longitudinal coordination of care longitudinal care plan sub workgroup 1

Longitudinal Coordination of Care

Longitudinal Care Plan Sub Workgroup

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Agenda

• Welcome• LCC Introduction• The LCC Challenge• LCC Structure and Work-to-date• Work Streams• Timeline – High-level• Use Case Scope• White Paper

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Introductions and Welcome

• Round-robin introductions• Overall LCC F2F Agenda

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Time Agenda Topic Room

Thursday

8:00 am – 10:00 am

LCC Status and Introduction

Edison E

10:30 am – 12:00 pm

LTPAC Working Session

1:30 pm – 3:30 pm PAS Working Session

4:00 pm – 6:00 pm LCP Working Session

Friday

8:00 am – 10:00 am

Use Case Working Session

10:30 am – 12:00 pm

Use Case Working Session and Recap F2F Progress/ Next Steps

LCC Overview

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Longitudinal Coordination of

Care Workgroup*

Patient Assessment Summary Sub-

Workgroup

LTPAC Care Transition Sub-

Workgroup

Longitudinal Care Plan Sub-

Workgroup

• Providing subject matter expertise and coordination of SWGs

• Developing systems view to identify interoperability gaps and prioritize activities

• Establishing the standards for the exchange of patient assessment summary documents

• Inform the development of the Keystone Beacon Patient Assessment Summary Document Exchange.

• Inform HL7 balloting of LTPAC-specific enhancements to the C-CDA

• Identifying the key business and technical challenges that inhibit long-term care data exchanges

• Defining data elements for long-term and post-acute care (LTPAC) information exchange and using a single standard for LTPAC transfer summaries

• Near-Term: Developing an implementation guide to standardize the exchange of Form CMS-485 (Home Health Certification and Plan of Care)

• Long-Term: Identify and develop a longitudinal care plan spanning multiple care settings

* 75 interested parties, including 28 active, committed members

Observations on progress to date

• Excellent progress:– Keystone Feedback on PAS CCD– RTI Data feedback– Input on CMS HL7 Balloting– Use Case – Gap Analysis, Scoping and Functional/ Data Requirements

• Complexity– Broad view of trading partner community– Many types of transitions and roles of receivers

• Focus Challenges– External Drivers– Multiple Demands

• Coordination Challenges– Separate SWGs– Lack of cohesive overall plan

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Related Work Streams

• S&I Process - Use Case/ Requirements to Advance interoperability for the LTPAC community.

– Building on the ToC Initiative work and ToC V1.1 Use Case as a foundation for LCC– S&I process (Use Case, Harmonization, IG) provides actionable implementation path for the

LTPAC community– LLC WG would like implementable specifications to support pilots before the end of 2012

• Influence and impact ongoing policy discussions– LCC WG has a strong set of LTPAC interoperability policy stakeholders at the table– White paper would allow for the articulation of a vision and objectives that would be in a format

that is familiar to policy-makers.

• Support specific WG objectives– Continue to use LCC WG as the working forum to support the Challenge, Beacon and VNSNY

project objectives– Project-specific deliverables based on Challenge, Beacon and other requirements

• Serve as a platform for responding to important and related standards activities– Care/ CMS collaboration with HL7 and S&I LCC WG– Standardization of Content for Functional Status, Cognitive Status and Pressure Ulcer work (C-

CDA structure review, Data Elements Review)– Impacting a variety of Assessment Instruments (MDS, OASIS, CARE, etc…)– All LCC SWGs as well as the LTPAC community at large, looks to leverage the standards work

emerging from this collaboration– Analysis-supporting deliverables

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White Paper

• Detailed articulation of environment• Detailed articulation of current efforts• Vision for Longitudinal Coordination of Care - Roadmap

• Extend Baseline to other care settings • Extend interoperability interchanges and system functions to more

sophisticated care processes, e.g. CDS

• Articulate how S&I first LCC Use Case (HHA) supports overall vision and roadmap for incrementally building trading-partner specific Use Cases

• Standards-improvement roadmap• NPRM response and implications• Use White Paper to manage any unanticipated complexity• What else??

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Use Case Content Guidance

• Requirements document for use by business/ clinical analysts to hand-off to technical implementers

• Document designed for business and technical implementers (not policy makers)

• Get the best possible coverage of likely overall data elements with the least number of specifically defined transactions

• Use Baseline Use Case to replicate for other care settings, e.g., IRF, BH, and to add scenarios and more sophisticated process transactions and content

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ACH to HHA/SNF

Admission to HHA/SNF

Order for Skilled Care (HHA/SNF)

ToC Data

Initial Assessment

(Nsg, etc)

HHA- CMS 485SNF- Start of Care Orders

SNF- Initial Plan of Care

OASISMDS

Comprehensive Plan of Care

PAS

HHA/SNF Episode of Care

Change in Condition

Order for referral to

Acute Care

Referral to specialist

View of LTPAC Flow

Strawman Proposal for Use Case

An evidence-based approach to supporting

LTPAC needs

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MA DPH Universal Transfer Form

• Started with DPH’s 3-pg Discharge Form• Sought input from LTPAC “receivers”• Reviewed existing forms and datasets:

– MDS– OASIS– IRF-PAI– INTERACT

• Sought expert opinions• Resulted in 7-page UTF

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Massachusetts Paper UTF Pilot

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Too Long!

UTF Data Element Survey

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• 46 Organizations completing evaluation• ~300 Data elements evaluated• 1135 Transition surveys completed

11 Types of Organizations

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12 User Roles

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Findings from UTF Survey

• Largest survey of Receivers’ needs• Identified for each transitions which data

elements are required, optional, or not needed

• Each of the 300+ data elements is valuable to at least one type of Receiver

• Many data elements are not valuable in certain care transition

• Paper form can’t represent these needs

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Transitions to (Receivers)In Patient ED Out patient LTAC IRF SNF/ECF HHA Hospice Amb Care CBOs Patient/

Transitions From (Senders) Services (PCP) Family

In patient

ED

Out patient services

LTAC

IRF

SNF/ECF

HHA

Hospice

Ambulatory Care (PCP)

CBOs

Patient/Family

11x11 Sender (left column) to Receiver (top)

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Transitions to (Receivers)In Patient ED Out patient LTAC IRF SNF/ECF HHA Hospice Amb Care CBOs Patient/

Transitions From (Senders) Services (PCP) FamilyV = H V = H V = H V = H V = H V = H V = H V = H

In patient CI = H CI = H CI = M CI = M CI = L CI = M CI = L CI = MTV = H TV = H TV = H TV = H TV = H TV = H TV = H TV = HV = H V = H V = H V = H V = M V = H V = M V = H

ED CI = H CI = H CI = H CI = M CI = M CI = L CI = L CI = MTV = H TV = H TV = H TV = H TV = H TV = H TV = H TV = HV = H V = H V = H V = H V = L V = H V = H

Out patient services CI = H CI = M CI = M CI = M CI = L CI = L CI = LTV = H TV = H TV = H TV = H TV = H TV = H TV = L

V = H V = H V = H V = M V = H V = H V = M V = H V = H V = HLTAC CI = H CI = H CI = H CI = M CI = M CI = M CI = M CI = M CI = M CI = M

TV = H TV = H TV = H TV = H TV = H TV = H TV = H TV = H TV = H TV = HV = H V = H V = H V = L V = H V = H V = L V = H V = H V = H

IRF CI = H CI = H CI = M CI = H CI = L CI = L CI = M CI = L CI = L CI = LTV = H TV = H TV = H TV = H TV = H TV = H TV = H TV = H TV = H TV = HV = H V = H V = H V = M V = L V = L V = H V = M V = H V = H V = H

SNF/ECF CI = H CI = H CI = M CI = H CI = M CI = M CI = M CI = M CI = L CI = M CI = LTV = H TV = H TV = H TV = M TV = M TV = M TV = H TV = M TV = M TV = H TV = HV = H V = H V = L V = M V = H V = H V = H

HHA CI = H CI = H CI = L CI = L CI = L CI = L CI = LTV = H TV = H TV = L TV = L TV = L TV = L TV = LV = L V = M V = M V = L V = L V = L V = M V = L

Hospice CI = H CI = H CI = M CI = L CI = L CI = M CI = L CI = MTV = H TV = H TV = M TV = M TV = M TV = L TV = L TV = MV = M V = H V = L V = M V = L V = L V = M V = L

Ambulatory Care (PCP) CI = H CI = H CI = M CI = M CI = L CI = L CI = L CI = LTV = H TV = H TV = H TV = M TV = H TV = M TV = M TV = L

CBOs

Patient/Family

Prioritize Transitions by Volume, Clinical Instability and Time-Value of Information

Black circles = highest priority Green circles = high priority

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Transitions to (Receivers)

In Patient ED Out patient LTAC IRF SNF/ECF HHA Hospice Amb Care CBOs Patient/Transitions From (Senders) Services (PCP) Family

In patient

ED


LTAC

IRF

SNF?ECF

HHA

Hospice


CBOs

Patient/Family

Black circles = highest priorityGreen circles = high priority

49 Documents

Is Too Many!

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Prioritize Transitions by Volume, Clinical Instability and Time-Value of Information

1. Report from Outpatient testing, treatment, or procedure

2. Referral to Outpatient testing, treatment, or procedure

3. Shared Care Encounter Summary (Office Visit, Consultation Summary, Return from the ED to the referring facility)

4. Consultation Request Clinical Summary (Referral to a consultant or the ED)

5. Permanent or long-term transfer to a different facility or care team or Home Health Agency

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5 High-priority Transition Datasets

Transitions to (Receivers)

In Patient ED Out patient LTAC IRF SNF/ECF HHA Hospice Amb Care CBOs Patient/Transitions From (Senders) Services (PCP) Family

In patient

ED


LTAC

IRF

SNF?ECF

HHA

Hospice


CBOs

Patient/Family

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24

3

5

5

5

51


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5 – Transfer of Care Summary

4 – Consultation Request Clinical Summary3 – Shared Care Encounter Summary

2 – Test/Procedure Request1 – Test/Procedure Report

Type 3 Dataset:• Office Visit to PHR• Consultant to PCP• ED to PCP, SNF, etc…

Type 4 Dataset:• PCP to Consultant• PCP, SNF, etc… to ED

Type 5 Dataset:• Hospital to SNF, PCP, HHA, etc…• Hospital, SNF, etc… to HHA• PCP to new PCP


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Relationship to Other Transfer Forms




Type 3 Dataset:• Office Visit to PHR• Consultant to PCP• ED to PCP, SNF, etc…

Type 4 Dataset:• PCP to Consultant• PCP, SNF, etc… to ED

MA Universal Transfer Form

INTERACT

Type 5 Dataset:• Hospital to SNF, PCP, HHA, etc…• Hospital, SNF, etc… to HHA• PCP to new PCP

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Relationship to Assessment Tools

Minimum Data Set (MDS)IRF-PAI

OASISContinuity Assessment Record and Evaluation (CARE) Tool

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Relationship to Plan of Care




Plan of Care

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Relationship to Patient Instructions




Plan of Care

Patient Instructions

A.

B.

C.

D.

E.

5 – Transfer of Care Summary5 – Transfer of Care Summary5 – Transfer of Care Summary5 – Transfer of Care Summary5 – Transfer of Care Summary5 – Transfer of Care Summary5 – Transfer of Care Summary5 – Transfer of Care Summary5 – Transfer of Care Summary5 – Transfer of Care Summary5 – Transfer of Care Summary

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Situation-specific Data Elements




Plan of Care


Variable Base on Situations:A. SettingB. DiagnosesC. MedicationsD. TreatmentsE. Procedures

5 – Transfer of Care Summary5 – Transfer of Care Summary5 – Transfer of Care Summary5 – Transfer of Care Summary5 – Transfer of Care Summary5 – Transfer of Care Summary5 – Transfer of Care Summary5 – Transfer of Care Summary5 – Transfer of Care Summary5 – Transfer of Care Summary5 – Transfer of Care Summary

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Optionality of Data Elements




Plan of Care


Optionality within each dataset:• Shall• Should• May

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Plan of Care Permeates Datasets




Plan of Care


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Sometimes Subsets are Used




Plan of Care

Hospital Discharge Instructions is a subset of #5

Patient InstructionsDischarge Instructions

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Sometimes Subsets are Used




Plan of CareCMS- 485

CMS-485 is a subset of #5

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Timing of Producing Datasets




Plan of Care


Transition of Care Workgroup recognized that the Patient Instructions may be generated independently and given to the patient prior to the full transition dataset.

Sending a patient to the ED starts with #4, but upon admission, #5 should be sent

Discharge Instructions

Original S&I ToC Use Case

Scenario 1 - Provider to provider: User Story 1 - Hospital/ED to PCP

• Discharge Instructions• Discharge Summary

User Story 2 - Closed Loop Referral • Consult Request• Consult Summary

Scenario 2 - Provider to patient:User Story 1 - Discharge Instructions and Discharge

Summary to patient’s PHR

User Story 2 - Closed Loop Referral where copies of Consult Request and Consult Summary are sent to patient’s PHR

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Relationship to S&I ToC Scenarios




Type 3 Dataset:• Scenario 1 & 2/User Story 2

Consult Summary

Plan of Care



Type 4 Dataset:• Scenario 1 & 2/User

Story 2 Consult Request

5 – Transfer of Care Summary5 – Transfer of Care Summary5 – Transfer of Care Summary

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LTPAC “Poster Child” Scenarios





Consult Summary• ED to SNF

Type 4 Dataset:• Scenario 1 & 2/User

Story 2 Consult Request• SNF to ED

Type 5 Dataset:• Scenario 1 & 2/User Story 1• Hospital to Home Health Agency• HHA PCP (CMS-485 Subset)

Plan of Care


CMS- 485

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LCC - Timeline for Phase 2LCC Work Stream 1: Indirect to S&I Process

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LCC - Timeline for Phase 2LCC Work Stream 2: S&I Process

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LCC - Timeline for Phase 2LCC Work Stream 3: Vision/ Policy/ Roadmap

Baseline Transaction and Build

Master Longitudinal Care Use Case

Version 1: Baseline Developed with HHA/ SNFCreates base LCC Use Case Structure and focuses on HHA/ SNF as the starting point that gives the best overall coverage

of data elements.

Version 2: (IRF, Behavioral Health, CBO, ???)White Paper Roadmap lays out priority order to incrementally

add requirements of other trading partners

Version 3: (IRF, Behavioral Health, CBO, ???)

Version 4: (IRF, Behavioral Health, CBO, ???)

Version …: Other trading partnersRound out full longitudinal picture

Now:Foundation

Future:Full LCP Support

Building Incrementally

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S&I Process: Baseline and Build in Parallel

HHA/ SNF UCNext

LTPAC UC

HHA/ SNF Harmonization

Next LTPAC Harm

Next LTPAC Harm

HHA/ SNF Pilots

Other LTPAC Pilots

Next LTPAC

UC

Next LTPAC

UC

Continue to develop and refine requirements in parallel with developing implementation guidance and pilots

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Baseline Use Case Transactions

Scenario 1: Transitions of Care and ReferralRepresentative Transitions

1. Acute Care to LTPAC (as represented by HHA) #5:• Note post-condition populating POC and OASIS

2. LTPAC (as represented by SNF/ NF) to ED #4:• Note pre-condition reusing MDS and INTERACT

3. ED to LTPAC (as represented by SNF/ NF) #3:• Note post-condition populating MDS

Scenario 2 –Patient Communications:4. Copy all ToC and PoC transactions to patient/care giver PHR

Scenario 3 – HHA Plan of Care:

5. Initial & Recertification PoC from HHA to Physician, Physician to HHA

6. Interim Changes to PoC from HHA to Physician, Physician to HHA• Requirements for all PoC transactions to consider date stamp/ versioning

requirement

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PAS SWG Standards and Data Analysis

Determine next steps with Harmonization Team

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Structuring WG Activities to meet our challenge

• Do we have the right structure?• How might we modify to better fit current and future needs?• Re-engaging the LCC WG-level to build out White Paper

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Schedule Reminder

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Time Agenda Topic Room

Thursday

8:00 am – 10:00 am

LCC Status and Introduction

Edison E

10:30 am – 12:00 pm

LTPAC Working Session

1:30 pm – 3:30 pm PAS Working Session

4:00 pm – 6:00 pm LCP Working Session

Friday

8:00 am – 10:00 am

Use Case Working Session

10:30 am – 12:00 pm

Use Case Working Session and Recap F2F Progress/ Next Steps

Confirm Meeting Actions

• Confirm objectives for the F2F?

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longitudinal coordination of care longitudinal care plan sub workgroup 1

Documents

pmuse case

ltpac communityllc wg

lccsi process use case

working forum

multiple care settings

hl7 balloting of ltpac

plan of carelong

data elements reviewimpacting