1. Dynamic Care Team Management
IHE Patient Care Committee (PCC)

2. Profile Concepts
The Dynamic Care Team Management (DCTM) Profile provides the means for sharing care team information about a patient’s care teams that meet the needs of many users, such as providers, patients and payers.
Supports HL7 Care Coordination Service Functional Model Sub- capabilities:
Discovering Care Teams
Creating/updating Care Teams
Listing Care Teams

3. Care Team Concepts
Patient centered care teams with the overarching goal to support collaborative care.
Care teams can be made up of a single individual, a single group of individuals or multiple groups of individuals providing various types of services.
Care teams can be discipline and or condition specific.
Uses LHS Classification of types of care teams:
Encounter-focused Care Team; Episode-focused Care Team; Condition- focused Care Team; Care-coordination focused Care Team; Research-focused Care Team.

4. DCTM Volume 1

5. DCTM Actor Diagram

6. Basic Process Flow

7. Interaction Diagram

8. DCTM Use Case
Reuses the HL7 Care Plan Domain Analysis Model specification storyboard 2: Chronic Conditions
Slight modifications made to depict care team management needed for chronic disease management as well as transition of care episodes
Use case is sub-divided to reflect HL7 LHS Care Team Definition Project’s classification of types of care teams

9. DCTM Volume 2

10. Transaction: Update Care Team
A CareTeam resource is submitted to a Care Team Service where the update or creation is handled
Update uses HTTP or HTTPS PUT of a CareTeam resource
See FHIR update interaction -
Create uses HTTP or HTTPS POST of a CareTeam resource
See FHIR create interaction -
You go to update but if the resource does not exist then you create.

11. Transaction: Search for Care Team
Care Team Contributor initiates Search for Care Team in order to locate a CareTeam resource of interest.
Care Team Service responds to the Search
Search uses FHIR search operation using REST platform constrained to HTTP or HTTPS GET
See FHIR CareTeam search parameters -

12. Transaction: Retrieve Care Team
Care Team Contributor requests a specific CareTeam resource
Initiates retrieve request using HTTP or HTTPS GET
Care Team Service returns the requested CareTeam resource (or an error if the requested resource does not exist)
Care Team Service responds according to FHIR GET specification
See FHIR read interaction

13. Transaction: Subscribe to Care Team Updates
Care Team Contributor subscribes to updates based upon changes to a CareTeam resource
Care Team Service evaluates the involved resources of the Subscription and uses the defined channel to notify a Care Team Contributor about changes
Care Team Contributor inspects the response from the Care Team Service
See FHIR CareTeam create interaction
Care Team Contributor can update an existing subscription
Update uses HTTP or HTTPS PUT of a Subscription resource
See FHIR update interaction -

14. Transaction: Provide Care Team
Care Team Service provides updated CareTeam resources to subscribed Care Team Contributors
Provide uses HTTP or HTTPS POST of a CareTeam resource
Care Team Contributor that has Subscribed to Care Team Updates receives updates of changed CareTeam resources

15. PCC Volume 3
FHIR Content Module

16. dctmCareTeam StructureDefinition
See section 6.6.1
Profiled the following
Identifier
Identifier value
Status
Name
Subject (patient)
context
Period
Start
participant

17. dctmSubscription StructureDefinition
See section 6.6.2
Profiled the following
type (rest-hook)
Endpoint
payload