’s first chronic care longitudinal care plan being passed on to the next care site. This is a major value proposition that is currently being ignored as we look at patients in single disease states.

 

About the Author

John F. Derr, RPh, is CEO of JD & Associates Enterprises, specializing in strategic clinical technology with a focus on person-centric electronic longitudinal medication management and LTPAC. He has over 50 years of top executive-level experience with Squibb, Siemens, Tenet (NME), Kyocera, MediSpan, and EVP of AHCA. He was SVP, CIO, and CTO for Golden Living, LLC. He is a member of corporate boards providing guidance on clinical health IT and medication management. He represents LTPAC and pharmacy as a member of HHS HITECH Committee on Standards. Derr is a graduate of the Purdue School of Pharmacy and a 2006 distinguished Purdue alumnus.

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This is the fourth article in a series of articles addressing the value proposition of long-term, post-acute care (LTPAC) providers and health IT vendors. These articles are based on the LTPAC health IT collaborative brief written in May 2015 for Karen B. DeSalvo, national coordinator for health information technology and acting assistant secretary for health with the U.S. Department of Health and Human Services (HHS), titled Health Information Technology Use & Value Delivered By The Long-Term & Post-Acute Care (LTPAC) Sector.

To assist the first-time readers of this series, the following was covered in the first three articles:

The first article, published in October 2015, included an overview of the LTPAC sector of care and the role that these providers play in the spectrum of care, as well as the percentage of hospital discharges that are transitioned to LTPAC providers. 

The second article, published in November 2015, introduced the five VQCC differentials that the LTPAC provider care sector has, as compared to the ambulatory and acute-care sectors. This also introduced a suggested definition of person-centric electronic longitudinal care.

The third article, published in December 2015, focused on the second value quality coordination of care (VQCC) duration differential that LTPAC has in the quality proposition of the new spectrum of care. LTPAC providers have persons under their care in an controlled environment, with physicians, nurses, pharmacists, therapists, dietitians, social professionals, etc. available for diagnosis, care, the creation of a person-centric longitudinal care plan, and the establishing of a maintenance plan for rehabilitation in the transition to the next care site.

This article will address the second VCQQ: eAssessments. Each LTPAC provider is required to conduct electronic assessments. The regulation requiring the performance of a Centers for Medicare & Medicaid Services (CMS) standard electronic assessment went into effect years before the Health Information Technology for Economic and Clinical Health (HITECH) Act. Initially, the eAssessment was required to ensure that specified care was conducted at a specific time for each patient. As the years have passed, however, eAssessments have been used more in the development of the person-centric longitudinal care record and predicative medicine. You cannot have a longitudinal record that looks at a medical condition over time without having a standard electronic assessment tool on which to build the trending of medical elements and alerts. Today there are software programs that can assist the provider in trending specific conditions that could predict the possibility of a re-hospitalization. The provider has to be aware that the required timing of conducting an assessment nonetheless might be too late to predict a re-hospitalization. 

The major VQCC eAssessment differentials that LTPAC providers have, as compared with those of the other providers listed in Appendix I of the ONC brief, are:

  • A comprehensive clinical and functional electronic assessment of the patient;
  • An eAssessment performed in adherence with CMS regulations and approved standards that is updated to a schedule and altered as necessary;
  • An eAssessment conducted by a coordinated team of licensed personnel in accordance with CMS regulations; and
  • Clinical knowledge over a long duration of time, allowing an electronic medical record (EMR) software application to develop pattern recognition and alerts to potential incidents, preventing re-hospitalizations regardless of the site of care.

Some think of the eAssessment as an EMR. In my conversations with CMS personnel and others developing the updated eAssessments, however, it has become clear that it is not the intention of CMS to have the eAssessment serve as the EMR. The eAssessment should be a byproduct of a comprehensive enterprise EMR. It is worrisome that some leaders of independent skilled nursing facilities (SNFs) and home health agencies think that the SNF MDS and the HHA OASIS is their clinical EMR. Today’s EMRs are very comprehensive in how they acquire data, apply analytics, and provide professional care providers the information and knowledge required to produce high quality of care and improved quality outcomes. The eAssessment is developed and submitted from the EMR.

The following is a 2015 graph that is being updated as CMS develops eAssessments that fit into person-centric electronic longitudinal care plans through the spectrum of care. As you may know, eAssessments across the spectrum of care have to be in harmony, as we do not want a person going from one site to the next to have a different clinical assessment just because he or she changed sites or went home.


 

Why are eAssessments a VQCC differential advantage in the value proposition of care? Non-LTPAC providers certainly perform patient assessments, and most are electronic, but typically they are based on an incident and are not holistic. As we become more involved in treating complex chronic care conditions with comorbidities, we have to have holistic assessments that are in harmony.

Today the LTPAC arena tends to be the site that a person’s chronic conditions are diagnosed and managed. The reason is that the VQCC of duration provides the time and professional resources to accomplish standardized holistic eAssessments over a reasonable period of time. Informal, non-standard eAssessments will not accomplish the objective of creating a person-centric longitudinal care plan with a focus on prevention and wellness. This will be addressed in the next article, which will cover VQCC No. 3: chronic care.

Please read the other articles in this series by John Derr addressing the value proposition of long-term, post-acute care (LTPAC) providers and health IT vendors:

LTPAC Providers to Play Key Role as VBP Takes Hold

VQCC Differentials to Impact Providers: A Brief History of Changes in Long-Term, Post-Acute Care – Part 2

Duration and its Role in Valued Quality Coordination of Care

About the Author

John F. Derr, RPh, is CEO of JD & Associates Enterprises, specializing in strategic clinical technology with a focus on person-centric electronic longitudinal medication management and LTPAC. He has over 50 years of top executive-level experience with Squibb, Siemens, Tenet (NME), Kyocera, MediSpan, and AHCA. He was SVP, CIO, and CTO for Golden Living, LLC. He is a member of corporate boards providing guidance on clinical health IT and medication management. He represents LTPAC and pharmacy as a member of HHS HITECH Committee on Standards. 

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This is the third article in a series on the value of long-term, post-acute care providers (LTPACs) and health IT vendors. These articles are based on the LTPAC Health IT Collaborative Brief written in May 2015 for Karen B. DeSalvo, M.D., M.PH., M.Sc., national coordinator for health information technology and acting assistant secretary for health with the U.S. Department of Health and Human Services (HHS); the brief is titled Health Information Technology Use and Value Delivered By The Long-Term & Post-Acute Care (LTPAC) Sector.

To address any first-time readers of this series, the following was covered in the first two articles:

The article published Oct. 27 featured an overview of the LTPAC sector of care and the role that these providers play in the spectrum of care, as well as the percentage of hospital discharges that are transitioned to LTPAC providers.

The article published Nov. 20 introduced the five valued quality coordination of care (VQCC) differentials that the LTPAC provider care sector works with as compared to the ambulatory and acute-care sectors. This article also introduced a suggested definition of person-centric electronic longitudinal care to provide a basis of the VQCCs: “the aggregation of a person’s medical data points over a period of time, established using analytic trends to determine a person-centric, normal health state while healthy or ill – and to set off alarms when the trending begins to go the wrong direction, allowing for the consideration of an intervention.”

The second article also contained a table of the five VQCCs and their comparison to LTPAC, which is repeated here as background.

This article will focus on VQCC No. 1 – Duration of care differential. In summary, this is defined as:

  • Prolonged care duration over a hospital length of stay for continued diagnosis, care, and clinical outcomes;
  • Person-centric clinical care, activities of daily living, and social observations over a long course of care;
  • The development of a person-centric electronic longitudinal care plan; and
  • The trending of clinical information to establish alerts, early potential intervention, and preventive care, as well as a beginning of care maintenance and wellness goals.

Why is duration an important VQCC?

In today’s episodic care healthcare system, duration could be defined as the time it takes to fix a person’s problem – or it could be defined as the time a person spends with their primary care provider or the physician in the hospital. Length of stay (LOS) is an important measurement in the hospital DRGs. Duration of time from hospital discharge to a possible re-hospitalization is an important measurement in the hospital reimbursement penalty program. Very seldom is duration thought of as a time when a person-centric care plan can be established to prevent incidents and to engage the patient in their own prevention of a new disease (or the prevention of acerbating the current condition). The payment systems based on “fixing” do not allow the time to set the baselines for prevention. This is especially true with patients with comorbidities requiring chronic care.

What is required to change the definition of duration, and where does LTPAC play a role?

Coordination of the care team is becoming an important requirement in person-centric longitudinal care because there are various care providers involved during each patient’s travels though their spectrum of care. We strive to ensure that each patient receives the right care at the right time in the right place at the right cost, and I have always added “at the patient’s right acuity,” which incorporates chronic care conditions.

Care coordination was defined in 2007 by the Agency for Healthcare Research and Quality of the U.S. Department of Health and Human Services, as:

“Care coordination is the deliberate organization of patient care activities between two or more participants 

(including the patient)  involved in a patient’s care to facilitate the appropriate delivery of healthcare services. Organizing care involves the marshaling of personnel and other resources needed to carry out all required care activities, and is often managed by the exchange of information among participants responsible for the different aspects of care.”

This process of coordination of the various aspects of person-centric care has to be handled in a controlled environment where all the necessary care professionals and services can work together. It is difficult to set the parameters of quality of care without professionals working as a team in a controlled environment over a reasonable duration.

I don’t want anyone reading this article to conclude that I am recommending extending the duration of care or length of stay in a hospital or with an LTPAC provider. I think if the current LOS assigned to care plans is of sufficient duration, we simply must add to our focus of fixing the establishing of the person-centric longitudinal care record and using the transitions of care standard electronic health record to pass on the longitudinal plan to the next provider site to add to the proper data elements and analytics.

These are the factors that may require a longer duration of care than what is provided in the hospital LOS or the infrequent visits to the physician’s office:

  • Assessments of the person’s total health condition over a period of time (VQCC No. 2)
  • Chronic care conditions leading to comorbidities (VQCC No. 3)
  • Medication management, including polypharmacy (VQCC No. 4)
  • Conditions of daily living
  • Evaluation of the person’s health leading up to the hospital incident
  • Necessary long-term rehabilitation therapy
  • Behavioral health
  • Social observations
  • Family observations

Duration is an LTPAC VQCC differential because within skilled nursing facilities (SNFs) and long-term, acute-care hospitals (LTACHs), there is a team of professionals (physicians, nurses, pharmacists, therapists, dietitians, social professionals) at work. With home care and hospice agencies there is a long duration of care with the access to other care professionals. Even the evolution of the assisted living and CCRC can provide the duration of care and observation required, establishing a longitudinal care plan and moving us into a preventative model with each patient engaged in their own health.

The barrier is reimbursement for resources required to develop the coordination care team and the person-centric electronic longitudinal care record. The duration of stay within LTPAC is sufficient if the electronic medical record (EMR) software is a current version. The top LTPAC software applications will provide a longitudinal record, and they are working on proving analytics that are predictive and moving in the direction of preventative medicine. The LTPAC also has the time and the expertise to train each person under their care on their new activities of life and their new quality-of-life parameters, as well as learning how to live in their home of choice.

In summary, the care coordination team’s utilization of the duration of stay in LTPAC affords the healthcare system and the care coordination team the opportunity to start the person-centric electronic longitudinal record. The primary objective of the LTPAC provider and the health IT vendor developers is always to provide a high quality of care with positive clinical outcomes to successfully treat the episodic event that caused the admission to LTPAC. But, if reimbursed, the secondary objective could be to develop the person-centric electronic longitudinal care record for the transition to the next member of the care coordination team to follow up and to engage the person in his or her own treatment. In many respects, longitudinal care is already being done in many progressive LTPAC settings, but it is not always recognized.

About the Author

John F. Derr, RPh is CEO of JD & Associates Enterprises specializing in Strategic Clinical Technology with a focus on person centric electronic longitudinal medication management and LTPAC. He has over fifty years of top executive level experience Squibb, Siemens, Tenet (NME), Kyocera, MediSpan and EVP of AHCA. He was SVP, CIO and CTO for Golden Living, LLC. He is a member of Corporate Boards providing guidance on clinical Health IT and medication management. He represents LTPAC and Pharmacy as a member of HHS HITECH Committee on Standards. Derr is a graduate of Purdue School of Pharmacy and a 2006 Distinguished Purdue Alumnus.

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This is the second in a series of articles concerning long-term post-acute care (LTPAC) providers and vendors. In this article I will introduce the five major Valued Quality Care Coordination (VQCC) differentials and their value proposition as compared to other healthcare providers. In later articles I will go through each VQCC differential.

In May 2015, Dr. Karen DeSalvo, MD, of the Office of the National Coordinator (ONC) asked me to provide her with a brief on LTPAC. At first I jumped to the conclusion that I would write a paper about all the regulations that seem to have been piled on this sector of healthcare, the cuts in reimbursement, and finally the fact that we were left out of the 2009 ARRA HITECH Act incentive program to digitize and upgrade health information technology. After mulling a negative approach, I decided that other advocates of LTPAC have made a case for the regulatory pressures placed on this sector of care and that I would look at the glass as being half full, documenting the positive differentials of LTPAC care and the value we bring in coordinating care for individuals who are among the most vulnerable, clinically complex, and in many cases, the most costly. This value of LTPAC complements the role of acute and ambulatory care providers, making the sector a valuable partner to support patient-centered, longitudinal care. I also thought that the ONC brief should be quantifiable – not just a narrative, but containing facts about the value proposition of LTPAC.

In 2004, at the press conference for President Bush’s executive order digitizing healthcare and forming the Office of the National Coordinator, then-Secretary Thompson asked me to coordinate LTPAC. At the time I was executive vice president of the American Health Care Association/National Center for Assisted Living (AHCA/NCAL). I felt it was important to form an informal organization of the LTPAC provider and vendor stakeholders. At the time there was no single organization to represent the many providers and vendors that I outlined in an October VBPmonitor article. One of the problems that we faced in AHCA/NCAL was that our sector of care spoke to the regulatory agencies in multiple tongues and did not provide a single perspective on issues. I felt that when it came to clinical technology, we had to work together.

In 2005, AHCA/NCAL, LeadingAge, and the American Health Information Management Association (AHIMA) formed an informal group called the LTPAC Health IT Collaborative. The Collaborative is made up of the stakeholders in LTPAC that are represented by this slide of their logos:

Since 2005 we have had a conference call once a week on average, held a LTPAC Health IT Summit every June, and written four LTPAC Health IT road maps. The Collaborative has provided comments in response to every major health IT request for comments. This activity has been very important, as since we were not included in the HITECH Act, we could not have provided comments on the evolving field of clinical technology. Even though we were not to be included officially in the ONC programs, we were listened to by the directors and staff of ONC and given grants and other programs to ensure that we were included in spirit – especially in the area of interoperability and continuity of care across the spectrum of services in this era of person-centric electronic longitudinal care.


 

Before President Bush’s executive order and after, LTPAC has provided person-centric electronic longitudinal care within their settings. After 2005, the Collaborative focused on this ultimate goal of the HITECH Act. LTPAC providers and vendors had to focus on longitudinal care because of the lengths of stay of the people under their care. This sector was not made up of episodic, acute-care providers, and when a person was under LTPAC care, it was more than the 3-5 days typically spent in a hospital or the mere minutes that persons were seen by a physician in their office.

What is longitudinal care? The legal definition is yet to be formed. At least I have not found a legal definition. To this point in implementing the HITECH Act, the term has been defined by how it is used. As an example, a few HIMSS meetings ago it was defined as the transition of a patient from a hospital to the home, longitudinally. If we are truly going to realize a healthcare system that features person-centric, longitudinal care with a focus on prevention and wellness, we have to define longitudinal care somewhat. My suggestion is as follows:

It is the aggregation of a person’s medical data points over a period of time established using analytic trends to determine a person-centric, normal health state while healthy or ill – and to set off alarms when the trending begins to go the wrong direction, allowing for the consideration of an intervention.

Of course, those wielding the power of regulations, etc. can place their own definition on longitudinal care, but they should to come up with something like this.

LTPAC providers are the only providers that see a person long enough in a controlled environment to establish a longitudinal care record, and duration is the first VQCC differential that was presented in the ONC brief. Below is a table of the VQCC differentials that will be discussed in the next five articles.

Using duration as an advantage easily can be misinterpreted, as can the term “long-term care.” This is especially true in an era in which we are trying to cut length of stay (LOS) and transition a person to their home of choice as soon as it is clinically advisable. Taking duration as an advantage might be interpreted as wanting a person to remain under care for longer than necessary in order to maximize reimbursement. Like longitudinal service, duration of stay within a provider’s care should be what is necessary and no more. If we are to establish a baseline longitudinal care record, a person should be in a controlled environment for a short period of time with healthcare professionals available (physicians, nurses, pharmacists, therapists, dietitians, social, etc.) to develop a longitudinal coordination of care plan, which can be transferred to the next provider of care through the transitions of care interoperability.

As you will see in future articles, LTPAC (or what we might now call “post-acute care”) is the ideal provider to establish the baseline electronic longitudinal care record, and in doing so, it should be reimbursed for the care it provides in developing the longitudinal care plan. The following table provides a future look into the five VQCC differentials.

About the Author

John F. Derr, RPh is CEO of JD & Associates Enterprises, specializing in strategic clinical technology with a focus on person-centric electronic longitudinal medication management and LTPAC. He has over 50 years of top executive-level experience with Squibb, Siemens, Tenet (NME), Kyocera, MediSpan, and EVP of AHCA. He also has served as SVP, CIO and CTO for Golden Living, LLC. He is a member of corporate boards providing guidance on clinical health IT and medication management. He represents LTPAC and pharmacy as a member of the HHS HITECH Committee on Standards. Derr is a graduate of the Purdue School of Pharmacy and a 2006 Distinguished Purdue Alumnus.

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This is the first in a series of VBPmonitor articles on the long-term, post-acute care (LTPAC) healthcare segment. LTPAC is the third major healthcare segment in the spectrum of healthcare providers, with the other two being acute care (hospitals) and ambulatory care (physicians).

In order to understand the role of LTPAC providers in the evolving spectrum of care, one must understand the providers of care that make up LTPAC. This can most easily be illustrated by the following graphic:

In 2004, President Bush signed an executive order to digitize healthcare and formed the sub-cabinet-level position of the Office of the National Coordinator for Health Information Technology (ONC). At the time there was no budget to form a ONC division of the U.S. Department of Health and Human Services (HHS) to develop the program. In 2005, the LTPAC HIT Collaborative was formed to coordinate all of the LTPAC associations in matters that concerned clinical technology. The Collaborative is the only group that has a LTPAC HIT focus, and it has held an annual LTPAC HIT summit since 2005 and published many roadmaps that are in harmony with the ONC roadmaps.

It was not until the 2009 ARRA HITECH Act was passed and the program financed and defined that the ONC Department gained financing and structure. The HITECH Act established an incentive program based on standards to establish the electronic health record (EHR). It defined the two eligible providers (EPs) that would receive financial incentives to update their health IT systems in order to meet the criteria of meaningful use (MU). These two EPs were hospitals and physicians. The legislation left out two important primary care providers: LTPAC and behavioral health (BH). Behavioral health crosses all care providers but has its own health IT requirements.

It was illogical that LTPAC was omitted from the HITECH Act, as 40-60 percent of those discharged from hospitals go to nursing centers (SNFs) or home health agencies (HHAs) for post-acute care to prevent re-hospitalization. The following graphic illustrates to where patients are discharged from a hospital episodic event:

In the years since the passage of the HITECH Act it has become obvious that LTPAC providers and software vendors play an important role in achieving the ultimate goal of person-centric, electronic longitudinal care with a focus on prevention and wellness. In today’s provider partnership care coordination payment models, it is important that all providers of care understand their roles as well as the roles and responsibilities of their care partners in person-centered coordinated care.

ONC has supported the inclusion of LTPAC providers in many effective grant programs even though there were not incentive monies to assist LTPAC providers to upgrade their health IT systems. The LTPAC sector did not just fold its arms and refuse to participate, however. The providers and support services understood that they were very valuable partners in longitudinal care and had a great deal to offer the new healthcare system in achieving the objectives of the HITECH. In spite of being left out of the HITECH Act, the LTPAC community has continued to prepare for inclusion even though their Medicare and Medicaid reimbursements have not provided the funds to upgrade their health IT infrastructure; both the provider and software vendors have moved forward because interoperability and care coordination speaks to a higher level of quality of care and quality of life. Besides, the LTPAC provider has been providing longitudinal care for years, as these providers have patients under their care in a controlled environment of healthcare professionals for a longer period of time than any other provider. This does not include the Medicare/Medicaid dual-eligible residents living in SNFs, as they do not have any other place to live.

This article and future articles in this series pertain to the short-term care patients who are under care for post-operative rehabilitation, chronic disease management, and other complex conditions that require a short period of time in a controlled healthcare professional environment before moving to the home of the person’s choice. The typical length of stay in a nursing center is from 10-15 days.

In May 2015, the ONC asked the LTPAC HIT Collaborative to produce a brief on the LTPAC Value Proposition and Valued Quality Care Coordination (VQCC) differentials between all provider healthcare sectors. In the ONC brief there were five major VQCC differentials that were identified. It is these that will form the basis for the subsequent articles in this series.

About the Author

John F. Derr, RPh, is CEO of JD & Associates Enterprises, specializing in strategic clinical technology with a focus on person-centric electronic longitudinal medication management and LTPAC. He has over 50 years of top executive-level experience with Squibb, Siemens, Tenet (NME), Kyocera, MediSpan, and EVP of AHCA. He was SVP, CIO, and CTO for Golden Living, LLC. He is a member of corporate boards providing guidance on clinical health IT and medication management. He represents LTPAC and pharmacy as a member of HHS HITECH Committee on Standards. Derr is a graduate of Purdue School of Pharmacy and a 2006 Distinguished Purdue Alumnus.

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