1. Omnibus Care Plan (OCP) Care Coordination System
Reimagining Care Planning and Care Coordination
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Kenneth Salyards, SAMHSA

2. Reimagining the Care Plan to improve outcomes
SAMHSA engaged with subject matter experts to recommend changing the care plan model from a process-based model to an outcome-based model using SOAP notes as an ongoing opportunity to maintain and track constant engagement with the patient:
Subjective self-evaluation
Objective, measurable goals
Assessments to identify problems and track progress/outcomes
Planned interventions, medications, encounters, etc.
Improve engagement and social connectedness to improve patient outcomes
User-friendly data entry to reduce documentation burden by using a SOAP note – a standard method of documenting care

3. Omnibus Care Premise
Patient-centered care revolves around effective and efficient care coordination across care providers, patient engagement, social connectedness, and facilitating the patients’ treatment beyond episodic or chronic treatment.
Today, the healthcare environment is fragmented and ineffectual in providing 3600 whole-patient care with the mix of private and public insurers and self- pay with a large number of no-pay patients.
SAMHSA is devoted to the care and treatment of behavioral health patients. New models of paying for care are being developed and initiated with the objective to reduce the cost of healthcare.

4. Omnibus Care Plan Functional Overview
Administrative
Program, Services, Locations
Patient Enrollment
Practitioners, Organizations
Patient Consent
Episode of Care
Scheduling/ Appointment
Appointments/ Scheduling
Encounter Management
Care Coordination
Caseload Mgmt. Dashboard
Enrollee/ Consumer Dashboard
Outreach/ Activity Management
Smart Notes
Program Mgmt.
Screeners/ Assessments
Scored screening and assessments (MA Assessment, PHQ9, PHQ4, etc.)
Comprehensive Assessment
Computable Scores/sub-scores (LOINC)
Care Planning and Delivery
SOAP and Visit Notes
Dynamic Care Plan Summary
Goals and Interventions based on Outcomes/scores
Standards-based Data Shared Among Applications

5. Omnibus Care Plan Technical Architecture Cloud-based, Secure, HIPAA-Compliant, Scalable, Extensible Web Platform
Browser-based, supports phone/mobile
Low Information Technology (IT) overhead
Web-application
HL7 Fast Healthcare Interoperability Resources (FHIR),
Integration with Electronic Health Record (EHR), billing, quality systems
Standards-based Data Services
HIPAA compliant cloud services
Business Associate Agreement
Centralized management, secure, scalable
Cloud-based & HIPAA-Compliant
Reuses existing software components
Extensible to integrate other applications
Reusability and Extensibility
Encryption
Identity & Access Mgmt.
User roles (Permissions)
Patient Consent
Security/Privacy
Automatic increase in memory, storage to match user needs cloud services
Scalable

6. Omnibus Care Plan Roadmap: Data Standards, Interoperability, and Analytics
Sharing data among applications in a seamless manner
Monitor and report patient outcomes
Interoperability
EHR systems
Pre-authorization
Billing system
Electronic Visit Verification
Quality reporting system
Patient engagement through mobile devices
Expanded provider access to telemedicine
Analytics
Data warehouse and integration
Business intelligence (BI) reporting and health analytics
Quality outcome reporting
Clinical decision support
HHS agencies are driving interoperability efforts and change in US healthcare.
Office of National Coordinator for Health IT (ONC) is leading interoperability through standardization workgroups, collaboration with Standards Development Organizations (SDO) and certification programs of the healthcare systems
SAMHSA is leading interoperability specifically for the behavioral health domain by working with SDOs and other federal agencies

7. Omnibus Care Plan Solution Overview: Solution Component Diagram
Clinician
Patient
Care Team
Care Coordination
Program Management
Alerts & Notifications
Consent Management
Task/Activity Management
Referral Management
Scheduling/ Appointments
Functional Services
Program Administration
Continuity of Care
Billing Support
Infrastructure Services
Security/ Privacy
EHR & HIE Integration
Reporting
Analytics
We need the EOB ?
C-CDA
FHIR
SMART-on-FHIR
Standards

8. Reusable SMART-on-FHIR modules/ applications
Standard-Based Wraparound Application
(e.g. EHR system, MESC system, OCP)
Reusable SMART-on-FHIR modules/ applications

10. SMART-on-FHIR app launch
FHIR Resources
FHIR Search
C-CDA

11. Demonstration
Enabling