Thursday, 17 December 2015 05:48

Duration and its Role in Valued Quality Coordination of Care

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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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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.