LCC Use Case 2.0 ParagraphAs the number of Health Concerns increases, the health care of that individual becomes more complex. Often this complexity is manifested by acute and chronic issues that intertwine and create management dilemmas, care in multiple sites by multiple care team members and an increased risk of care plan failure resulting in admissions and readmissions. Each additional problem, team member and site of care increases the complexity of care. Recent Medicare data (2012 Chartbook) showed that of individuals with six or more chronic conditions, two thirds were hospitalized and 16% were hospitalized 3 or more times in 2010. Of the 1.9 million readmissions in 2010, 98% occurred in individuals with two or more chronic conditions, and 14% of Medicare beneficiaries with six or more chronic conditions accounted for 70% of all readmissions. Only 1% of beneficiaries with 0-1 chronic conditions received care in PAC settings (SNF, LTAC, IRF and Home Care), while 41% of those with six or more chronic conditions received PAC care. Nearly half of these individuals had 13 or more PCP office visits in 2010; and 70% had at least one ER visit and 27% had three or more visits. In order to avoid gaps in care, conflicting interventions and duplicate services, these individuals with complex medical, behavioral and functional issues require a care plan that can be shared across sites and teams. This use case examines the requirements for two high volume exchanges: the transfer of a care plan between a Hospital-based Team to a Home Health Agency based team and the individual’s Primary Care Team (PCMH), between the Primary Care Team and the full Community Based Care Team.

Assumptions:• Although there may be some overlap in the Home Health-Based and Community-Based Teams, these are treated as separate teams• 1A and 1B could occur at the same time

Discussion:• A patient can be discharged from the hospital to home health, primary care, community based, meals on wheels, transportation, etc.

Discharge orders and referrals may or may not go from the hospital to the receiving care provider. The only certainty is that it goes to the physician and patient. The community based team members may not even be recognized by the hospital or physician.

• We will not focus on the technology (Direct, fax, e-fax, etc) for the exchange of information between teams. We will only focus on the information flow, functional requirements, and content.

• This diagram does not reflect our previous discussion of 2 types of exchanges. 1). medically complex patient (high risk) 2). general patient• Open Question: Is there any form of electronic exchange between Hospital and Community-based Non-Medical Team?• Need to include a statement in the Background section of the Use Case stating that several of the information exchanges between teams

is not / may not be electronic

Scenario 1A• Exchange of care plan from hospital team to PCP/Primary Care team. The

team members listed are a subset of the potential team members.

Scenario 1B• The exchange of a care plan from the Hospital Team to the Home Health

Agency-based Team.

Scenario 2• Exchange of a care plan between the Primary Care Team and the

Community-based team.

Patient Stories• Two patient stories, same patient with different degrees of complicating issues.

High Complexity Moderate Complexity

a Diabetes a Diabetesb Glycemic control b Glycemic controlc Diabetic Foot Ulcer - h Neuropathyd non weight-bearing on ulcer i Gait impairmente dressing changes and monitoring n Depression/anxiety - f Retinopathy p COPDg Low vision v Environmenth Neuropathy x Lack of supportsi Gait impairment aa Lives alone, 3rd Floor Walkup j Chronic pain dd Health Maintenancek Infectious Disease ee Vaccinationsl MRSA colonization of foot ulcer ff Cardiovascular risk factors

m Positive PPD gg Suicide risk assessmentn Depression/anxiety - hh Poor complianceo Cognitive Impairment ii Dietp COPD jj Medicationsq Substance Abuse kk Follow-up carer Intermittent opiate abuse ll PCPs Alcoholism mm Opthalmology t Smoking nn Psychu Malnutritionv Environmentx Lack of supportsy Lack of access to appropriate dietz Social isolation

aa Lives alone, 3rd Floor Walkup bb Unable to drivecc Limited mobilitydd Health Maintenanceee Vaccinationsff Cardiovascular risk factorsgg Suicide risk assessmenthh Poor complianceii Dietjj Medications

kk Follow-up carell PCP

mm Opthalmology nn Psychoo Smoking

Hospital-Based Care Team

Community-based care Medical Team

Community-Based Care Non-Medical Team

Primary Care Team

Home Health Care Team

Nursing Home

DME provider

Hospice

Other

DME provider

Labs

Pharmacy

Out-patient therapy

Meals on Wheels

Housing Services

Transportation

Other

Patient

1

1

2

2A

A

Lines1: Current state. Note: This obfuscates (and thus allows for variation in) the current state of HIE between the hospital and the community based medical team. E.g.:• Do hospital exchange info with:

• only the CB doc?• The HHA?• The OPT provider?• Do CB doc exchange info w/ other members of the CB

medical team?

• Can we for purposes of this UC state that the current state of affairs is diverse and varies.

Lines2: Use Case Scenarios

Hospital-based Care Team

Community-based Care Team (Non-Medical)

PatientCommunity-based

Care Team (Medical)Primary Care Team

Home Health Care Team

Nursing Home

DME Provider

Hospice

Out-Patient Therapy

DME Provider

Pharmacy

Labs

Meals on Wheels

Housing Services

Transportation

Other

Hospital-based Care

Team

Community-based Care Team

(Non-Medical)

Primary Care Team

Home Health Care Team

Nursing Home

DME Provider

Hospice

Out-Patient Therapy

DME Provider

Pharmacy

Labs

Meals on Wheels

Housing Services

Transportation

Other

Primary Care Team

Home w/ No Services

Home w/ Services

Home Health Agency

Home w/ Services Other Certifying

Physician

FROM TO Hosp Team Specialist PCMH HHA CBO

Hosp Team B A A C

Specialist C C C B C

PCMH C B A A

HHA C B A A

CBO C C C C C

Priority/Frequency of Exchange of Care Plans

Hospital-based Care Team to PCMH only

HHA Team

PCMH Team

Specialist

CBO Team

Hospital-based Care Team to HHA

HHA TeamPCMH Team Specialist

CBO Team

Hospital-based Care Team to PCMH and Specialist

HHA Team

PCMH Team Specialist

CBO Team

Communication on discharge to PCMH and Specialist

Then: PCMH to HHA and CBO

Then HHA to CBO