Proposal Presented for the Master Plan For Aging (#26)
Disclaimer
Throughout the MPA process, more than 100 proposals were developed thanks in particular to thousands of hours of work by external stakeholders and members of the public. These proposals and the MPA Council commentary are being submitted to the Governor and shared with policymakers and the public to inform policymaking. These proposals represent a starting point for discussion. Further discussion is necessary between relevant state agencies and stakeholders to both refine these proposals and assess which may be appropriate to adopt and implement.
Summary
Leverage the Statewide Health Information Network for New York (SHINNY) in a series of three pilots to integrate information from medical, behavioral, and mixed payer client data systems to connect to Qualified Entities such as HIXNY or Healthix to facilitate use of electronic information from local provider systems. The pilots would prioritize data sharing to facilitate better transitions across care settings.
Justification
The New York State health care system lacks efficient communication, access to holistic care coordination, knowledge about navigating a fragmented LTSS, and reimbursable or affordable evidence-based care transition programs. This lack of effective care transition service results in avoidable hospitalizations, rehospitalizations, Emergency Room use post discharge, increased medical errors, increased healthcare spending, and adverse health outcomes. The creation of a pilot which will leverage the SHINNY to integrate critical information from client data systems and facilitate meaningful use of electronic health information in a real-time data exchange using evidence-based care transition models, could contribute to a reduction in avoidable hospital and Emergency Room use, avoidable healthcare spending, and avoidable adverse health outcomes.
Full Proposal
Leverage the SHINNY in a series of three pilots to integrate critically needed information from medical, behavioral, and mixed payer client data systems to connect to Qualified Entities such as Hixny or Healthix, to facilitate efficient, meaningful use of electronic information from local provider systems that are experienced in addressing long-term care and aging-related and health-related social needs. These pilots would prioritize real-time data exchange of provider agencies participating in care transitions models shown to be effective and inform decision making through the provision of a concise, actional summary of holistic needs and critical contact information aligned with federal guidance on web accessibility.
The three pilots would be implemented in the following steps:
- Care Transition: Hospital to facility (Skilled Nursing Facility, ACF/ALR with home care).
- Care Transition: Hospital/Facility to community-based setting (including independent senior housing, OMH housing, subsidized housing).
Community Care Navigation: Post-acute phase, one individual is stabilized after transition, HCBS organizations across the service systems, skilled in utilizing evidence-based care transition models and engagement with aging populations at high risk for losing community tenure, facilitate the individual’s connection to community-based services, entitlements, and benefits (includes Aging Network providers, Naturally Occurring Retirement Communities/NORCs, Senior housing and OMH housing, Health Homes and Health Home Plus, and Social Care Networks).
MPA Council Commentary
This proposal is categorized as infrastructure. The integration of electronic health information systems across healthcare settings and the community is operationally, administratively, regulatorily, and statutorily complex. Proposed first steps for implementation could include the development of partnerships with key state agency bodies and contractors such as the SHINNY and the Regional Health Information Organizations (RHIOs) as well as representatives from all service systems engaged in transitions across healthcare settings. Following these discussions, DOH would need to conduct a review of the likely costs and savings associated with this proposal. Any additional resources or funding allocations would be subject to the annual budget process and available resources. Policymakers may reference this proposal during the legislative session, as this proposal may require legislative action.