1. Longitudinal Coordination of Care
Longitudinal Care Plan Sub Workgroup

2. Agenda Welcome LCC Introduction The LCC Challenge
LCC Structure and Work-to-date
Work Streams
Timeline – High-level
Use Case Scope
White Paper

3. Introductions and Welcome
Round-robin introductions
Overall LCC F2F Agenda
Time
Agenda Topic
Room
Thursday
8:00 am – 10:00 am
LCC Status and Introduction
Edison E
10:30 am – 12:00 pm
LTPAC Working Session
1:30 pm – 3:30 pm
PAS Working Session
4:00 pm – 6:00 pm
LCP Working Session
Friday
Use Case Working Session
10:30 am – 12:00 pm
Use Case Working Session and Recap F2F Progress/ Next Steps

4. LCC Overview Longitudinal Coordination of Care Workgroup*
Providing subject matter expertise and coordination of SWGs
Developing systems view to identify interoperability gaps and prioritize activities
Longitudinal Coordination of Care Workgroup*
Longitudinal Care Plan Sub-Workgroup
LTPAC Care Transition Sub-Workgroup
Patient Assessment Summary Sub-Workgroup
Near-Term: Developing an implementation guide to standardize the exchange of Form CMS-485 (Home Health Certification and Plan of Care)
Long-Term: Identify and develop a longitudinal care plan spanning multiple care settings
Identifying the key business and technical challenges that inhibit long-term care data exchanges
Defining data elements for long-term and post-acute care (LTPAC) information exchange and using a single standard for LTPAC transfer summaries
Establishing the standards for the exchange of patient assessment summary documents
Inform the development of the Keystone Beacon Patient Assessment Summary Document Exchange.
Inform HL7 balloting of LTPAC-specific enhancements to the C-CDA
* 75 interested parties, including 28 active, committed members

5. Observations on progress to date
Excellent progress:
Keystone Feedback on PAS CCD
RTI Data feedback
Input on CMS HL7 Balloting
Use Case – Gap Analysis, Scoping and Functional/ Data Requirements
Complexity
Broad view of trading partner community
Many types of transitions and roles of receivers
Focus Challenges
External Drivers
Multiple Demands
Coordination Challenges
Separate SWGs
Lack of cohesive overall plan

6. Related Work Streams
S&I Process - Use Case/ Requirements to Advance interoperability for the LTPAC community.
Building on the ToC Initiative work and ToC V1.1 Use Case as a foundation for LCC
S&I process (Use Case, Harmonization, IG) provides actionable implementation path for the LTPAC community
LLC WG would like implementable specifications to support pilots before the end of 2012
Influence and impact ongoing policy discussions
LCC WG has a strong set of LTPAC interoperability policy stakeholders at the table
White paper would allow for the articulation of a vision and objectives that would be in a format that is familiar to policy-makers.
Support specific WG objectives
Continue to use LCC WG as the working forum to support the Challenge, Beacon and VNSNY project objectives
Project-specific deliverables based on Challenge, Beacon and other requirements
Serve as a platform for responding to important and related standards activities
Care/ CMS collaboration with HL7 and S&I LCC WG
Standardization of Content for Functional Status, Cognitive Status and Pressure Ulcer work (C-CDA structure review, Data Elements Review)
Impacting a variety of Assessment Instruments (MDS, OASIS, CARE, etc…)
All LCC SWGs as well as the LTPAC community at large, looks to leverage the standards work emerging from this collaboration
Analysis-supporting deliverables

7. White Paper Detailed articulation of environment
Detailed articulation of current efforts
Vision for Longitudinal Coordination of Care - Roadmap
Extend Baseline to other care settings
Extend interoperability interchanges and system functions to more sophisticated care processes, e.g. CDS
Articulate how S&I first LCC Use Case (HHA) supports overall vision and roadmap for incrementally building trading-partner specific Use Cases
Standards-improvement roadmap
NPRM response and implications
Use White Paper to manage any unanticipated complexity
What else??

8. Use Case Content Guidance
Requirements document for use by business/ clinical analysts to hand-off to technical implementers
Document designed for business and technical implementers (not policy makers)
Get the best possible coverage of likely overall data elements with the least number of specifically defined transactions
Use Baseline Use Case to replicate for other care settings, e.g., IRF, BH, and to add scenarios and more sophisticated process transactions and content

9. View of LTPAC Flow ACH to HHA/SNF Admission to HHA/SNF
HHA/SNF Episode of Care
Change in Condition
Order for Skilled Care (HHA/SNF)
Initial Assessment (Nsg, etc)
OASIS
MDS
Order for referral to Acute Care
ToC Data
HHA- CMS 485
SNF- Start of Care Orders
Comprehensive Plan of Care
Scenario 1: Transitions of Care and Referral
Representative Transitions
Acute Care to LTPAC (as represented by HHA) #5:
Initial PoC from HHA to Physician, Physician to HHA
Ongoing PoC from HHA to Physician, Physician to HHA
Recertification PoC from HHA to Physician , Physician to HHA
Populate OASIS
LTPAC (as represented by SNF/ NF reusing MDS and INTERACT) to ED #4
ED to LTPAC (as represented by SNF/ NF and populating MDS) #3
Scenario 2 –Patient Communications:
Copy all ToC and PoC transactions to patient/care giver PHR
Referral to specialist
SNF- Initial Plan of Care
PAS

10. Strawman Proposal for Use Case
An evidence-based approach to supporting LTPAC needs

11. MA DPH Universal Transfer Form
4/22/2017
MA DPH Universal Transfer Form
Started with DPH’s 3-pg Discharge Form
Sought input from LTPAC “receivers”
Reviewed existing forms and datasets:
MDS
OASIS
IRF-PAI
INTERACT
Sought expert opinions
Resulted in 7-page UTF

12. Massachusetts Paper UTF Pilot
4/22/2017
Massachusetts Paper UTF Pilot
Too Long!
Already done. Found to be too long. Need to define subsets for various transitions

13. UTF Data Element Survey
46 Organizations completing evaluation
~300 Data elements evaluated
1135 Transition surveys completed

14. 11 Types of Organizations

15. 4/22/2017
12 User Roles

16. Findings from UTF Survey
Largest survey of Receivers’ needs
Identified for each transitions which data elements are required, optional, or not needed
Each of the 300+ data elements is valuable to at least one type of Receiver
Many data elements are not valuable in certain care transition
Paper form can’t represent these needs

17. 11x11 Sender (left column) to Receiver (top)
Sender-Receiver grid. 11x11. The sites across the top are the same as those down the left hand column. The result is a 121 cell grid. It includes the traditional PAC sites: LTACs, IRFs, SNFs, HHA, Hospice. And some “non-traditional” PAC sites including the PCP in the office, Community Based Service providers, the ASAPs, and most importantly, the Patient and Family at home. At the other end of the grid are three Acute Care Hospital sites that send the most patients to PAC and receive the most patients from PAC sites: the in-patient unit, ED and outpatient testing and treatment areas.
The grid could have easily been enlarged to include outpatient therapy, pharmacists, ALFs, foster homes, and many other sites. We proceeded on the assumption that data sets identified for these high volume transitions would likely include the information required by the lower volume transitiions.
Every site is both a “sender” and a “receiver”
The next task was to prioritize among these 121 possible transitions. For this we applied three parameters, each ranked high, medium and low. The first was volume. The second, the clinical instability of the patient. And the third, the time-value or “Acuity” of the information. How quickly did the receiver need the information. These are clinical parameters. We could have gotten a different result using cost data.
Applying these parameters results in my favorite grid where red is high, yellow medium and blue low. The transitions on this grid, then look like this.
NEXT 17

18. Black circles = highest priority Green circles = high priority
Prioritize Transitions by Volume, Clinical Instability and Time-Value of Information
Cells with three “red” (=high) scores are highest priority. Those with two “high” scores are next. (Medium is “yellow” and “low” is blue).
Using this approach, there are 16 highest priority transitions and 33 high priority transitions out of The black and grey cells are very rare and not scored.
I don’t expect to be able to read this grid but there are three priority areas: on the left are the transfers FROM PAC to the ACH, across the top are transitions FROM the ACH to PAC sites, and in the middle are transitions among PAC sites.
Pulling the colors out gives the following grid with black as highest and green as next highest transitions.
NEXT
Black circles = highest priority Green circles = high priority 18

19. Prioritize Transitions by Volume, Clinical Instability and Time-Value of Information
49 Documents
Is Too Many!
Here are the priority transitions based on the criteria in the title. The individual scoring of each cell has been removed leaving only the “circle”.
The next grid indicates the essential receiver “roll-groups”
Black circles = highest priority
Green circles = high priority 19

20. 5 High-priority Transition Datasets
Report from Outpatient testing, treatment, or procedure
Referral to Outpatient testing, treatment, or procedure
Shared Care Encounter Summary (Office Visit, Consultation Summary, Return from the ED to the referring facility)
Consultation Request Clinical Summary (Referral to a consultant or the ED)
Permanent or long-term transfer to a different facility or care team or Home Health Agency

21. 5 High-priority Transition Datasets4 2 3 1
Here are the priority transitions based on the criteria in the title. The individual scoring of each cell has been removed leaving only the “circle”.
The next grid indicates the essential receiver “roll-groups”

22. 5 High-priority Transition Datasets
Type 3 Dataset:
Office Visit to PHR
Consultant to PCP
ED to PCP, SNF, etc…
5 – Transfer of Care Summary
4 – Consultation Request Clinical Summary
3 – Shared Care Encounter Summary
2 – Test/Procedure Request
1 – Test/Procedure Report
Type 4 Dataset:
PCP to Consultant
PCP, SNF, etc… to ED
Type 5 Dataset:
Hospital to SNF, PCP, HHA, etc…
Hospital, SNF, etc… to HHA
PCP to new PCP

23. Relationship to Other Transfer Forms
Type 3 Dataset:
Office Visit to PHR
Consultant to PCP
ED to PCP, SNF, etc…
5 – Transfer of Care Summary
INTERACT
4 – Consultation Request Clinical Summary
MA Universal Transfer Form
3 – Shared Care Encounter Summary
2 – Test/Procedure Request
1 – Test/Procedure Report
Type 4 Dataset:
PCP to Consultant
PCP, SNF, etc… to ED
Type 5 Dataset:
Hospital to SNF, PCP, HHA, etc…
Hospital, SNF, etc… to HHA
PCP to new PCP

24. Relationship to Assessment Tools
Continuity Assessment Record and Evaluation (CARE) Tool
Minimum Data Set (MDS)
OASIS
IRF-PAI

25. Relationship to Plan of Care
5 – Transfer of Care Summary
4 – Consultation Request Clinical Summary
3 – Shared Care Encounter Summary
Plan of Care
2 – Test/Procedure Request
1 – Test/Procedure Report

26. Relationship to Patient Instructions
5 – Transfer of Care Summary
4 – Consultation Request Clinical Summary
3 – Shared Care Encounter Summary
Plan of Care
2 – Test/Procedure Request
1 – Test/Procedure Report
Patient Instructions

27. Situation-specific Data Elements
5 – Transfer of Care Summary
5 – Transfer of Care Summary
4 – Consultation Request Clinical Summary
Variable Base on Situations:
Setting
Diagnoses
Medications
Treatments
Procedures
3 – Shared Care Encounter Summary
Plan of Care
5 – Transfer of Care Summary
2 – Test/Procedure Request
1 – Test/Procedure Report
Patient Instructions
5 – Transfer of Care Summary
5 – Transfer of Care Summary
5 – Transfer of Care Summary

28. Optionality of Data Elements
5 – Transfer of Care Summary
5 – Transfer of Care Summary
4 – Consultation Request Clinical Summary
Optionality within each dataset:
Shall
Should
May
3 – Shared Care Encounter Summary
Plan of Care
5 – Transfer of Care Summary
2 – Test/Procedure Request
1 – Test/Procedure Report
Patient Instructions
5 – Transfer of Care Summary
5 – Transfer of Care Summary
5 – Transfer of Care Summary

29. Plan of Care Permeates Datasets
5 – Transfer of Care Summary
4 – Consultation Request Clinical Summary
3 – Shared Care Encounter Summary
Plan of Care
2 – Test/Procedure Request
1 – Test/Procedure Report
Patient Instructions

30. Hospital Discharge Instructions is a subset of #5
Sometimes Subsets are Used
Hospital Discharge Instructions is a subset of #5
5 – Transfer of Care Summary
4 – Consultation Request Clinical Summary
Discharge Instructions
3 – Shared Care Encounter Summary
Plan of Care
2 – Test/Procedure Request
1 – Test/Procedure Report
Patient Instructions

31. CMS-485 is a subset of #5 CMS- 485 Sometimes Subsets are Used
5 – Transfer of Care Summary
CMS-485 is a subset of #5
4 – Consultation Request Clinical Summary
CMS- 485
3 – Shared Care Encounter Summary
Plan of Care
2 – Test/Procedure Request
1 – Test/Procedure Report

32. Timing of Producing Datasets
Transition of Care Workgroup recognized that the Patient Instructions may be generated independently and given to the patient prior to the full transition dataset.
5 – Transfer of Care Summary
4 – Consultation Request Clinical Summary
Discharge Instructions
3 – Shared Care Encounter Summary
Plan of Care
2 – Test/Procedure Request
1 – Test/Procedure Report
Patient Instructions
Sending a patient to the ED starts with #4, but upon admission, #5 should be sent

33. Original S&I ToC Use Case
Scenario 1 - Provider to provider:
User Story 1 - Hospital/ED to PCP
Discharge Instructions
Discharge Summary
User Story 2 - Closed Loop Referral
Consult Request
Consult Summary
Scenario 2 - Provider to patient:
User Story 1 - Discharge Instructions and Discharge Summary to patient’s PHR
User Story 2 - Closed Loop Referral where copies of Consult Request and Consult Summary are sent to patient’s PHR

34. Relationship to S&I ToC Scenarios
5 – Transfer of Care Summary
Type 3 Dataset:
Scenario 1 & 2/User Story 2 Consult Summary
4 – Consultation Request Clinical Summary
3 – Shared Care Encounter Summary
Plan of Care
2 – Test/Procedure Request
1 – Test/Procedure Report
Patient Instructions
Type 4 Dataset:
Scenario 1 & 2/User Story 2 Consult Request
Type 5 Dataset:
Scenario 1 & 2/User Story 1

35. CMS- 485 LTPAC “Poster Child” Scenarios Type 3 Dataset:
Scenario 1 & 2/User Story 2 Consult Summary
ED to SNF
5 – Transfer of Care Summary
5 – Transfer of Care Summary
4 – Consultation Request Clinical Summary
CMS- 485
3 – Shared Care Encounter Summary
Plan of Care
2 – Test/Procedure Request
1 – Test/Procedure Report
Patient Instructions
Type 4 Dataset:
Scenario 1 & 2/User Story 2 Consult Request
SNF to ED
Type 5 Dataset:
Scenario 1 & 2/User Story 1
Hospital to Home Health Agency
HHA  PCP (CMS-485 Subset)

36. LCC - Timeline for Phase 2
LCC Work Stream 1: Indirect to S&I Process

37. LCC - Timeline for Phase 2
LCC Work Stream 2: S&I Process

38. LCC - Timeline for Phase 2
LCC Work Stream 3: Vision/ Policy/ Roadmap

39. Baseline Transaction and Build
Master Longitudinal Care Use Case
Future:
Full LCP Support
Version …: Other trading partners
Round out full longitudinal picture
Version 4: (IRF, Behavioral Health, CBO, ???)
Version 3: (IRF, Behavioral Health, CBO, ???)
Building Incrementally
Version 2: (IRF, Behavioral Health, CBO, ???)
White Paper Roadmap lays out priority order to incrementally add requirements of other trading partners
Version 1: Baseline Developed with HHA/ SNF
Creates base LCC Use Case Structure and focuses on HHA/ SNF as the starting point that gives the best overall coverage of data elements.
Now:
Foundation

40. S&I Process: Baseline and Build in Parallel
Continue to develop and refine requirements in parallel with developing implementation guidance and pilots
HHA/ SNF UC
Next LTPAC UC
Next LTPAC UC
Next LTPAC UC
HHA/ SNF Harmonization
Next LTPAC Harm
Next LTPAC Harm
HHA/ SNF Pilots
Other LTPAC Pilots

41. Baseline Use Case Transactions
Scenario 1: Transitions of Care and Referral
Representative Transitions
Acute Care to LTPAC (as represented by HHA) #5:
LTPAC (as represented by SNF/ NF) to ED #4
ED to LTPAC (as represented by SNF/ NF) #3
Scenario 2 –Patient Communications:
Copy all ToC and PoC transactions to patient/care giver PHR
Scenario 3 – HHA Plan of Care:
Initial PoC from HHA to Physician, Physician to HHA
Ongoing PoC from HHA to Physician, Physician to HHA
Recertification PoC from HHA to Physician , Physician to HHA

42. Baseline Use Case Transactions
Scenario 1: Transitions of Care and Referral
Representative Transitions
Acute Care to LTPAC (as represented by HHA) #5:
Note post-condition populating POC and OASIS
LTPAC (as represented by SNF/ NF) to ED #4:
Note pre-condition reusing MDS and INTERACT
ED to LTPAC (as represented by SNF/ NF) #3:
Note post-condition populating MDS
Scenario 2 –Patient Communications:
Copy all ToC and PoC transactions to patient/care giver PHR
Scenario 3 – HHA Plan of Care:
Initial & Recertification PoC from HHA to Physician, Physician to HHA
Interim Changes to PoC from HHA to Physician, Physician to HHA
Requirements for all PoC transactions to consider date stamp/ versioning requirement

43. PAS SWG Standards and Data Analysis
Determine next steps with Harmonization Team

44. Structuring WG Activities to meet our challenge
Do we have the right structure?
How might we modify to better fit current and future needs?
Re-engaging the LCC WG-level to build out White Paper

45. Schedule Reminder Time Agenda Topic Room Thursday 8:00 am – 10:00 am
LCC Status and Introduction
Edison E
10:30 am – 12:00 pm
LTPAC Working Session
1:30 pm – 3:30 pm
PAS Working Session
4:00 pm – 6:00 pm
LCP Working Session
Friday
Use Case Working Session
10:30 am – 12:00 pm
Use Case Working Session and Recap F2F Progress/ Next Steps

46. Confirm Meeting Actions
Confirm objectives for the F2F?