1. Longitudinal Coordination of Care (LCC) Workgroup (WG) HL7 Tiger Team Service Oriented Architecture (SOA) Care Coordination Services (CCS) May 8, 2013 1

2. Meeting Etiquette Remember: If you are not speaking, please keep your phone on mute Do not put your phone on hold. If you need to take a call, hang up and dial in again when finished with your other call o Hold = Elevator Music = frustrated speakers and participants This meeting is being recorded o Another reason to keep your phone on mute when not speaking Use the Chat feature for questions, comments and items you would like the moderator or other participants to know. o Send comments to All Participants so they can be addressed publically in the chat, or discussed in the meeting (as appropriate). From S&I Framework to Participants: Hi everyone: remember to keep your phone on mute All Participants

3. Agenda Introductions Goals Schedule Discussion of Risks, Health Concerns, Barriers and Preferences as they relate to LCCs vision of care plan exchange and workflow –Ongoing comments can be submitted and viewed on wiki: http://wiki.siframework.org/LCC+HL7+Tiger+Team+SWG Next Steps 3

4. 4 For this initiative: Interoperable and shared patient assessments across multiple disciplines Shared patient and team goals and desired outcomes Care plans which align, support and inform care delivery regardless of setting or service provider For this Tiger Team: Alignment of HL7 artifacts with LCC artifacts to support care plan exchange HL7 CCS provides Service Oriented Architecture Care Plan DAM provides informational structure LCC Implementation Guides provide functional requirements Goals

5. Schedule – May 2013 SUNDAYMONDAYTUESDAYWEDNESDAYTHURSDAYFRIDAYSATURDAY 1 234 11 AM ET: Overview of HL7 LCC Domain Analysis Model 567891011 11 AM ET Discussion: Risks, Health Concerns, Barriers 12131415161718 11 AM ET Discussion: Risks, Health Concerns, Barriers 5 PM ET Tentative Touch Point with PCWG 19202122232425 11 AM ET: Map out how to designate/model Prioritizations 262728293031 11 AM ET: Map out how to assign Care Team Members to prioritizations

6. 6 Health Concern Definition Overview as it relates to care plan exchange and workflow Overview: Health Concern

7. 7 Health concerns reflect the issues, current status and likely course identified by the patient or team members that require intervention(s) to achieve the patient's goals of care, any issue of concern to the individual or team member. Problems and diagnoses will capture medical/surgical diagnosis but are insufficient to capture the full array of issues that are important to individuals. Health concerns include: Medical/surgical diagnoses and severity Nursing/Allied Health/Behavioral Health issues Patient reported health concerns Behavioral/Cognition/Mood issues Functional status, including ADL issues Environmental factors (e.g. housing and transportation) Social factors including availability of support and relationships Financial issues (e.g. insurance, eligibility for disability) Care Plan Glossary Definition of Health Concerns

8. 8 High Level Health Concerns

9. 9 Risk Definition Intrinsic: family history, genetic predisposition to condition/disease Extrinsic: comes with an intervention (such as risks caused by drugs the patient is taking) Some risks are not necessarily health concernscan be decision by patient themselves or something care team member identifies as risk Should well accepted risks be identified as health concerns or is the presence of that risk sufficient to identify that risk for the sake of decision support? (e.g. bleeding risk with anti-coagulant medications) Inbound vs. outbound risks (HL7 concept) Overview as it relates to care plan exchange and workflow Overview: Risk

10. 10 Barrier Definition If a barrier is identified is it automatically considered a health concern? Are barriers associated with goals or interventions? (suggest interventions) Does a coded value set for barriers exist? Overview as it relates to care plan exchange and workflow Overview: Barrier

11. 11 Preference Definition How are preferences represented? Positive vs. negative preferences Overview as it relates to care plan exchange and workflow Overview: Preference

12. 12 Define how Risks, Barriers and Preferences relate to Health Concerns, map out how to categorize them Represented as Health Concerns Perhaps represented as negative preferences in model Is the opposite of a Risk a mitigating factor (in relation to decision support)? Discuss how Risks, Barriers and Preferences relate to Goals and Interventions, map out how to categorize them Points for Discussion

13. 13 Care Plan Workflow

14. 14 Care Plan Relationships

15. 15 Define Goals, Concerns and Interventions, map out how to designate prioritization of each Map out how to mitigate irrational choices For Next Week

16. Proposed Next Steps Schedule Touch Point meeting(s) with PCWG Update discussion schedule Finalize LCCs Comments by August 4, 2013 for submittal as part of September Ballot

17. 17 Contact Information Were here to help. Please contact us if you have questions, comments, or would like to join other projects. S&I Initiative Coordinator Evelyn Gallego evelyn.gallego@siframework.orgevelyn.gallego@siframework.org Sub Work Group Lead Russ Leftwich cmiotn@gmail.comcmiotn@gmail.com Program Management Lynette Elliott lynette.elliott@esacinc.comlynette.elliott@esacinc.com Becky Angeles becky.angeles@esacinc.combecky.angeles@esacinc.com