Does Long-Term Care Hold the Key to the ACO Puzzle?

As the timeline for accountable care organization (ACO) implementation ramps up, providers in every sector of the healthcare industry are scrambling to assess the value of buying into this new, more coordinated care model. Hospitals, health systems and physician groups have all been vocal in their opinions of the pros and cons associated with ACOs and shared savings. The long-term care industry, however, has been a bit more subdued. This isn't that surprising, as healthcare reform and its Meaningful Use guidelines - predecessor to the ACO concept - has not focused incentives and penalties on long-term care facilities.

puzzlepiececms"The long-term care facility industry has historically, from my perspective, not been part of the normal sort of conversation when people think about healthcare delivery, which has generally focused on physician practices and hospital/acute-care facilities," explains Ritu Agarwal, Ph.D., founder and director of the Center for Health Information and Decision Systems (CHIDS), as well as a professor and Dean's Chair of Information Systems at the University of Maryland's Robert H. Smith School of Business. "And now as they're slowly being brought into this ecosystem as key players - because so much money goes into long-term care - they are a bit late getting to the table."

Long-Term Care Vital to Preventing Readmissions

As accountable care concepts come more squarely into focus, however, providers to patients of all ages are realizing that long-term care facilities will need to be extended an invitation to the ACO fold, especially with regard to the role they have to play in preventing unnecessary readmissions.

"[Long-term care facilities] see their ability to communicate with the hospitals as influencing the referrals they receive," explains David Horrocks, President of the State of Maryland's Chesapeake Regional Information System for our Patients (CRISP). At the same time, Horrocks explains, these hospitals are going to be punished for readmissions. "There will be disincentives for that. Hospitals are not going to want to send someone to a long-term care facility that's not going to create a good continuum of care.

"What I hear from long-term care facilities is that there is a sense in the marketplace that coordination of care is going to be the name of the game as we move forward," Horrock emphasizes. "We're not quite sure what the mechanisms will be to incentivize that, but organizations are moving to improve their capacity to coordinate care, and long-term care has to be a part of that." 

With this realization comes questions around how best to bring skilled nursing homes up to speed technologically, and then coordinate data exchange amongst these organizations and their neighboring acute-care facilities and primary care physicians.

Coordinating the Coordination
Agarwal, Horrocks and their colleague Kenyon Crowley, Associate Director at CHIDS, are working to answer these questions and bring long-term care facilities and neighboring hospitals and physicians together through the use of a recently awarded Challenge Grant from the Office of the National Coordinator for Health Information Technology (ONC). The grant is designed to encourage health information exchange (HIE) innovation that can be leveraged by healthcare providers nationwide.

The purpose of the project, "Facilitating Effective Transitions of Care between Long-Term Care Facilities and Hospital Emergency Departments," is to leverage Maryland's operational statewide HIE to electronically share critical pieces of clinical information where they exist in real time, as residents of the state's long-term care facilities transition from one care setting to another.

"The frail elderly and disabled frequently move from long-term care facilities to acute-care hospital settings and back, receiving care from an array of providers with different objectives and access to oftentimes incomplete information," explains Crowley. "Medical records may be exchanged by delivery of paper records or via fax, which may cause delays, errors or confusion among providers. This can result in duplicative tests and procedures, frequent dosage modification, or adverse drug interactions. Further, in this fragmentary and uncertain information environment, it is often impossible for treating providers to align care with a patient's long-term treatment goal, or even that patient's stated wishes.

"Based on a preliminary environmental scan of Maryland's long-term care facilities and hospitals, the vast majority of patient-care transfers is accompanied by paper or faxed records. Anecdotally, geriatricians and other clinicians in long-term care settings in Maryland indicate that a great opportunity exists to provide more seamless, safer, effective and efficient care across the multiple settings where their patients receive care."

Maryland is currently home to 235 nursing homes. More than 77% are affiliated with a group, hospital, integrated system or regional chain. The state has some experience with information exchange of this kind. A Maryland-based continuing-care retirement community and an acute care hospital went live in 2007 with an HIE - the first of its kind in the nation that is still in use today.

Making a Measurable Difference
"The participants who are helping to build out the HIE have a good background in long-term care," says Horrocks, adding that "concerns about seniors showing up at the hospital with inadequate information was one of the problems that really got us going on HIE in the state."

According to Crowley, the program will develop a direct integration service to deliver clinical summary information directly to a facility's EMR, leveraging the state's CRISP HIE. Additionally, clinical discharge data will be made available via a portal to all facilities that currently lack an EMR system. Facilities may use the portal to route information to a fax or printer.

"Our evaluation will assess the intervention from a multidimensional perspective," he explains, "including healthcare outcomes, process measures that influence outcomes, organizational drivers of adoption and use, social factors and technical factors. By rigorously identifying the specific drivers and barriers to successful uptake and use, we hope to accelerate the meaningful use of HIE-based care transition solutions nationwide."

"The whole value proposition for HIE is predicated on the ability to make data liquid across different care providers in any geographic region," adds Agarwal. "I think the big part of the Challenge Grant is to demonstrate that this kind of HIE is going to improve outcomes - either related to cost or quality or both. What we're trying to do with this challenge grant is to say, 'if we stand up this infrastructure, can we actually show that the exchange of this information is having some demonstrable effect on things such as readmissions?'"

Moving Forward
The majority of hospital and long-term care facility participants are expected to go live on the HIE by the fourth quarter of this year. The project is expected to last through the first quarter of 2013, with the expectation being that its framework will be adopted by HIEs and long-term care facilities in other states.

"We have about 10 hospitals in the state that are connected now," says Horrocks. "We have another 20 that are in the testing process. We feel very optimistic that we'll make excellent progress on the hospital front over the next 12 months, perhaps even having every hospital in the state connected.

"On the long-term care front, it's a little trickier. We're not quite sure how best to integrate with facilities that are mostly paper based. So the work of the challenge grant is to really figure that out. The challenge grant work is really just starting, so we don't have any facilities that are connected, but we do have six that are committed."

Time will tell if Maryland's Challenge Grant project will work. Long-term care providers and vendors to this segment of the industry weigh in with their predictions in the second installment of this series: " Nursing Homes Vital to ACO Success? Depends on Whom You Ask?"