IMPACT - Improving Massachusetts Post Acute Care Transfers

IMPACT, which stands for Improving Massachusetts Post-Acute Care Transfers, was an Office of the National Coordinator (ONC) grant-funded project designed to improve care transitions using an enhanced electronic Universal Transfer Form (UTF) and Electronic Health Information (HIE) exchange.  

This project focused its efforts in Worcester County, a region where 85% of the healthcare for its 800,000 person population stays within the county.  IMPACT was able to analyze almost 100,000 patient transfers per year, as well as 20,000 Medicare Advantage patients whose claims data will be used for total cost of care analyses. A pre- and post-test model using claims and other metrics were used to evaluate the success of the project objectives.

The Massachusetts Health Information Highway (The Mass HIway) was the nexus for the transmission of the electronic UTF between acute providers and the post-acute care settings. Recognizing that many long-term and post-acute care (LTPAC) providers will not have electronic health records (EHR) for several years, IMPACT created a system for information exchange between health care providers within pilot sites that allowed groups with EHRs and those without to share information about their patients electronically. Tools to generate, translate, and view the electronic UTF will be added to these HIEs and made available to other states. The system architecture is called LAND and SEE.

IMPACT will not forget about the patient: part of the project was to create a patient-friendly tool to help patients better understand what is happening during the care transition process. IMPACT recognized that care transitions are more than just collecting the appropriate data elements in electronic form: it is about the process. The Learning Collaborative and Galaxy team reviewed the care transition process to make the process the best that it can be, using the new data and format of information exchange.

Goals:

  • Enable nursing homes and home health agencies to participate in regional and statewide Health Information Exchange
  • Improve the speed, efficiency, and satisfaction of processes to provide essential clinical data during transitions of care
  • Decrease avoidable ER visits, hospital admissions, and hospital readmissions
  • Reduce unnecessary tests and treatments
  • Reduce the total cost of care Replicate this model in other communities

IMPACT Objectives:

  • Build on existing learning collaboratives to help design, implement and disseminate tools
  • Finish development and testing of Massachusetts Universal Transfer Form (UTF)
  • Extend HL7 Continuity of Care Document (CCD) to include all UTF data elements (CCD+)
  • Develop application to view/edit/send CCD+
  • Develop consumer-oriented translator of CCD+ Pilot tools in Worcester County Measure outcomes 

 

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