Colorado Demonstration
Grant for the Testing
Experience and Functional
Tools (TEFT)
The Colorado Department of Health Care Policy and Financing
March 18th, 2015
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Our Mission
Improving health care access and
outcomes for the people we serve
while demonstrating sound stewardship
of financial resources
The Four Domains for Outcomes
• Lab Results
• Health Risk
Assessments
• Client
Engagement
• Satisfaction
• Choice and
Control
• ADLs
• Self-Efficacy
• Personal Story
Clinical
Functional
Quality of
Life
Utilization
• ED visits
• Hospital Visits
• PCP
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TEFT Components
Experience of Care
Survey
e-LTSS
Records
S&I Framework
Continuity
Assessment
Record &
Evaluation Tool
Personal
Health
Record
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TEFT Timeline
Year One – 2014 – Planning Phase
Year Two – 2015 – Implementation of Phase One
Year Three – 2016 – Implementation of Phase Two
Year Four – 2017 – Implementation of Phase Three
TEFT Partnerships:
 National Partnerships
 2 Federal Partners – (CMS, ONC)
 3 Contractors (Truven, Lewin, RTI)
 9 Grantees (CO, AZ, CT, GA, MN, KY, LA, MD,
NH)
 State Partnerships
 Stakeholders
 HCPF
 HIEs – CORHIO & QHN
 Waiver Populations
 Elderly Blind Disabled & Supported Living
Services
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State Partnerships
CIVHC – Center for Improving Value in Health Care
Telligen (formerly CFMC)
QHN, Quality Health Network
Colorado Department of Human Services, Aging and Adult
Services
Area Agency on Aging
Colorado HealthCare Association
State Partnerships – Con’t.
Colorado Health Foundation
Colorado Gerontological Society
State of Colorado Governor’s Office – IT
Leading Age
Colorado Hospital Association
The Alliance
Key Achievements
 Completed Round One - Experience of Care survey
 Sent surveys - Health Information Technology
surveys to stakeholders state-wide
Held stakeholder Meetings - throughout Colorado in
person and via webinar
Created Criteria for PHR vendors
Developed implementation
work plan
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Solutions: Criteria for PHR Products
1. Must be able to integrate data coming from a HIE
2. Must be able to take data input from a client,
caregiver or provider in the form of other devices
3. Must be customizable to suit the different user
needs including non-clinical and clinical data
4. Must be able to display benefits and waiver
related information or partner with a vendor who can
5. Must be secure in managing the data including
HIPAA compliance
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Solutions: Criteria for PHR Products
Con’t.
6. Must be able to meet the basic Standards and
Interoperability (S&I) Framework requirements
7. Must accept data input from secure Direct Messaging
8. Must be able to send alerts to any stakeholder, including
providers and physicians
9. Must be customizable or open sourced
10. Must be from a vendor that is financially viable
Lessons Learned From
Planning Phase
Need to facilitate stronger communication for round two
EoC & investigate lower response rate in SLS waiver
Important to include open brainstorming in stakeholder
meetings regarding PHR
Going state-wide is challenging but allows us to see
trending and patterns with clients in LTSS
There is already identifiable criteria important for PHR
development
Go slow to go fast – stages of implementation will
be important
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Stakeholder Meetings
Community meetings held from July, 2014
through December 2014
11 on-site meetings and 3 webinars
Attendees included the community centered
boards, Single entry points, RCCO’s, ACO’s,
HCBS providers and state partners
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What Our Stakeholders Want…
Non-Clinical
Clinical
• Personal Story
• Active Medications/Allergies
• Staff Schedules
• Lab/Radiology Results
• Track Units
• Past Visits & Upcoming
Appointments
• Alerts
• Support Plan/Goals
• Push Alerts for ED visits &
Hospitalizations
How Query-Based HIE
Works
Laboratories
Public Health Departments
Radiology Centers
Hospitals
Pharmacy
Information
CIIS
Immunizations
Reportable Conditions
Immunizations
Public Health Alerts
Medications lists
Newborn
Radiology Reports
Lab Results
Screening
Pathology Reports
Diagnostic-Quality
Results
Medical Images
Hospital ADT Info
Consult Reports
Transcription Notes
Lab/Rad
Community Health
Record
(with CTN)
Data
Analytics
Immunizations
Future
CCD
Orders
CCD Upload
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The “Perfect State” of HIE
Full Integration
of Public
Health
Integration
of
Behavioral Health
Statewide &
National
Connectivity
Increased
Interoperability
Key Considerations:
Security of information
User flexibility
Opt-Out features
Designed to aid Client in managing LTSS
Services
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What This Means for
Implementation…
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Implementation: Three Phases
Phase One - Navigation
 Teach how to navigate the PHR - Non-clinical, clinical (only a couple
elements)
Phase Two – Data Feeds Added
 PHRs connect to the state HIEs, add more data
Phase Three – Dynamic Phase
 Clinical enters data, interactive – personal story, answers daily questions,
tracks own wellness, interacts with PHR
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Three Measures of Success
 Frequency of Use
 Who is using it and how often
 Efficient coordination of services
 Tracking scheduled appointments and units
 Increase in quality of services
 Patient engagement impacts services
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Key Milestones
Identified 5 communities in Colorado to be Focus
Group settings
Demo’d three electronic Personal Health Record
(PHR) for LTSS (ManaHealth, Get Real Health and FEI
Systems)
Developed a state partner advisory committee
Developing partnership with HCPF IT Department
to design MMIS/PHR solution
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Upcoming Challenges…
HCBS Providers at different levels of Health Information
technology
Case Managers and Care coordinators utilizing home grown or
purchased “EHR” systems that are not certified to be
integrated with an HIE
Accessibility to internet, laptops and computers at varying levels
PHRs must be usable for the elderly, blind, disabled populations
PHR usage across the board very limited
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Next Steps
Focus Groups begin March 2015
Pilot Sites to be identified from the Focus Groups
PHR Demos to be initiated for clients, caregivers
and providers
 Designed to aid Client in managing LTSS Services
Work with HCPF and new MMIS system
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Thank You
Tim Cortez
Manager, Community Options Search
Community Living Office
Department of Health Care Policy & Financing
[email protected]
Pamela A. Russell
LTC Program Director
CORHIO
[email protected]
Danielle Culp
Department of Health Care Policy & Financing
[email protected]