Longitudinal Coordination of Care LCP SWG

1. Longitudinal Coordination of Care LCP SWG Thursday July 18, 2013

2. Agenda

3. Announcements and Reminders • Voting is CLOSED on the LCC Care Plan Exchange Use Case. • We received 24 votes (LCC has 124 Committed Member Organizations) • 18 Yes • 4 Yes (with Comments) • 2 Object (with Comments) • http://wiki.siframework.org/LCC+Care+Plan+Exchange+Use+Case+Consensus • Upcoming HITPC MU Meetings to review Care Plan Recommendations. Final recommendations to be presented to HITPC in August • HITPC MU: July 30th 2013 10:00 to 12:00pm EST http://www.healthit.gov/policy-researchers-implementers/policy-meaningful-use-workgroup-2 • HITPC: Aug 7th 2013 9:30 to 3:00pm EST http://www.healthit.gov/policy-researchers-implementers/hit-policy-committee-19 • Call for Pilot Participation! • LCC gave a Presentation to ONC State HIE LTPAC CoP on July 17th 2013 • LCC Pilot Wiki Page & Pilot Survey: http://wiki.siframework.org/LCC+Pilot+Plan • Meeting Reminders (this and next week) • LCC HL7 Tiger Team SWG meeting – Friday at 1:30pm ET • LTPAC SWG Meeting – Monday at 11am ET • LCP SWG Meeting – Monday at 5pm ET • LCC HL7 Tiger Team SWG meeting – Wednesday at 11am ET • LCP SWG Meeting – Thursday at 5pm ET

4. CMS Demonstration Grant • The purpose of this funding opportunity announcement is to solicit applications for participation in the Testing Experience and Functional Tools (TEFT) in Community-Based Long Term Services and Supports (CB-LTSS) planning and demonstration grant. The TEFT initiative furthers adult quality measurement activities under Section 2701 of the Patient Protection and Affordable Care Act. The Centers for Medicare & Medicaid Services (CMS) strategy for implementing Section 2701 is to support state Medicaid agencies in collecting and reporting on the adult core measures. The goals for the work conducted under the TEFT are consistent with the National Quality Strategy, Section 3011 of the Affordable Care Act, and CMS priorities to achieve better care, a healthier population, and more affordable care.  • Funding Opportunity Number: CMS-1H1-13-001 • Eligible Applicants: State Governments • Award Ceiling: $500,000 • Closing date for applications: 02NOV13 • Grants.govlink: http://www07.grants.gov/search/search.do;jsessionid=0CpKRyvHSyY3nd5gFGhcKZPDrGLGr1nvD6WvQnyDzvD8MQzLxT62!828175176?oppId=195253&mode=VIEW

5. CMS Demonstration Grant • States may participate in one or more of following TEFT Components: • Field test a beneficiary experience survey within multiple CB-LTSS programs for validity and reliability;  • Field test a modified set of Continuity Assessment Record and Evaluation (CARE) functional assessment measures for use with beneficiaries of CB- LTSS programs;  • Demonstrate use of personal health record (PHR) systems with beneficiaries of CB-LTSS; and  • Identify, evaluate and harmonize an electronic Long Term Services and Supports (e-LTSS) standard in conjunction with the Office of National Coordinator’s (ONC) Standards and Interoperability (S&I) Framework.

6. Care Plan - CDA Document Type Development Relationship Types & Interventions/Instructions Sarah Gaunt Gaye Dolin RN, MSN July 18, 2013

7. Objective • Decide on modeling for Interventions/Instructions Section

8. C-CDA and LCC • LCC: Interventions/Instructions Component • Interventions Section is an existing C-CDA Section • 62387-6: Interventions (Class: DOC.MISC) • Instructions Section is an existing C-CDA Section • 69730-0: Instructions (Class: DOC.MISC)

9. LCC Interventions/Instructions Component • Definition: Interventions are planned and ordered actions taken to maximize the prospects of achieving the patient’s or provider’s goals of care, including the removal of barriers to success. Instructions are information or directions to the patient and other providers including how to care for the individual’s condition, what to do at home, when to call for help, any additional appointments, testing, and changes to the medication list or medication instructions, clinical guidelines and a summary of best practice. Interventions include actions that may be ongoing (e.g. maintenance medications that the patient is taking, or monitoring the patient’s health status or the status of an intervention). Instructions are a subset of interventions and may include self- care instructions.

10. C-CDA Interventions Section • Definition: The Interventions section contains information about the specific interventions provided. Depending on the type of intervention(s) provided (procedural, education, application of assistive equipment, etc.), the details will vary but may include specification of frequency, intensity, and duration.

11. Proposal • Change the C-CDA Interventions Section definition to be more like the LCC Interventions/Instructions component definition. • State that instructions are a subset of Interventions • Leave the name of the section as Interventions Section • Title is not mandated, so can choose own title

12. LCC Interventions Component • Change Definition slightly (to be worked on): Interventions are actions taken to maximize the prospects of achieving the patient’s or provider’s goals of care, including the removal of barriers to success. Interventions can be planned or ordered or historical, etc. Interventions include actions that may be ongoing (e.g. maintenance medications that the patient is taking, or monitoring the patient’s health status or the status of an intervention). Instructions are information or directions to the patient and other providers including how to care for the individual’s condition, what to do at home, when to call for help, any additional appointments, testing, and changes to the medication list or medication instructions, clinical guidelines and a summary of best practice. Instructions are a subset of interventions and may include self- care instructions.