Personal Health Records for Long-term Services and Supports Demo
A Minnesota Personal Health Record Demonstration Project
Minnesota’s Personal Health Record for Long Term Services and Supports Demonstration is a pilot project that tests the concept of a personal health record (PHR) that's designed for people receiving long term services and supports (LTSS). It is a four-year TEFT planning and demonstration grant awarded to DHS by the Centers for Medicare & Medicaid Services for Testing Experience and Functional Tools (TEFT) in community-based long-term services and supports from April 1, 2014 through March 31, 2018. Minnesota is currently pursuing a No Cost Extension for CMS, which would allow the project to continue through March 31, 2019 if approved.
There are currently two community collaboratives testing out the PHR for LTSS, which are the Otter Tail County collaborative and the Southern Prairie collaborative. More information about these community collaboratives and the TEFT project can be found below.
The Southern Prairie PHR Community Collaborative uses the RelayHealth PHR portal in Cottonwood, Jackson, and Redwood counties. This collaborative utilizes the multi-county agencies of Southwest Health and Human Services and Des Moines Valley Health PHR was launched in October of 2017.
The Otter Tail collaborative has been meeting monthly with DHS staff and contractors since November 2015 to further define the functions of an electronic Personal Health Record for Medical Assistance (MA) Waiver beneficiaries, and to participate in the first of two rounds of pilot testing to help define an electronic Long-Term Services and Supports (eLTSS) Standard. This collaborative uses the RelayHealth PHR portal, which was launched in October of 2016.
We've divided the four year PHR for LTSS Demo Project timeline into seven waves. We are currently in wave six (4/1/2017 - 9/30/2017). Here is the latest:
Personal Health Record for LTSS Waiver beneficiaries:
MN.IT @ DHS has built functionality that allows for automatic updates to be sent to the PHR on a daily basis. Each morning at 6:30 AM, the system automatically checks to see if any relevant data has changed about PHR users in MMIS and/or MAXIS. If it has, the system automatically creates Health IT industry HL7 standard messages (ADT and XDS.b) that securely update the PHR with data and place an updated .pdf version of a “Profile Page” in the user's PHR. We continue to document important lessons learned about internal DHS systems, the PHR system and what it takes to integrate data from DHS to the PHR.
MN.IT @ DHS has built the recipient and case worker back-end management tool. This allows for TEFT admin staff to have better control over the management of beneficiary and case manager accounts in the PHR.
There are 43 people using the PHR in Otter Tail County:
16 beneficiaries/legal representatives
8 county case managers
20 provider staff members
There are 21 people using the PHR in Southern Prairie:
11 beneficiaries/legal reps
7 case managers
3 county staff
We hosted our first set of focus groups in February 2017 and received some excellent feedback on the PHR from beneficiaries, legal representatives, case managers and provider staff. The feedback we received related to the usability of the PHR portal and the activities of the PHR pilot project.
eLTSS:
We're continuing to participate in weekly ONC S&I Framework calls to harmonize the national eLTSS standard. Also, provider organizations of the new Southern Prairie Community Collaborative are progressing with analyzing their data systems in preparation for sharing data based on the Otter Tail County eLTSS standard. Partner organizations have completed an inventory of available data fields and have begun discussions about how to export that data to other partners using a common template.
The Otter Tail Collaborative is currently exchanging continues to exchange the Otter Tail eLTSS data elements about real beneficiaries by sending a standardized form to each other through the secure messaging function in the RelayHealth portal. These messages include information about a beneficiary who is on Medical Assistance.
FASI:
We are concluding round one of FASI and have completed 192 FASI assessments. While we weren't able to reach the target number of assessments for beneficiaries of the Brain Injury (BI) Wavier and beneficiaries with Serious Mental Illness (SMI) due to various barriers we faced such as limited guardianship data and participant refusal due to possible survey fatigue, we were able to reach our targets with the Developmentally Disabled (DD) Waiver population.
We've drafted a work plan for round two and are hoping to learn from FASI testing whether there are aspects of FASI that could/should be incorporated at a later date into MnCHOICES, or which could help us improve on the way we ask existing MnCHOICES questions. We do not intend to use the FASI instrument itself beyond the end of the TEFT Grant.
A copy of the most current reports are available online:
As noted before, we received permission from CMS to forego the second round of testing of the Experience of Care survey a/k/a Beneficiary Experience Survey. DHS leadership concluded that further testing of this survey would unduly burden the targeted population as it would duplicate other efforts already under way in MN.
The goal of the PHR for LTSS Demo project is to demonstrate the benefit of a personal health record for people enrolled in community-based services and supports that contains both their acute health care and long-term services and supports information.
Demonstrate use of an “untethered” personal health record with long-term services and supports beneficiaries. An untethered personal health record is a patient’s compilation of medical records from providers. A “tethered” record is the patient’s view of a subset of the physician’s electronic medical record.
Identify, evaluate and test an electronic long-term services and supports stand with the Office of National Coordinator’s Office of Interoperability and Standards Framework Process.
Field test a beneficiary experience survey within multiple long-term services and supports programs for validity and reliability.
Field test a modified set of Functional Assessment Standardized Items (FASI) for use with long-term services and supports beneficiaries.
TEFT complements the Minnesota Accountable Health Model, part of the State Innovation Model (SIM) initiative, by providing additional resources so integrated community service delivery models can share health care, behavioral health, home and community-based service and community prevention services information for person-centered care.
Stakeholders include representatives of the Minnesota Department of Health’s e-Health Initiative and Office of Health Information Technology; the Regional Extension Assistance Center for Health IT; the Department of Human Services administrations for Health Care, Continuing Care and Chemical and Mental Health; managed care organizations; lead agencies; health care and home and community-based services providers; advocates and consumers; and others.
Review the list of Acronym Definitions (PDF) provided by CMS to help you understand the “alphabet soup” that surrounds Health Information Technology (HIT)
Review the presentation (PDF) from the June 19, 2014 Stakeholder Kickoff Meeting
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This email list provides periodic updates about Minnesota's Person Health Record for Long Term Services and Supports Demonstration which is funded by a CMS TEFT Grant. To subscribe to the list, enter your email and click subscribe.
Contact business project manager Tom Gossett at tom.l.gossett@state.mn.us or 651-431-2601 if you are having problems with this link.
The past updates will keep you informed on Minnesota's Personal Health Record for Long Term Services and Supports Demonstration (PHR for LTSS Demo) project.
