1. Longitudinal Coordination of Care (LCC) Workgroup (WG) LCC All Hands Meeting February 7, 2013 1

2. Agenda ONC S&I Updates Key Accomplishments of the WG & SWGs Use Case Working Session Next Steps 2

3. ONC S&I Updates Developing S&I LCC Support Work plan to support next phase of LCC Initiative Engaging with S&I Transitions of Care (ToC) Support team to align and build from ToC artifacts and membership Identifying and engaging with additional LCC Stakeholder groups Engaged with ONC Office of Policy & Planning (OPP) to review and schedule LCC WG presentation to the HITPC 3

4. LCC WG Key Accomplishments Held two webinars regarding the Meaningful Use (MU) Stage 3 Request for Comments –Reviewed relevant Meaningful Use (MU) Stage 3 sections –Proposed concepts and definitions to reframe the recommendations –Gathered community feedback to develop a shared response Submitted Comments for the Meaningful Use (MU) Stage 3 Request for Comments Updated the LCC and SWG Wiki pages –Streamlined content –Meeting Information more visible –PAS SWG is Completed

5. Wiki Re-Design http://wiki.siframework.org/Longitudinal+Coordination+of+Care+%28 LCC%29http://wiki.siframework.org/Longitudinal+Coordination+of+Care+%28 LCC%29

6. LTPAC SWG Key Accomplishments Developing a roadmap for a public and private collaboration –Create and ballot through HL7 Implementation Guides to support transitions of care and the care plan/home health plan of care. Proposed a new CDA template section known as theMAP (AKA Master All-care Plan) which maps the many-to-many relations that connect the various elements of the care plan (e.g. Health Concerns, Goals, Interventions, Assessments, and Care Team). Reviewed and provided feedback to Lantana to support their work on defining a high-level Implementation Guide for the Transfer of Care dataset. 6

7. LCP SWG Key Accomplishments Led review and consolidation of LCC Community comments on Care Plan Glossary and RFC Webinar Supported review and deep dive of care plan components of IMPACT dataset 7

8. PAS SWG Key Accomplishments New website regarding transform tool: www.transform.keyhie.orgwww.transform.keyhie.org –Will be updated often as project unfolds –Currently able to see info on benefits and pricing –Sign up under take a test drive and you will be included in updates on project Aggressive launch schedule –Started pilots in mid-January with: –Presbyterian Senior Living (SNF) –Sun Home Health (HHA) –Will bring on Geisinger Beacon facilities in Mar/Apr –Anticipate full public launch in April Jim Younkins ONC presentation on project will be posted to wiki 8

9. Use Case Outline NEXT STEPS: Look at the Problem list – expand or reduce the list Take the list and under each heading identify which health concerns are for what team members and which team members are working collaboratively Team members: Hospitalist Floor nurse Psych Consultant Case manager Delivered to: PCP Community-based care coordinator HHA nurse CBSO Behavior Health professional 9

10. Use Case Outline Patient has the following Problems: Diabetic Ulcer – –non weight-bearing on the foot with the ulcer –neuropathy –gait impairment Depression – –self-medicating with alcohol Substance Abuse Issues –Malnutrition from alcohol abuse Lives alone in a 3rd Floor Walkup with Kerosene Heater (no elevator) Infectious Disease –MRSA PPD is positive Vaccination Status Visually Impaired - Unable to Drive Cognitive Status Smoking / COPD 10

11. Use Case Outline Insurer: Medicaid/Medicare (dual) Achieve following Goals: Marginal disease management Quality of life improvement Figure out what the patient really wants – what is important and how the care team can help (i.e., get housing on the first floor) Break the cycle of re-admission in ED Substance Abuse Intervention Assumption: The Clinical Summary exists and wraps around this Use Case 11

12. Use Case Map

13. 13 Next Steps Finalize S&I LCC WG Support Plan Update LCC Use Case with new Care Plan component definitions –Revise functional specifications Kick-off IMPACT/ASPE public private partnership for development of ToC and Care Plan/ HHPoC Implementation Guides