1. Longitudinal Coordination of Care (LCC) Pilots Template Insert the Name of Your Pilot / Organization Here MM/DD/YYYY

2. Pilot Team Identify the members of your organization who will be supporting this pilot. If possible include the role he/she will play in the pilot and contact information 2 NameRoleEmail

3. Full Disclosure?

4. Goal of the Pilot Please include a write up or create a Visio diagram of what you intend to show/prove/support during the pilot process. Make this an actionable statement with specifics. Also include in this description what you hope to gain from this pilot. 4

5. Which of the 5 C-CDA Revisions are you Piloting? Please use this section to document which of the 5 LCC Standards (Transfer Summary, Consultation Request, Consult Note, Care Plan, and/or Home Health Plan of Care ) you are intending to pilot. Please be as specific as possible. 5 SDC Standard / GuidanceSpecifics to PilotNotes

6. What Relevant Scenario (from the Use Cases) does your Pilot support? Exchange of Clinical Information from Provider to Provider Exchange of Clinical Information from Provider to Patient Other: ____(Please specify) Link to download Consensus Approved Use Case 1: http://wiki.siframework.org/LCC+WG+Use+Case+%26+Functional+ Requirements http://wiki.siframework.org/LCC+WG+Use+Case+%26+Functional+ Requirements Link to download Consensus Approved Use Case 2: http://wiki.siframework.org/LCC+WG+Use+Case+2.0 http://wiki.siframework.org/LCC+WG+Use+Case+2.0

7. Identify the Use Case Actors/Systems Involved: A pilot may involve the following participants from the longitudinal coordination of care ecosystem: –Sending Entity Care Team –Receiving Entity Care Team –Sending Entity Information System (EHR) –Receiving Entity Information System (EHR) –Patient and/or Caregiver –Home Health Agency (HHA) Care Team –Home Health Agency (HHA) Information System (EHR) –PHR Application

8. Minimum Configuration What is your current technical / infrastructure set up? What systems / applications will you be using to conduct the pilot? Examples: –Electronic Health Record (EHR) system –Health Information Exchange (HIE) –External database (which one/type) –Existing interfaces –New interfaces (to be developed as part of the pilot)

9. Timeline What is your proposed timeline given we want to wrap-up Pilots by Q4 2014 Guidance: ~6 months minimum / ~1 year maximum Evaluation: starts @ 6-9 months / final evaluation when pilot is complete Example Timeline –September – Kickoff and Logistics –October – Start Pilots –November – Continue with Pilots –March – Conclude Pilots MilestoneTarget DateResponsible Party

10. Success Criteria What will you/your organization use to determine the success of this pilot? This needs to be quantitative and not subjective in as much as possible. Examples: –X% Reduction in readmission rate –X% Increase in number of unique patient transfers between sites with complete set of Care Plan data elements

11. Example: IMPACT Performance Metrics Target Outcom e Target ValueTarget PopulationData Source NumeratorDenominator Reduce hospital readmissi on rate 5% decrease in 30 day hospital readmission rates from baseline Unique FCHP patient discharges from St. Vincent Hospital and UMass Memorial Hospital that are readmitted to any hospital from IMPACT Pilot Sites Fallon Community Health Plans claims data via Reliant Medical Group Number of unique patient discharges from St. Vincent Hospital and UMass Memorial Hospital that are readmitted to any hospital from IMPACT Pilot Sites within 30 days during measurement period Number of unique patient discharges from St. Vincent Hospital and UMass Memorial Hospital during measurement period Reduce Hospital Admissio n Rate 5% decrease in Hospital Admission Rate from baseline Unique FCHP members seen in St. Vincent Hospital and UMass Memorial Hospital ER that had been under the care of an IMPACT Pilot Site during the measurement period, that are subsequently admitted to the hospital from the ER Fallon Community Health Plans claims data via Reliant Medical Group Number of unique FCHP members in an IMPACT Pilot Sites care during measurement period that are transferred to the St. Vincent Hospital or UMass Memorial Hospital ER that are subsequently admitted to the hospital Number of unique FCHP members in an IMPACT Pilot Sites care during measurement period that are transferred to the St. Vincent Hospital or UMass Memorial Hospital ER Increase overall complete ness of data included in transition process 70% of patients transferred with complete set of required data elements included in electronic Universal Transfer Form (UTF) Unique patient transfers between IMPACT pilot sites LAND and SEE data Number of unique patient transfers between IMPACT Pilot Sites during measurement period with complete set of required data elements in electronic UTF Number of unique patient transfers between IMPACT Pilot Sites during measurement period

12. In Scope / Out of Scope If you already know what will be in and out of scope for your pilot (beyond the Implementation Guidance (IG) or the Use Case) please document it here. Example:

13. Risks & Challenges Identify any risks or challenges

14. Questions / Needs Please include those items you wish to consider any questions you have or hope the pilot addresses. Additionally, please include those items you need in order to succeed. We will try to accommodate as many of these needs as possible within the scope of ONC, S&I and LCC (and resource availability).

15. Useful Links LCC Wiki Main Page: http://wiki.siframework.org/Longitudinal+Coordination+of+Care+%28LCC%29 http://wiki.siframework.org/Longitudinal+Coordination+of+Care+%28LCC%29 Use Case 1.0 Transfer of Care: http://wiki.siframework.org/LCC+WG+Use+Case+%26+Functional+Requirements http://wiki.siframework.org/LCC+WG+Use+Case+%26+Functional+Requirements Use Case 2.0 Care Plan Exchange: http://wiki.siframework.org/LCC+WG+Use+Case+2.0 http://wiki.siframework.org/LCC+WG+Use+Case+2.0 Transfer of Care Harmonization: http://wiki.siframework.org/LCC+Long-Term+Post- Acute+Care+%28LTPAC%29+Transition+SWG#Lantana%20Working%20Documentshttp://wiki.siframework.org/LCC+Long-Term+Post- Acute+Care+%28LTPAC%29+Transition+SWG#Lantana%20Working%20Documents Care Plan Exchange Harmonization: TBD Pilots Wiki Page: http://wiki.siframework.org/LCC+Pilot+Planhttp://wiki.siframework.org/LCC+Pilot+Plan

16. LCC WG Timeline: Mar 2013 – Dec 2013 Mar 13Apr 13May 13Jun 13Jul 13Aug 13Sep 13Oct 13Dec 13 Milestones Pilot Site Identification & Engagement Care Plan C-CDA Revisions Complete HL7 Project Scope Statement Due HL7 Intent to Ballot Due HL7 Fall Ballot Open NY Pilots Monitoring LCC Care Plan Use Case 2.0 Development & Consensus IMPACT ToC Pilot Monitoring HL7 Ballot Publication ToC IGs Development (Transfer Summary, Referral Note, Consult Note) ToC C-CDA Revisions Complete HL7 Final Ballot Due LCC Stakeholder Engagement: Lantana, IMPACT, ASPE, NY, CMS Care Plan/ Home Health Plan of Care IG Development HL7 Ballot Package Development HL7 Ballot & Reconciliation FACA LCC WG Briefings LCC & HL7 Care Plan Coordination IMPACT Go-Live NY Care Coordination Go-Live Appendix A: LCC Timeline