LTSS providers routinely observe individuals in their homes. Their observations of function, behavior, medication adherence, and safety could be important to health care service providers who are required to report Medicaid Quality Measures and Meaningful Use attestation. The examples which are routinely monitored by LTSS providers are fall risk assessment, depression screening and observation of cognitive impairment without a formal diagnosis of dementia.
For a variety of reasons, these observations are not shared. However, that does not have to be the case. The process under development for the Universal Transfer Protocol among LTSS and health care providers applies as well to the process of exchanging these important observations in which only the information is transferred and not the individual. What is needed is a concerted effort to apply this process to these issues.
The process starts with the health care providers learning from their LTSS colleagues about the range of observations that are possible and the range of staff who are making them. From this, the health care providers can determine the current capabilities of the LTSS providers to make and report the observations of most value to them. Based on this information, the health care providers prioritize the observations they want to received based upon the value of these observations for patient care, safety, efficiency and reporting requirements.
For each item selected for reporting, the health care providers identify the specific observations that provide the greatest value. As the “receiver” of this information, they have the primary responsibility for defining what it is: the range and type of observations, who reports them, when and how they are reported. Fall risk, as an example, might require a specific set of observations using a standardized process. The “senders”, the LTSS providers, work with the health care providers to create a reliable set of observations that are reported in a standard manner.
Why would LTSS want to do “extra work” that gives them no direct benefit? First, they are contributing to improved care for their clients. Second, by demonstrating value to the health care service providers they open up a wider range of collaborations which might create funding opportunities. Third, at different times everyone is either a sender or a receiver of information; and the work LTSS does to improve performance for the health care providers is reciprocated when LTSS asks them for information that improves the quality, safety and efficiency of the services they provide to newly referred clients. What goes around, comes around.