Workflow and Tracking System Development. Phase 1 Overview By December 2019, the State is to develop and implement a system to identify and monitor individuals in the Target Population who remain in Louisiana Medicaid after their transition from a NF. This will allow the State to ensure health and safety in the community, assess whether supports identified in the individual’s discharge plan are in place and achieving the goals of integration, identify any gaps in care, and proactively address any such gaps to reduce the risk of readmission or other negative outcomes. The Agreement also requires the State to implement a monitoring system that includes both face-to-face meetings with individuals in the Target Population and tracking by service utilization and other data. In addition, the Agreement specifically requires the State to assign a Transition Coordinator who will initiate contact with the individual within three working days of admission. This will require the State to develop new functionality to track admissions to NFs on a real-time basis. The State established an internal, cross-agency workgroup to review existing data systems across various offices. This workgroup is responsible for the development of a permanent, comprehensive tracking system for the Agreement. The workgroup identified the necessary data sources needed to document activities occurring in order to meet the Agreement requirements. In addition, the State met with other states to learn from their experiences of developing tracking systems in order to guide the development of the system requirements. To support the immediate work of Transition Coordinators, the State developed an interim tracking and work support system using SharePoint in 2018. This allowed the State to assign individuals to Transition Coordinators and track completion of key transition tasks. While the State is planning to develop and implement a more sophisticated approach to tracking, the interim system currently captures critical information regarding outreach activities, the transition assessment and development of transition plans, as well as services requested by the individual— including specific information on preferences regarding housing. The interim system also tracks the progress of the individuals who have transitioned to the community. Information and data reports from this interim system are easily accessible to state staff and will provide a good foundation for a long-term tracking system in 2020.
Workflow and Tracking System Development. Phase 1 After spending the past year assessing vendor solutions available for a tracking system, the State has decided that an existing solution does not exist to meet all aspects of the agreement. We will be using State resources to build some key components of the tracking system specific to the requirements of the Agreement and assure interface with our existing systems. Initial 18-month Implementation Plan focus: Defining requirements for the system as a whole and working with our Office of Technology Services (OTS) to build the first phase of the system. Our goal is to have the first phase of the system built by the end of the Initial Implementation phase. This chart will detail the tasks for the first phase of the workflow and tracking system development.
Workflow and Tracking System Development. Phase 1 Overview By December 2019, the State will develop and implement a system to identify and monitor individuals in the Target Population who remain in Louisiana Medicaid after their transition from a nursing facility. This will allow the State to: ensure health and safety in the community; assess whether supports identified in the individual’s discharge plan are in place and achieving the goals of integration; identify any gaps in care; and proactively address any such gaps to reduce the risk of readmission or other negative outcomes.
