UPMC is a large integrated delivery and finance system with 62,000 employees and $10 billion in revenue. It operates 20+ hospitals, senior living communities, insurance plans, and international services across 18 countries. UPMC aims to promote high quality, low cost care through its integrated structure. In 2011, UPMC launched several initiatives in hospitals, long-term care facilities, and communities focused on palliative care, transitions of care, quality improvement, consistent staff assignments, end of life training, and palliative care consult teams. The health plan developed a Care Through Transitions model to provide functional assessments, interdisciplinary care planning, and transitional care days to reduce avoidable hospitalizations. ClinicalConnect is an HIE system that connects

1. Hospital of Tomorrow Panel
Managing the Care Continuum
Charleeda Redman RN, MSN, ACM, FAACM
Vice President, Accountable Care
UPMC

2. UPMC’s Global Academic Integrated Delivery
and Finance System (IDFS)
62,000 employees, $10B Revenue
Enterprise Services
Insurance
Services
International and
Commercial Services
Physician
Services
• 20+ hospitals
• 17 Senior Communities
• Joint Venture Home Health
Services
• 264,000 admissions
• >3.6M outpatient visits
• 3,200 employed
• 5,000 total
• 2.0 M members • 18 countries
• Hospitals: Italy, Ireland
IDFS structure promotes high quality, low cost care and unleashes
innovation while others live “Life in the Gap”
Oracle
Informatica
Hospital and
Community Services

3. UPMC’s Decision
• In 2011, UPMC Community Provider Services decided to launch
several initiatives in hospitals, LTC, and the community setting:
– Palliative Care and Transitions
– Payer Provider Programs
– QI initiatives in LTC
– Consistent assignment
– Interact III training
– POLST training
– Hard Conversation Training
– End of Life Training
– Clinical Staff: Hospital PC consult teams, Gero-Palliative CRNPs in LTC

4. Health Plan: Care Through Transitions Model of Care
4
Functional
Geriatric
Assessment
CTT
Interventions
IDT Team
Meetings
Transitional
Care Day -
E& M CPT
Codes
CRNP Reimbursement:
Functional Geriatric Assessment
•Completed upon admission / re-admission
•Reimbursed per assessment
Interdisciplinary Care Plan Team Meetings
•Skilled Members – completed weekly
•Custodial Members – completed quarterly
and with the occurrence of a MDS
Significant Change
•Reimbursed per Member discussion
Transitional Care Day (TCD)
•Reimbursed for Subsequent Nursing
Care Evaluation and Management CPT
Codes 99304-99310

5. Reduce Avoidable Hospitalizations using Evidence-based
Interventions for Nursing Facilities (RAVEN)
5

6. 6
ClinicalConnect HIE at UPMC
UPMC Clinical
Information
Systems
Patient
PA Statewide
Immunization
Information System
(PA-SIIS)
Home Health
&
Skilled Nursing
Facilities
UPMC Health
Plan Claims Data
Transition of Care
External Data
ClinicalConnect HIE,
Western
Pennsylvania
ClinicalConnect HIE,
UPMC