Longitudinal Coordination of Care

1. Longitudinal Coordination of Care Longitudinal Care Plan Sub Workgroup

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

3. Introductions and Welcome Round-robin introductions Overall LCC F2F Agenda

4. LCC Overview Longitudinal Coordination of Care Workgroup* Longitudinal Care Plan Sub-Workgroup LTPAC Care Transition Sub-Workgroup Patient Assessment Summary Sub-Workgroup • 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 • 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 • 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 * 75 interested parties, including 28 active, committed members • Providing subject matter expertise and coordination of SWGs • Developing systems view to identify interoperability gapsand prioritize activities

5. 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

6. 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

7. 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??

8. 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

9. View of LTPAC Flow ACH to HHA/SNF HHA/SNF Episode of Care Admission to HHA/SNF Change in Condition Order for Skilled Care (HHA/SNF) Initial Assessment (Nsg, etc) OASIS MDS Order for referral to Acute Care HHA- CMS 485 SNF- Start of Care Orders ToC Data Comprehensive Plan of Care Referral to specialist SNF- Initial Plan of Care PAS

10. Strawman Proposal for Use Case An evidence-based approach to supporting LTPAC needs

11. 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

12. Massachusetts Paper UTF Pilot Too Long!

13. UTF Data Element Survey • 46 Organizations completing evaluation • ~300 Data elements evaluated • 1135 Transition surveys completed

14. 11 Types of Organizations

15. 12 User Roles

16. 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

17. 11x11 Sender (left column) to Receiver (top) 17

18. Prioritize Transitions by Volume, Clinical Instability and Time-Value of Information Black circles = highest priority Green circles = high priority 18

19. Prioritize Transitions by Volume, Clinical Instability and Time-Value of Information 49 Documents Is Too Many! Black circles = highest priority Green circles = high priority 19

20. 5 High-priority Transition Datasets Report from Outpatient testing, treatment, or procedure Referral to Outpatient testing, treatment, or procedure Shared Care Encounter Summary (Office Visit, Consultation Summary, Return from the ED to the referring facility) Consultation Request Clinical Summary (Referral to a consultant or the ED) Permanent or long-term transfer to a different facility or care team or Home Health Agency

21. 5 High-priority Transition Datasets 5 3 1 5 5 2 4 5

22. 5 High-priority Transition Datasets • Type 3 Dataset: • Office Visit to PHR • Consultant to PCP • ED to PCP, SNF, etc… 5 – Transfer of Care Summary 1 – Test/Procedure Report 2 – Test/Procedure Request 4 – Consultation Request Clinical Summary 3 – Shared Care Encounter Summary • 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

23. Relationship to Other Transfer Forms • Type 3 Dataset: • Office Visit to PHR • Consultant to PCP • ED to PCP, SNF, etc… 5 – Transfer of Care Summary INTERACT 1 – Test/Procedure Report MA Universal Transfer Form 2 – Test/Procedure Request 4 – Consultation Request Clinical Summary 3 – Shared Care Encounter Summary • 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

24. Relationship to Assessment Tools Continuity Assessment Record and Evaluation (CARE) Tool IRF-PAI OASIS Minimum Data Set (MDS)

25. Relationship to Plan of Care 5 – Transfer of Care Summary Plan of Care 1 – Test/Procedure Report 2 – Test/Procedure Request 4 – Consultation Request Clinical Summary 3 – Shared Care Encounter Summary

26. Relationship to Patient Instructions 5 – Transfer of Care Summary Patient Instructions Plan of Care 1 – Test/Procedure Report 2 – Test/Procedure Request 4 – Consultation Request Clinical Summary 3 – Shared Care Encounter Summary

27. Situation-specific Data Elements Variable Base on Situations: Setting Diagnoses Medications Treatments Procedures 5 – Transfer of Care Summary 5 – Transfer of Care Summary 5 – Transfer of Care Summary 5 – Transfer of Care Summary 5 – Transfer of Care Summary 5 – Transfer of Care Summary 5 – Transfer of Care Summary 5 – Transfer of Care Summary 5 – Transfer of Care Summary 5 – Transfer of Care Summary 5 – Transfer of Care Summary 5 – Transfer of Care Summary 5 – Transfer of Care Summary 5 – Transfer of Care Summary 5 – Transfer of Care Summary 5 – Transfer of Care Summary Patient Instructions Plan of Care 1 – Test/Procedure Report 2 – Test/Procedure Request 4 – Consultation Request Clinical Summary 3 – Shared Care Encounter Summary

28. Optionality of Data Elements • Optionality within each dataset: • Shall • Should • May 5 – Transfer of Care Summary 5 – Transfer of Care Summary 5 – Transfer of Care Summary 5 – Transfer of Care Summary 5 – Transfer of Care Summary 5 – Transfer of Care Summary 5 – Transfer of Care Summary 5 – Transfer of Care Summary 5 – Transfer of Care Summary 5 – Transfer of Care Summary 5 – Transfer of Care Summary 5 – Transfer of Care Summary 5 – Transfer of Care Summary 5 – Transfer of Care Summary 5 – Transfer of Care Summary 5 – Transfer of Care Summary Patient Instructions Plan of Care 1 – Test/Procedure Report 2 – Test/Procedure Request 4 – Consultation Request Clinical Summary 3 – Shared Care Encounter Summary

29. Plan of Care Permeates Datasets 5 – Transfer of Care Summary Patient Instructions Plan of Care 1 – Test/Procedure Report 2 – Test/Procedure Request 4 – Consultation Request Clinical Summary 3 – Shared Care Encounter Summary

30. Sometimes Subsets are Used Hospital Discharge Instructions is a subset of #5 5 – Transfer of Care Summary Patient Instructions Discharge Instructions Plan of Care 1 – Test/Procedure Report 2 – Test/Procedure Request 4 – Consultation Request Clinical Summary 3 – Shared Care Encounter Summary

31. Sometimes Subsets are Used CMS-485 is a subset of #5 5 – Transfer of Care Summary CMS- 485 Plan of Care 1 – Test/Procedure Report 2 – Test/Procedure Request 4 – Consultation Request Clinical Summary 3 – Shared Care Encounter Summary

32. Timing of Producing Datasets Transition of Care Workgroup recognized that the Patient Instructions may be generated independently and given to the patient prior to the full transition dataset. 5 – Transfer of Care Summary Patient Instructions Discharge Instructions Plan of Care 1 – Test/Procedure Report 2 – Test/Procedure Request 4 – Consultation Request Clinical Summary Sending a patient to the ED starts with #4, but upon admission, #5 should be sent 3 – Shared Care Encounter Summary

33. 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

34. Relationship to S&I ToC Scenarios • Type 3 Dataset: • Scenario 1 & 2/User Story 2 Consult Summary 5 – Transfer of Care Summary Patient Instructions Plan of Care 1 – Test/Procedure Report 2 – Test/Procedure Request 4 – Consultation Request Clinical Summary 3 – Shared Care Encounter Summary • Type 4 Dataset: • Scenario 1 & 2/User Story 2 Consult Request • Type 5 Dataset: • Scenario 1 & 2/User Story 1

35. LTPAC “Poster Child” Scenarios • Type 3 Dataset: • Scenario 1 & 2/User Story 2 Consult Summary • ED to SNF 5 – Transfer of Care Summary 5 – Transfer of Care Summary 5 – Transfer of Care Summary 5 – Transfer of Care Summary Patient Instructions CMS- 485 Plan of Care 1 – Test/Procedure Report 2 – Test/Procedure Request 4 – Consultation Request Clinical Summary 3 – Shared Care Encounter Summary • 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)

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

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

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

39. Baseline Transaction and Build Master Longitudinal Care Use Case Future: Full LCP Support Version …: Other trading partners Round out full longitudinal picture Version 4: (IRF, Behavioral Health, CBO, ???) Version 3: (IRF, Behavioral Health, CBO, ???) Building Incrementally Version 2: (IRF, Behavioral Health, CBO, ???) White Paper Roadmap lays out priority order to incrementally add requirements of other trading partners Version 1: Baseline Developed with HHA/ SNF Creates base LCC Use Case Structure and focuses on HHA/ SNF as the starting point that gives the best overall coverage of data elements. Now: Foundation

40. S&I Process: Baseline and Build in Parallel Continue to develop and refine requirements in parallel with developing implementation guidance and pilots HHA/ SNF UC Next LTPAC UC Next LTPAC UC Next LTPAC UC HHA/ SNF Harmonization Next LTPAC Harm Next LTPAC Harm HHA/ SNF Pilots Other LTPAC Pilots

41. Baseline Use Case Transactions Scenario 1: Transitions of Care and Referral Representative Transitions • Acute Care to LTPAC (as represented by HHA) #5: • Note post-condition populating POC and OASIS • LTPAC (as represented by SNF/ NF) to ED #4: • Note pre-condition reusing MDS and INTERACT • ED to LTPAC (as represented by SNF/ NF) #3: • Note post-condition populating MDS Scenario 2 –Patient Communications: • Copy all ToCand PoC transactions to patient/care giver PHR Scenario 3 – HHA Plan of Care: • Initial & Recertification PoCfrom HHA to Physician, Physician to HHA • Interim Changes to PoCfrom HHA to Physician, Physician to HHA • Requirements for all PoC transactions to consider date stamp/ versioning requirement

42. PAS SWG Standards and Data Analysis Determine next steps with Harmonization Team

43. 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

44. Schedule Reminder

45. Confirm Meeting Actions Confirm objectives for the F2F?