Northwest Regional Council’s Aging & Disability Resource Center (ADRC) implemented the evidence-based hospital-to-home Care Transitions Intervention® (CTI). The ADRC partnered with Whatcom County Health Information Network (HInet) to expand use of an electronic personal health record and communication tool to enhance outcomes for the care transition participants. The electronic PHR is free for residents of two counties targeted by the ADRC’s CTI program. The electronic PHR was implemented with care transition participants or their informal caregivers to provide a person-centered approach for the care-team in order to promote and facilitate positive health outcomes.
A curriculum was developed by HInet for ADRC staff to assist Care Transition grant participants and other community members in the registration and use of the Shared Care Plan. The ADRC increased community awareness of the innovation and the importance of maintaining a personal health plan through 46 community presentations. Forty-seven Care Transition participants and 254 additional community members were provided information about and access to both hardcopy and electronic forms of the PHR. All Care Transition participants and 247 additional community members (294 total) were assisted to completed PHRs.
Surveys were distributed to all 294 participants, with 30 (10%) responding. Primary results indicated a mixed response for using the electronic PHR and a positive response for using the paper PHR. It was observed that the CTI intervention of using an electronic Personal Health Record was somewhat unclear and intangible to participants immediately upon discharge from the hospital. Providing information about the Shared Care Plan (as part of the CTI intervention) and engaging the participants by providing a paper version of the Shared Care Plan made the personal health record tangible.
WHO WAS INVOLVED
WHAT THEY DID
Problem Addressed: Patients and their family members or others in their small social network bear primary responsibility for communicating their health information and managing it from care site to care site.
This is true in Whatcom County where there is 80% adoption of Electronic Medical Records by clinicians. Unfortunately, that 80% adoption occurs through use of more than twenty different EMR systems, which don’t exchange information. Connection to health information resources and the Microsoft Health Vault platform facilitate better self-management through education and ability to import data from other EMR systems, lab systems and home monitoring devices such as glucometers, blood pressure cuffs, and scales.
The program addresses the need for adults transitioning from hospital to home, often with medically complex situations, to establish and keep active a personal health record (PHR). A PHR is one of the four pillars toward success in the evidence-based Care Transitions Intervention Program (CTI) and is used as a communication and tracking tool in an effort to reduce the risk of re-hospitalization. The Shared Care Plan (SCP) is an electronic medical document where clients and/or their caregivers can manage their information through an on-line system. Having an electronic PHR provides a means for the patient or his/her caregiver to exchange information more efficiently with healthcare professionals in support of better health outcomes, including reducing the risk of re-hospitalizations.
In addition to care transitions participants, the general community is ill-prepared for a hospital stay and the transition back to home. Knowledge about, and participation in, an electronic PHR accessible to individual’s circle of caregivers, community supports, and healthcare providers could enhance communication, improve care, and relieve stress upon admittance to a hospital.
Patient Population: The program was developed for older adults and persons 18 years and over with disabilities in Whatcom and Skagit Counties, including participants in Washington State’s Administration on Aging-funded Option D Evidence-based Care Transitions Grant; and other interested community members.
Description of Program:
As part of the Care Transition Intervention activities, the Shared Care Plan (SCP) was included as an option for the Personal Health Record that is typically used in the evidence-based care transitions model. Coaches would meet directly with clients and family caregivers to explain the use and usefulness of the PHR tool. In order to facilitate understanding of the components of the SCP, coaches would also leave a modified hard copy, paper version of the SCP with the client to use to gather their health information prior to adding it to the electronic version. For individuals requesting more help, ADRC Specialists provided one-on-one assistance/training to populate either the paper or electronic version of the PHR.
In addition to the above, ADRC Specialists and other NWRC staff conducted trainings throughout the target geographical areas about pre-admission planning for hospitalizations using a program called “Hospital 101”. This program was provided to a variety of groups of older people including retired employee associations, communities of faith, senior centers, clinics, caregivers, tribal groups, and professionals in social work and health. As part of this presentation, the establishment of a Personal Health Record was emphasized and hard copy documents distributed as well as electronic registration documents provided for those interested in the on-line system.
Using both of these routes to expand the use of the program, 301 people received information about the importance and use of the SCP. CTI clients, in general did not take advantage of the opportunity to enter their health information into the electronic PHR, but instead overwhelmingly chose the paper version.
HInet staff conducted Train-the-trainer sessions for ADRC Specialists so they in turn could train CTI participants and other community members in the advantages and use of the electronic Shared Care Plan.
HInet also supported ADRC staff to assist individuals in registering and completing electronic Personal Health Records with internet capable wireless devices (laptops and iPads); paper forms to facilitate information gathering; and onsite personal and telephone support.
Patient Recruitment and Uptake:
All CTI participants were offered assistance with the electronic PHR; however, approximately 75% had no access to a computer or the Internet; many were fearful of entering personal identifying information; and most who attempted became discouraged early on with the registration process. Data on number of online accounts and those signing in to create PHRs were supplied by HInet.
Survey Results from Recruited Patients
HOW THEY DID IT
Context of the Innovation: Several local factors that served as an impetus for this program. In 2001, five provider organizations in Whatcom County Washington took up the challenge of the Institute of Medicine Report, Crossing the Quality Chasm, to develop a system of chronic care whose goals were to meet six aims: Safe, Timely, Effective, Efficient, Equitable, and Patient-Centered care. This effort was stimulated and aided by the Robert Wood Johnson Foundation’s Pursuing Perfection Grant. Patients, family members and professionals participated in the design of a system that would achieve self-management and communication among care team members; and the Shared Care Plan evolved into the current web based application by employing user-centered design methodologies. Further refinement of the application has been made possible through grants from the Agency for Healthcare Research and Quality (AHRQ), the Foundation for Health Initiative (HRSA OAT), HRSA grants, and the ongoing contributions and efforts of PeaceHealth, a network of health communities in the Pacific Northwest. The tool is free to individuals living in Whatcom and Skagit counties.
HInet participated in the Washington State Healthcare Authority’s (HCA's) health record bank (HRB) pilot project which was developed and implemented to address the problem of no Lead Organization responsible to securely collect and assemble consumer's comprehensive health information so that it can be accessible by consumers when and where it is needed. Initial HRB implementation was modest in 2008 and 2009 to test viability and consumer interest. At that time HRBs provided three to five items of data to consumers through a personal health record (PHR). The Shared Care Plan PHR and Microsoft HealthVault provide the technical infrastructure for HInet’s Health Record Bank. Significant progress has been made in the three state HRB communities and the Department of Defense Madigan Healthcare System HRB (MHS). Established objectives were substantially achieved with renewed consumer enrollment efforts now underway. The HRBs have also added more sophisticated applications such as cell phone text-enabled registration, planned for in the Community Choice HRB, and an iPhone HRB application available to consumers in Whatcom County in the St Joseph HRB.
A CMS 9th scope of work contract with Qualis Health (the Beacon Regional Extension Center) allowed HInet to develop a Workflow Assisted Care Transitions software module building upon the infrastructure of HInet and the Shared Care Plan.
Planning and Development Process:
The planning and development process benefited by pre-planning with program collaborators. Input was obtained on how to enhance participants’ experiences and outcomes as part of the state’s AoA-funded ACA Option D Evidence-based Care Transitions grant. Online meetings were used to ensure ongoing progress reporting, problem solving, and discussions of possible innovations. At certain points additional resources were tapped to ensure observations either matched expectations and/or needed interventions.
Getting Started With This Program: It is imperative that the program team commit to honest, shared, and facilitated root cause analyses of the challenges they face; and to collectively improve their approach and delivery. Differences, ground rules, and communication channels should be ironed out at the beginning to establish shared goals, objectives and how success will look. Taking the time to do frequent check-ins and re-establishment (or revision) of project parameters will help maintain focus on the end results.
For successful engagement with interested patients/consumers, dedicated staff is needed to provide one-on-one education, training, assistance and ongoing support. Individuals going through transitions are often challenged by the numerous individuals coming in and out of their lives and homes.
Security concerns can become a large barrier to expanded use of an electronic PHR. There needs to be a way to address this not only from the technological perspective, but also from the consumer education perspective so consumers are knowledgeable about when and where they are relatively safe to share personal health information, and how to protect themselves.
Sustaining This Program: The Shared Care Plan application is continuing to be used and supported in Whatcom and adjacent counties. Its ongoing operation is funded through HInet’s access fees. Development of new functionality will continue.
Health Information Technology Considerations: