UTP Project

Executive Summary

im21: Sal Rasa, Barbara Kivowitz, Richard Weissberg, Terrence O’Malley, MD

 

INTRODUCTION

Effective transitions of care and coordination of care among providers are dependent upon accurate, relevant, and up-to-date information exchange. Standardized information exchange among acute and post-acute health care providers, and community based supportive care service providers, and patients/families/caregivers will enable Vermont to reach the next level of performance and service integration, with lower total medical expenditure (TME), lower readmission rates, and higher patient satisfaction.  Significant constraints on improved integration and coordination include the lack of

• agreed upon content,
• common information exchange processes, and
• access to a shared health information exchange platform.

 

A Unified Transfer Protocol provides an essential grounding for the health care infrastructure needed to address these deficits and to advance toward achieving the Triple Aim.

 

1.  Elements of the Universal Transfer Protocol (UTP)

Our charge is to develop the Universal Transfer Protocol required for the exchange of necessary information among providers, along with a set of performance expectations for the process of exchange and metrics for ongoing performance improvement.  The UTP is not a “form,” rather it is

1. a set of re-usable data elements,
2. rules that govern their communication/transmission/exchange
3. methodologies for the continual refinement of these elements and rules
4. performance metrics for the exchange of the data.

The UTP has the following characteristics:

• Applicable to a broad range of health care (HC) and long term support service (LTSS) providers
• Based on high value use cases (i.e. use cases which can further the triple aim and have the greatest positive impact on the greatest number of people)
• Modular — datasets can be organized into reusable prepackaged subsets.
• Iterative — continually evolving to meet changing needs
• Expandable to other service providers
• Standardized data elements
• Scalable
• Compatible with electronic exchange

 

1.  Population Focus

We must balance four  requirements around the issue of “Scope”:

1. Leverage work already done or underway in VT such as (these are just a few, unprioritized, examples):
   1. Bennington: ADRC, etc
   2. Rutland, St. Johnsbury, Burlington Learning Collaboratives
   3. State-wide initiative around TBI transitions
   4. Regional initiatives around substance abuse treatment and interdiction
2. Identify high priority  populations that use LTSS providers.  Example possibilities:
   1. Medicare beneficiaries over 60 years old, with their applicable services and service
   2. Dually eligible
   3. ACO patients
3. Identify  LTSS providers that contribute to the care of the largest number of individuals
4. Identify Use Cases that will produce the most comprehensive set of data elements
5. Perhaps use Medicare and Medicaid data to identify people with the most costly/complex care coordination needs.

In this phase of the UTP project, we will start with a single, representative high-risk population in a single geographic region. The data exchanges required among these initial service providers, patients, and family caregivers will be representative of other high-risk populations.  What we learn and develop for this population will be applicable to other populations and communities and serve as the platform for further expansion and refinement of the UTP.  The ultimate goal is to expand the UTP to encompass a broad range of populations, services, service providers, and locations across the state.

 

No matter what population(s) we start with, ultimately the UTP can be expanded to include other populations.  These populations could be people with known serious health health conditions such as:

• Severe and persistent chronic mental illness,
• Traumatic brain injuries,
• Chronic pain,
• Complex pediatric medical conditions,
• Substance abuse, and
• Over 60 with multiple chronic conditions, especially those dually eligible for Medicaid and Medicare.

 

Other populations may be people with known social risk factors.  Examples:

• Veterans
• Transitioning from incarceration
• Homeless
• Unemployed

 

III.  Service Focus

 

Our approach is to start with the high value service providers — those that treat our designated patient population in our designated geography — who are identified by individuals, caregivers, and health care professionals in that geography.  Our process is to build towards a future state that is as inclusive as possible and addresses the needs of all service providers required for the optimal outcome for each individual.  As additional high value exchanges are identified, the UTP might expand to include them in successive project phases,  such as (but not limited to):

 

• Patient and family caregivers (the family itself is a high value service provider)
• Supports for family caregivers
• Housing
• Transportation
• Meals
• Vocational education………………………………….
• Housing modification and maintenance
• Chore services
• HHA/Homemaker
• Recreational therapy
• Community integration
• Emergency response

We will also need to identify the use case or cases that will provide the context for the data exchanges.  This could include among others:

• Service intake (benefit to service providers and users)
• Eligibility determination (benefit to service providers)
• Referral management from request to service delivery to performance measurement:  (benefit to service providers)
• Readmission (benefit to hospitals and at risk entities)
• Admission avoidance (benefit to payers and State as risk bearing entities)

 

• ED admission avoidance (benefit to payers)

 

• EMS as home based triage and stabilization followed by HHA maintenance (ED avoidance)

1.  Project Process

1. Establish governance structure for project within VT
   • Who holds the overall responsibility for this project?
   • Who prioritizes and reviews deliverables?
   • Who determines the index population and location to develop and test UTP
   • Who selects Use Case(s) with the greatest applicability, ones that will provide the context for identifying the data exchange.  This could include:

• Service intake (benefit to service providers and users)
• Eligibility determination (benefit to service providers)
• Referral management from request to service delivery to performance measurement (benefit to service providers)
• Readmission (benefit to hospitals and at risk entities)
• Admission avoidance (benefit to payers and State as risk bearing entities)

 

• ED admission avoidance (benefit to payers)

 

• EMS as home based triage and stabilization followed by HHA maintenance (ED avoidance)

• Who provides ongoing project management and support, makes introductions, encourages and monitors participation
• Implement Community based approach to identify LTSS providers, patients, family caregivers, payers (including the ACOs and Blue Cross):
  • Ask health care service providers who they identify as LTSS providers
  • Ask community service providers to self-identify as LTSS providers
  • Ask individuals, their caretakers, family members to identify LTSS providers they have used
• Convene stakeholders (LTSS and “Health Care” providers)
  • Learn what the other service providers do, what services they provide
  • Identify a “value proposition” for stakeholder pairs
  • Identify what each stakeholder needs from the other stakeholders in order to provide their services
• Select one or more Use Cases
  • Identify stakeholder connections
  • Define data elements required within use case for each pair of stakeholders
  • Measure time spent by recipient to obtain required information that is not currently provided during an exchange (“Current state baseline”)
  • Measure the current time required by sender to collect, assemble and send the information to the recipient recognizing that it is incomplete (“Current state baseline”)
• Create data set that meets all stakeholder requirements for selected Use Case(s)
  • Test on paper
  • Refine
  • Measure time required by recipient to obtain required information that is not provided (“Post intervention performance”)
  • Measure time required by sender to collect, assemble and send the information needed by the recipient (“Post intervention performance”)
• Create exchange standards (UTP) mutually agreed upon by stakeholders
  • Completeness of information
  • Timeliness
  • Format
  • Process of exchange
• Assess with providers the extent to which they will need to change their internal processes, resources, sign-offs, etc. in order to exchange the required data.

The initial emphasis of this project is on the data to be exchanged, not how it is exchanged.  That said, this work will ultimately provide the basis for electronic information exchange by all stakeholders.  First, stakeholders will identify the information they need to receive, as they consider typical examples where efficient exchange of essential information could improve care.  Then later, when there is a compelling business case for exchange, performance gaps can be closed to make the exchange process as efficient as possible (and ultimately, as electronic as stakeholders’ infrastructure can accomodate).