This page provides reference materials for the eLTSS Initiative from federal fiscal year 2017 and earlier. The tables below serve to improve the organization of the materials. If you have a suggestion for a new table, or an edit to an existing table, please inform the project team by contacting Johnathan Coleman (jc@securityrs.com). Documents which have been reviewed and edited by stakeholders are posted to the eLTSS home page for ease of access.

Round 2 Pilot Activities:

Core eLTSS Data Elements (Round 2 Pilots)

Date Discussed	Data Element Name	Data Element Definition	Data Element Value Datatype / Format	Status	Comments / Discussion / Relevant Slide(s)	TEFT Grantee / Pilot Plan Element Mappings
7/27/2017 6/8/2017	Non-Paid Service Provider Relationship	The relationship (e.g., spouse, neighbor, guardian, daughter) of the individual providing a non-paid service or support to the person.	String / Free Text	Revised	7/27/2017: The community accepted the proposal to rename "Non-Paid Service Provider Relationship Type" to "Non-Paid Service Provider Relationship" to align with the "Emergency Contact Relationship" element. 6/8/2017: The community accepted the proposal to keep "Non-Paid Service Provider Relationship Type" without alteration, noting it is important to be able to distinguish family from friends & neighbors. Non-Paid Service Provider Relationship Slides	CO: Provider KY: PDS Employee Relationship MN: Provider
7/27/2017	Service Provider Signature Date	The date the service provider signed the plan.	Date / MM/DD/YYYY	New	The community accepted the proposal to add Service Provider Signature Date to align with the other signature elements in the dataset. Service Provider Signature Date Slides
7/27/2017	Service Provider Printed Name	The printed or typed name of the service provider.	String/ Free Text	New	The community accepted the proposal to add Service Provider Printed Name to align with the other signature elements in the dataset. Service Provider Printed Name Slides
7/27/2017	Emergency Backup Plan	Description of how to address unforeseen events,emergency health events, emergency events, problems with medical equipment and supplies, and unavailable staffing situations for critical services that put the person’s health and safety at risk. This can be included as free text or attachment.	String/ Free Text	Revised	The community rejected the proposal to remove this element from the core dataset due to the overlap with Risk Management Plan. The community stated that an Emergency Backup Plan is different from a Risk Management Plan. The community renamed "Emergency Backup Plan Text" to "Emergency Backup Plan". A slight definition tweak was made as well. Old definition: "The free text description of how to address unforeseen events,emergency health events, emergency events, problems with medical equipment and supplies, and unavailable staffing situations for critical services that put the person’s health and safety at risk." Emergency Backup Plan Slides
7/27/2017	Plan Monitor Phone Number	The primary phone number (and extension when applicable) of the plan monitor.	Number / 111-111-1111 x1111	New	The community accepted the proposal to add Plan Monitor Phone Number element to align with the other contact elements. Plan Monitor Phone Number Slides
7/27/2017 7/20/2017	Risk Management Plan	Description of planned activities to minimize identified risks that endanger a person’s health and safety. This can be included as free text or attachment.	String/ Free Text	New / Revised	7/27/2017: When discussing the proposal to remove the Emergency Backup Plan Text due to the overlap with this element, it was decided that both elements should remain. The Risk Management Plan definition was revised to remove all references to "emergency". Old Definition: Description of planned activities to minimize identified risks and how to address emergencies, emergency health events, problems with medical equipment and supplies, and unavailable staffing situation for critical services that put the person’s health and safety at risk. This can be included as free text or attachment. 7/20/2017: The community accepted the proposal to include Risk Management Plan, without alteration. Risk Management Plan Slides	HCBS Regulation(s): § 441.301(c)(2)(vi) § 441.725(b)(6)
7/20/2017	Plan Monitor Name	The name of the person responsible for monitoring the plan.	String / First Name, MI, Last Name	New	The community accepted the proposal to include Plan Monitor Name, without alteration. Plan Monitor Name Slides	HCBS Regulation(s): § 441.301(c)(2)(viii) § 441.725(b)(8)
7/20/2017	Service Provider Signature	The depiction of the service provider’s signature as proof they agree to the services they will provide.	String / Signature	New	The community accepted the proposal to include Service Provider Signature, without alteration. Service Provider Signature Slides	HCBS Regulation(s): § 441.301(c)(2)(ix) § 441.725 (b)(9)
7/13/2017	Preference	Presents the person’s personal thoughts about something he or she feels is relevant to his or her life experience and may be pertinent when planning. (Draft Definition)	String/ Free Text	New	The community accepted the proposal to keeping “Service Comment” as-is, updating this element to the singular element “Preference”, and changing the definition to reflect “life experience/experience” rather than focusing on services. Preference Slides	HCBS Regulation(s): § 441.301(c)(2)(ii) § 441.725(b)(2)
7/13/2017	Self-Directed Service Indicator	Indicates whether the individual chose to self-direct the service.	Boolean/ Yes, No	New	The community accepted the proposal to include Self-Directed Service Indicator, without alteration. Self-Directed Service Indicator Slides	HCBS Regulation(s): § 441.301(c)(2)(xi) § 441.725(b)(11)
7/13/2017	Person Setting Choice Options	The alternative home and community-based settings that were considered by the individual.	String/ Free Text	New	The community accepted the proposal to include Person Setting Choice Options, without alteration. Person Setting Choice Options Slides	HCBS Regulation(s): § 441.301(c)(1)(ix) § 441.725(a)(8)
7/13/2017	Person Setting Choice Indicator	Indicator that reflects the setting in which the person resides is chosen by the individual.	Boolean / Yes, No	New	The community accepted the proposal to include Person Setting Choice Indicator, without alteration. Person Setting Choice Indicator Slides	HCBS Regulation(s): § 441.301(c)(2)(i) § 441.725 (b)(1)
6/29/2017	Person Identifier Type	The type of unique identifier used to identify the person whom the plan is for.	String / List of Values Values include: Medicaid Number, State ID, Social Security Number, Claim Number, Medical Record Number, Other (free text)	Revised	The community accepted the proposal to modify the datatype/format to include a set list of values, which also includes (free text). Person Identifier Type Slides	CO: SSN CT: Medicaid # GA: Client Social Security Number, Client Medicaid # KY: Social Security Number, MAID# MD: MA# MN: MA# FEI: Medicaid #
6/22/2017	Identified Risk	An aspect of a person’s life, behavior, environmental exposure, personal characteristic, or barrier that increases the likelihood of disease, condition, injury to self or others, or interaction with the criminal justice system.	String/ Free Text	Unchanged	The community accepted the proposal to make no change to the DE. The commenters who requested risks to be broken down into categories can be accomplished at the implementation level. Categorization will vary across implementations based on how risks are carried over from disparate assessments. Identified Risk Slides	CO: Checkboxes + Comments field CT: Risk Mitigation Plan and Agreement form GA: Identified Areas of Risk KY: MWMA K-HAT assessment module or an uploaded assessment document MD: Risk Details MN: Identified risk and choice regarding services FEI: Risk Details
6/22/2017	Strength	A favorable attribute of oneself, his/her support network, environment and/or elements of his/her life as depicted by the person.	String/ Free Text	Revised	The community accepted the proposal to modify this element to “Strength” to align with the definition and to be consistent with the singular approach taken for other eLTSS elements. Strength Slides	CT: Captured in Universal Assessment KY: Element in "Life Story" or entered narrative in MWMA MD: Strength Detail MN: What are your strengths and needs?, Supports and strengths used to meet this need FEI: Strength Detail
6/22/2017	Step or Action	A planned measurable step or action that needs to be taken to accomplish a goal identified by the person.	String/ Free Text	Unchanged	The community accepted the proposal to make no change to the DE. Step or Action Slides	CT: My Goals - What do you hope to accomplish in your home and community with services GA: Interventions, Outcome Notes KY: Objective MD: Steps/Actions MN: Support Needed FEI: Steps/Actions
6/22/2017	Goal	A statement of a desired result that the person wants to achieve.	String/ Free Text	Unchanged	The community accepted the proposal to make no change to the DE. The commenters who requested goals to be broken down into categories can be accomplished at the implementation level. Categorization will vary across implementations based on how goals are carried over from disparate assessments. Goal Slides	CT: My Goals - What CFC services would you be using to accomplish this goal CO: Personal Goal, Service Goal GA: Desired Outcome KY: Goal MD: Desired Goals MN: Goal FEI: Desired Goals, Service Goals Desired Outcomes
6/22/2017	Assessed Need	The clinical and/or community-based necessity or desire as identified through an assessment that should be addressed by a service.	String/ Free Text	Revised	The community accepted the proposal to modify this element to “Assessed Need” to align with the definition and to be consistent with the singular approach taken for other eLTSS elements. Assessed Need Slides	CO: Things that NEED TO CHANGE CT: Captured in Universal Assessment. Needs related to Transitional Services, Assistive Technology and Home Modifications are captured in the CFC Service Tool Budget Form KY: Is this service a result of a Service Needs Assessment outcome? MN: What are your strengths and needs? FEI: Clinical Needs and Support Needs that are Important For
6/22/2017	Service Provider Selection Agreement Indicator	States whether or not the person feels he/she made an informed choice in selecting the provider for each service.	Boolean / Yes, No	New	The community accepted the proposal to split Person Service Provider Choice Indicator into 2 distinct data elements to satisfy the comments relating to the current element being overloaded with various statements. Person Service Provider Choice Slides	CO: Client has been informed of his/her right to change providers at any time, Client has been informed that providers have the right to accept or deny the request for services, Client has been informed of any potential conflict of interest KY: I certify that I have made an informed choice when selecting the providers/employees to provide each service, The Individual understands that under the waiver programs, they may request services from any Medicaid provider qualified to provide the service and that a listing of currently enrolled Medicaid providers may be obtained from Medicaid Services MD: A checkbox that indicates that the client has been given choice in their providers MN: I agree with the services, supports, and providers in my plan. (Yes/No) FEI: As the person this Plan of Services and Supports is being developed for, I agree that by signing this I was presented with all of my service options under this program. I also acknowledge that for the services selected, I was provided with all of the available providers of those services and authorize that I have selected the providers listed in this Plan of Services and Supports.
6/22/2017	Service Provider Options Given Indicator	States whether or not the person was offered a choice of providers for each service.	Boolean / Yes, No	New	The community accepted the proposal to split Person Service Provider Choice Indicator into 2 distinct data elements to satisfy the comments relating to the current element being overloaded with various statements. Person Service Provider Choice Slides	CO: Client has been offered or given a resource list of qualified providers, Client has been informed of the availability and right to select among qualified providers MD: A checkbox that indicates that the client has been given choice in their providers MN: I was offered a choice of providers for services I am receiving. (Yes/No) FEI: As the person this Plan of Services and Supports is being developed for, I agree that by signing this I was presented with all of my service options under this program. I also acknowledge that for the services selected, I was provided with all of the available providers of those services and authorize that I have selected the providers listed in this Plan of Services and Supports.
6/22/2017	Service Plan Agreement Indicator	States whether or not the person agrees to the services outlined in the plan.	Boolean / Yes, No	New	The community accepted the proposal to split Person Service Agreement Indicator into 3 distinct elements to satisfy the comments relating to the current element being overloaded with various statements. Person Service Agreement Indicator Slides	CO: I have participated in the development of this plan and I agree with the services outlined., Client/Guardian indicates that he/she is in agreement with the information in the Service Plan and agrees to receive services accordingly., Client has been informed of his/her choice of available long term care programs and services CT: If you are not interested in services in this section initial here: KY: This is to certify that Individual/Legal Representative have been informed of waiver services. Consideration for waiver program as an alternative to institutional placement is requested. MD: A checkbox that indicates that the client has they participated in making the plan, and that they agree with the requested services. MN: : I was given choices of different types of services that could meet my assessed needs as indicated on the Community Support Plan Worksheet I received and through discussion with my case manager. (Yes/No), I agree with the services, supports, and providers in my plan. (Yes/No) FEI: As the person this Plan of Services and Supports is being developed for, I agree that by signing this I was presented with all of my service options under this program. I also acknowledge that for the services selected, I was provided with all of the available providers of those services and authorize that I have selected the providers listed in this Plan of Services and Supports.
6/22/2017	Service Selection Indicator	States whether or not the person participated in the selection of the services outlined in the plan.	Boolean / Yes, No	New	The community accepted the proposal to split Person Service Agreement Indicator into 3 distinct elements to satisfy the comments relating to the current element being overloaded with various statements. Person Service Agreement Indicator Slides	Please see cell directly above for detail.
6/22/2017	Service Options Given Indicator	States whether or not the person was given a choice of services outlined in the plan.	Boolean / Yes, No	New	The community accepted the proposal to split Person Service Agreement Indicator into 3 distinct elements to satisfy the comments relating to the current element being overloaded with various statements. Person Service Agreement Indicator Slides	Please see cell 2 spaces above for detail.
6/15/2017	Service Rate per Unit	The rate of one unit for a service	Number / $	Unchanged	It was proposed that Service Rate per Unit be removed from the eLTS dataset. While some were indifferent to the information, others cited its usefulness in calculation, or in keeping the beneficiary aware of what is going on. The community rejected the proposal, Service Rate per Unit will remain in the core eLTSS dataset. Service Rate per Unit Slides	CT: Table A: Care Attendant Cost Chart Worksheet KY: Rate per Unit, PDS Rate per Units MD: Rate MN: Rate/Unit FEI: Rate
6/15/2017	Service Unit Quantity Interval	A period of time corresponding to the quantity of service(s) indicated.	String / List of Values	Unchanged	The community accepted the proposal to make no change to the DE. Service Unit Quantity Interval Slides	CO: Frequency KY: Service Frequency, Total Prior Authorized Frequency, Total NOT Approved Frequency, PDS Service Frequency, Non-Waiver Frequency MD: Frequency Type MN: Frequency
6/15/2017	Unit of Service Type	A named quantity in terms of which services are measured or specified, used as a standard measurement of like services.	String / List of Values	Unchanged	The community accepted the proposal to make no change to the DE. Unit of Service Type Slides	Includes element values from all Grantees (CO, CT, GA, KY, MD, MN, FEI)
6/15/2017	Service Unit Quantity	The numerical amount of the service unit being provided for a frequency.	Number / Numeric	Unchanged	The community accepted the proposal not to change Service Unit Quantity and to not add an element to capture the days of service delivery on the eLTSS Plan since that could change on an ongoing basis. Service Unit Quantity Slides	Includes element values from all Grantees (CO, CT, GA, KY, MD, MN, FEI)
6/8/2017	Service Funding Source	The source of payment for the service.	String / Free Text	Unchanged	The community accepted the proposal to keep "Service Funding Source" in the core dataset. Service Funding Source Slides	CO: Funding Source CT: CT’s CFC Service Tool only reflects monies awarded under the CFC program. Funding from other waivers are captured in the CFC Web Reporting Database KY: Source of Payment MN: Payer
6/8/2017	Service End Date	The end date of the service being provided.	Date / MM/DD/YYYY	Unchanged	The community accepted the proposal to keep "Service End Date" as a Core element. It was discussed if "Planned" should be included in the name, but it was ultimately decided best to keep it as is, allowing for it to provide broader meaning to whomever is using it. Service End Date Slides	CO: Service End Date GA: Service End Date KY: Service End Date, PDS Service Actual End Date MD: Frequency MN: Time Period FEI: Frequency
6/8/2017	Service Start Date	The start date of the service being provided.	Date / MM/DD/YYYY	Unchanged	The community accepted the proposal to keep "Service Start Date" as a Core element. It was discussed if "Planned" should be included in the name, but it was ultimately decided best to keep it as is, allowing for it to provide broader meaning to whomever is using it. Service Start Date Slides	CO: Service Start Date CT: Plan Date GA: Service Begin Date KY: Service Start Date, PDS Service Actual Start Date MD: Frequency MN: Time Period FEI: Frequency
6/8/2017	Total Cost of Service	The total cost of a service for the plan.	Number / $	Unchanged	The community accepted the proposal to keep "Total Cost of Service" as a core element. Total Cost of Service Slides	CT: Section Total Cost KY: Service Subtotal MD: Annual Cost MN: Plan Total FEI: Annual
6/8/2017	Service Provider Phone Number	The primary phone number (and extension when applicable) of the service provider	Number / 111-111-1111 x1111	Revised	The community accepted the proposal to modify "Service Provider Phone Number" to include an extension. Service Provider Phone Number Slides	CT: UCM Phone # GA: Provider Site Phone KY: PDS Provider Primary Phone Number, Non-Waiver Provider Primary Phone Number, CDO Representative Information
6/8/2017	Support Planner Phone Number	The primary phone number (and extension when applicable) of the support planner.	Number / 111-111-1111 x1111	Revised	The community accepted the proposal to modify the "Support Planner Phone Number" element to include an extension to be used when applicable. Support Planner Phone Number Slides	CO: Case Manager Phone CT: CFC Budget Form Support & Planning Coach Phone # GA: Care Coordinator Phone Number MD: Support Planner Phone Number in LTSS system Client Profile MN: Case Manager/Care Coordinator Phone Number FEI: Case Manager Phone
6/1/2017	Emergency Contact Relationship	The relationship (e.g., spouse, neighbor, guardian, daughter) of the individual identified to contact in case of emergency.	String/ Free Text	Revised	The community accepted the proposal to rename "Non-Paid Backup Relationship Type" to "Emergency Contact Relationship Type", with modification to not include "Type". This data element is modified to reflect the feedback of Round 2 pilots as "Emergency Contact Relationship". Emergency Contact Relationship Type Slides	CO: Contingency Plan CT: Contact Relationship in CFC Web Reporting Database KY: Element in an uploaded document in MWMA MD: Relationship MN: Relationship FEI: Contact Type
6/1/2017	Emergency Contact Phone Number	The primary phone number (and extension when applicable) of the individual or entity identified to contact in case of emergency.	Number / 111-111-1111 x1111	Revised	The community accepted the proposal to rename "Emergency Backup Phone Number" to "Emergency Contact Phone Number" to reflect how this is being used out in the field. Emergency Contact Phone Number Slides	CO: Contingency Plan CT: Contact Phone Number in CFC Web Reporting Database KY: Element in uploaded document in MWMA MD: Phone Number MN: Phone Number FEI: Emergency Contact Phone Number
6/1/2017	Emergency Contact Name	The name of the individual or entity identified to contact in case of emergency.	String / First Name, MI, Last Name	Revised	The community accepted the proposal to rename "Emergency Backup Name" to "Emergency Contact Name". This new name eliminates confusion and reflects that backup provider information is not usually documented in the beneficiary's service plan, but is handled at the contracted provider level. Emergency Contact Name Slides	CT: Contact Name in CFC Web Reporting Database KY: Element in uploaded document in MWMA MD: Name MN: Key contact name FEI: Emergency Contact Name
5/25/2017	Program Name	The state-administered funding source (e.g., Medicaid) in which the person is enrolled.	String / Free Text	Unchanged	The community did not accept the proposal of removing "Program Name" from the eLTSS Dataset. "Program Name" will remain unchanged. This element drives the potential funding source(s) and is useful for beneficiaries and members of their service team (e.g., case managers). A common theme in feedback was that this element and other financial information are usually included on a different form than the service plan. Including financial information on the service plan that is documented on a service authorization form is not necessarily better. It can be overwhelming and confusing. Program Name Slides	CO: HCBS Waiver Program / Program CT: captured in CFC web reporting data base and used to calculate total CFC budget GA: Program Name KY: Program MD: Program Type MN: Program FEI: Person is Enrolled In
5/18/2017	Service Delivery Address	The address where service delivery will take place if service will not be provided at the person’s address.	String / Street Address, City, State, Zip Code, County	New	The community accepted the request to add "Service Delivery Address" as a core element while reviewing the existing "Person Address" element. Service Delivery Address was added to the core dataset based on the request to distinguish a person's residence from where they receive a service. Person Address Slides	KY: Service Delivery Address, Address Line 1, Address Line 2, City, State, Zip, Zip +, County MD: Service Delivery Address MN: County of Service FEI: Service Delivery Address

Non-Core eLTSS Data Elements (Round 2 Pilots)

Date Discussed	Data Element Name	Data Element Definition / Usage Note	Data Element Value Datatype / Format	Comments / Discussion / Reason for Non-Core
7/27/2017	Assessment Summary	Contains a subset of information from one or more assessments pertinent to the delivery of a service.	String / Free Text	The proposal to include as non-core is because of the anticipated variability in how this could be implemented and to allow flexibility. The reasons for inclusion are: - Opportunity to exchange relevant assessment information with service providers, particularly those that might not have access to the comprehensive assessment information and/or for whom exchange of comprehensive assessment information may not be appropriate - Opportunity for exchange with individuals though consumer facing technology such as PHRs or mobile devices - Alignment and integration between the assessment content and the service plan, which could also include FASI content (functional assessment items, which are another component of TEFT) - Opportunity for analytics
6/29/2017 5/25/2017 5/18/2017	Person Gender Identity	An individual's personal sense of being a man, woman, or other gender, regardless of the sex that person was assigned at birth. Values include: Identifies as male, Identifies as female, Female-to-male transsexual, Male-to-female transsexual, Identifies as non-conforming, Other, Asked but unknown	String / List of Values	In working towards harmonization of what is collected and should be core to the beneficiary plan, it was determined by the community that while Person Gender Identity is important and continues to play a wider role in society and health as a whole, for now, it is not core to the plan. We recommended to refer to the best practices as noted in the ONC 2015 Edition Certification Companion Guide for Demographics (https://www.healthit.gov/sites/default/files/2015Ed_CCG_a5-Demographics.pdf). Person Gender Identity Slides
6/29/2017 5/25/2017 5/18/2017	Person Birth Sex	The sex recorded on the person’s birth certificate. Values include: Male, Female, Unknown	String / List of Values	It was determined by the community that Person Birth Sex is important is not core to the plan since it is collected at the assessment level. Person Birth Sex Slides
6/22/2017	Person Service Agreement Indicator	States whether or not the person was given a choice of services and participated in the selection of and agrees to the services outlined in the plan.	Boolean / Yes, No	The community accepted the proposal to split this element into 3 distinct elements to satisfy the comments relating to the current element being overloaded with various statements. Accordingly, this specific DE is no longer in the Dataset. Person Service Agreement Indicator Slides
6/15/2017	Service History	A history of services, changes in hours of care, or changes in providers.	String / Free Text	The request is to see a history of services or changes in hours of care or changes in providers and reasons why. They want to see a longitudinal history of services. Service History seems to be an implementation detail of the planning process (out of scope for eLTSS) and therefore we are proposing to not add service history to the eLTSS dataset. The community agreed that this request may exist more as a desired function of their EHR system, and not necessarily something specific to the dataset. For this reason, the proposal is accepted by the community, Service History will not be added to the eLTSS Dataset. Service History Slides
6/8/2017	Service Total Units	The total number of units for each service for the duration of the plan.	Number / Numeric	The community accepted the proposal to remove "Service Total Units" from the core dataset, citing that this may be better tracked elsewhere, and that the beneficiary may not like to have this information shared so readily. Service Total Units Slides
6/1/2017	Emergency Contact Phone Type	The type of telecommunication for the emergency contact. Values include, but not limited to: home, work, mobile, facility, toll free, fax, other	String / List of Values	The community decided "Emergency Contact Phone Type" is not core and this element will not be included in the eLTSS core dataset. Emergency Contact Phone Type Slides
6/1/2017	Emergency Contact Primary Indicator	States whether or not the emergency contact is the primary contact.	Boolean / Yes, No	The community decided "Emergency Contact Primary Indicator" is not core and this element will not be included in the eLTSS core dataset. Some reasons included that the first contact listed is generally presumed the primary, and that this may lead to confusion on general or emergency contact. Emergency Contact Primary Indicator Slides
5/25/2017	Total Plan Cost	The estimated total cost of all services and supports for a plan.	Number / $	Similar to Total Plan Budget, this information is frequently included on a form separate from the plan. Providers stated they typically do need to know this type of information. Pilot feedback included confusion between Total Plan Budget vs Total Plan Cost based on the use and definitions. It was decided by the community that the element should not be part of the eLTSS Core Dataset. Total Plan Cost Slides
5/25/2017	Total Plan Budget	The total allotment of funds for services and supports approved or authorized for a plan.	Number / $	The community agreed to remove Total Plan Budget from the eLTSS Core Dataset. Entities who find this element important and useful can continue to include it on their plan as a non-core element. Round 2 Pilot feedback included that this information is frequently included on a form (e.g., a billing or service authorization form) separate from the plan. Some providers thought this was not relevant to the participants. Other providers felt this element should not be shared with them at all. Another provider was confused on the difference between Total Plan Budget and Total Plan Cost based on the definitions supplied. Total Plan Budget Slides
5/25/2017	Plan Funding Source	The source(s) of payment for the plan.	String / Free Text	The community agreed to remove Plan Funding Source from the eLTSS Core Dataset since financial information at the plan level is mostly used for internal, administrative or planning purposes. Many providers indicated that this element may be confusing to include on a plan, there are many different payment sources, and although it is necessary information for billing purposes it should not be included on the service plan. It was decided by the community that Plan Funding Source should be a non-core element. Plan Funding Source Slides
5/18/2017	Person Environment	The free text description of the person’s environment where services will be delivered. Usage Note: The description could include but is not limited to: roommates, pets, devices or equipment that may be in the environment.	String / Free Text	The proposal to add "Person Environment" as a core element was not accepted by the community. It is collected on an initial form or during the assessment. This should be an optional element and not part of the Core eLTSS Dataset. Proposed Definition: The free text description of the person’s environment where services will be delivered. The description could include but is not limited to: roommates, pets, devices or equipment that may be in the environment. Proposed Format: String / Free Text Person Environment Slides

Round 1 Pilot Activities:

eLTSS Harmonized Data Elements

Date Discussed	Core Component	Data Element Name	Data Element Definition	Data Element Value Datatype / Format	Multiple Values (Y/N)	Comments / Discussion / Relevant Slide(s)	TEFT Grantee / Pilot Plan Element Mappings
8/4/2016	Risk	Identified Risk	An aspect of a person’s life, behavior, environmental exposure, an inborn or inherited characteristic, or barrier that increases the likelihood of a disease, condition or injury.	String / Free Text	Y	Identified Risk Slide	CO: Checkboxes + Comments field GA: Identified Areas of Risk MD: Risk Details MN: Identified risk and choice regarding services FEI: Risk Details
8/4/2016	Emergency Backup Plan	Emergency Backup Contact Phone Number	The phone number of the individual identified to provide necessary services and supports to the person in the event of an emergency.	Number / 111-111-1111	Y	Emergency Backup Contact Phone Number Slide	CO: Contingency Plan MD: Phone Number MN: Phone Number FEI: Emergency Contact Phone Number
8/4/2016	Emergency Backup Plan	Emergency Backup Contact Name	The name of the individual identified to provide necessary services and supports to the person in the event of an emergency.	String / Free Text	Y	Emergency Backup Contact Name Slide	MD: Name MN: Key contact name FEI: Emergency Contact Name
8/4/2016	Emergency Backup Plan	Emergency Backup Contact Relationship Type	The relationship of the individual identified to provide necessary services and supports to the person in the event of an emergency.	String / Free Text	Y	Emergency Backup Contact Relationship Type Slide	CO: Contingency Plan MD: Relationship MN: Relationship FEI: Contact Type
8/4/2016	Emergency Backup Plan	Emergency Backup Plan Text	The free text description of how to address unforeseen events, emergency health events, problems with durable medical equipment, or unavailable staffing that put the person’s health and welfare at risk.	String / Free Text	Y	Emergency Backup Plan Text Slide	CO: Contingency Plan CT: Please describe your Emergency Backup Plan MD: Current Back-Up MN: Plan for unforeseen events, Plan for emergency health events, Plan for unavailable staffing that puts you at risk
8/4/2016	Goals & Strengths	Assessed Needs	The clinical or nonclinical support necessary for each service as identified through an assessment.	String / Free Text	Y	7/28 the community decided to put this in the parking lot. On 8/4 it was revisited. Since most states did capture this information it was decided that this should be core. Assessed Needs Slides	CO: Things that NEED TO CHANGE KY: Is this service a result of a Service Needs Assessment outcome? MN: What are your strengths and needs? FEI: Clinical Needs and Support Needs that are Important For
7/28/2016	Beneficiary Demographics	Person Phone Number	The primary phone number of the person for whom the plan is for.	Number / 111-111-1111	N	Person Phone Number Slide	CO: Phone KY: Phone Number MD: Primary Phone # MN: Phone Number FEI: Primary Phone #
7/28/2016	Goals & Strengths	Strengths	A favorable attribute of oneself, his/her support network, or environment as depicted by the person.	String / Free Text	Y	Strengths Slide	MD: Strength Detail MN: What are your strengths and needs?, Supports and strengths used to meet this need FEI: Strength Detail
7/21/2016	Goals & Strengths	Step or Action	A planned measurable step or action that needs to be taken to accomplish the goal identified by the person.	String / Free Text	Y	Step or Action Slide	CT: Strategies GA: Interventions, Outcome Notes KY: Objective MD: Steps/Actions MN: Support Needed FEI: Steps/Actions
7/21/2016 7/14/2016 7/7/2016	Goals & Strengths	Goal	A statement of a desired result that the person wants to achieve.	String / Free Text	Y	Definition was modified from the 7/7 description of: A defined outcome that a person wants to achieve. This new proposal was discussed and approved on the 7/21 call. Goal Slides Revised Definition of Goal Slide	CT: Goal CO: Personal Goal, Service Goal GA: Desired Outcome KY: Goal MD: Desired Goals MN: Goal FEI: Desired Goals, Service Goals Desired Outcomes
7/7/2016	Beneficiary Demographics	Person Identifier	One or more character(s) used to identify the person for whom the plan is for. This may be the Medicaid ID number when applicable.	String / Free Text	N	Person Identifier Slide	CO: SSN CT: Medicaid # GA: Client Social Security Number, Client Medicaid # KY: Social Security Number, MAID# MN: MA# FEI: Medicaid #
7/7/2016	Beneficiary Demographics	Person Identifier Type	The type of unique identifier used to identify the person for whom the plan is for. May include State ID, Medicaid Number, Social Security number.	String / Free Text	N	This element is slated to be used in conjunction with Person Identifier. Person Identifier Type Slide	CO: SSN CT: Medicaid # GA: Client Social Security Number, Client Medicaid # KY: Social Security Number, MAID# MN: MA# FEI: Medicaid #
7/7/2016	Beneficiary Demographics	Person Address	The address of the person for whom the plan is for.	String / Street Address, City, State, Zip Code, County	N	Person Address Slide	CO: Street Address, City, State, Zip Code, County KY: Address Line 1, Address Line 2, City, State, Zip Code, Zip +4, KY County/ Out of State MD: Current Address, Street Number, Apt number, City, State, Zip MN: Address, City, State, Zip Code, COR FEI: Address, County, Street Number, Apt number, City, State, Zip
6/23/2016	Beneficiary Demographics	Date of Birth	The birth date of the person for whom the plan is for.	Date / MM/DD/YYYY	N	Person Date of Birth Slide	CO: DOB KY: Date of Birth MD: DOB MN: Date of Birth
6/23/2016	Beneficiary Demographics	Person Name	The name of the person for whom the plan is for.	String / First Name, MI, Last Name	N	NOTE: Person Name is a Common Clinical Dataset element. Person Name Slide	CO: First Name MI Last Name CT: Name GA: Client Name KY: First Name MI Last Name MD: Client Name MN: First Name MI Last Name FEI: Person's Name
6/23/2016	Service Information	Service Comment	Additional information related to the service being provided.	String / Free Text	N	This is notated as an optional element since it is not expected or required for a comment to be entered for each service. This field could capture additional information of the frequency of the service, how the client wants the service delivered and only used when the comment provides additional detail of the service not already handled by another element. Service Comment Slide	GA: Service Notes KY: Non-Waiver Service Comments MN: Comments; Support Instructions FEI: Comments
6/16/2016	Service Information	Service Funding Source	The source of payment for the service.	String / Free Text	Y	Service Funding Source Slide	CO: Funding Source KY: Source of Payment MN: Payer
6/16/2016	Service Information	Total Plan Cost of Service	The total cost of a service for the plan.	Number / $	N	Service Cost Slide	CT: Section Total Cost KY: Service Subtotal MD: Annual Cost MN: Plan Total FEI: Annual
6/16/2016	Service Information	Service Rate per Unit	The rate of one unit for a service.	Number / $	N	Service Rate Slide	CT: Medicaid Unit Cost of Service per Hour or Unit, Rate KY: Rate per Unit, PDS Rate per Units MD: Rate MN: Rate/Unit FEI: Rate
6/16/2016	Service Information	Service End Date	The end date of the service being provided.	Date / MM/DD/YYYY	N	Each service has a start and end date. These dates may or may not align with the start and end date of the service plan itself. Service Start and End Date Slide	CO: Service End Date GA: Service End Date KY: Service End Date, PDS Service Actual End Date MD: Frequency MN: Time Period FEI: Frequency
6/16/2016	Service Information	Service Start Date	The start date of the service being provided.	Date / MM/DD/YYYY	N	Each service has a start and end date. These dates may or may not align with the start and end date of the service plan itself. Service Start and End Date Slide	CO: Service Start Date GA: Service Begin Date KY: Service Start Date, PDS Service Actual Start Date MD: Frequency MN: Time Period FEI: Frequency
6/16/2016	Service Information	Service Total Units	The total number of units for each service for the duration of the plan.	Number / Numeric	N	This is the total number of units authorized per service. It is important for the beneficiary to know how much they started with, that way they can manage their services appropriately. Service Total Units Slide	CO: Total Units KY: PDS Total Units, Utilized Units
6/16/2016	Service Information	Service Unit Value	The numerical quantity of the service unit being provided for a frequency.	Number / Numeric (needs to accommodate fractions)	N	This element is slated to be used in conjunction with Service Frequency Type and Unit of Service Type elements to form a full description of how often a service is provided. For example, a service being provided 7 units per week, the Service Unit Value = "7". For a service being provided 8 hours a day, the Service Unit Value = "8". For a service being provided 1/4 hour per day, the Service Unit Value = "1/4". Service Unit Value Slide	Includes element values from all Grantees (CO, CT, GA, KY, MD, MN, FEI)
6/16/2016	Service Information	Unit of Service Type	A named quantity in terms of which services are measured or specified, used as a standard measurement of like services. Values include: unit(s), minute(s), hour(s), day(s), week(s), month(s), meal(s), mile(s), visit(s)/session(s), installation(s), none, other (free text).	String / List of Values	N	This element is slated to be used in conjunction with Service Frequency Type and Service Unit Frequency Value elements to form a full description of how often a service is provided. For example, a service being provided 7 units per week, the Unit of Service Type = "units". For a service being provided 8 hours a day, the Unit of Service Type = "hours". Unit of Service Type Slide	Includes element values from all Grantees (CO, CT, GA, KY, MD, MN, FEI)
6/16/2016	Service Information	Service Frequency Type	How often a service is provided. Values include: Day, Week, Month, Annual, One Time Only, Other (free text).	String / List of Values	N	This element is slated to be used in conjunction with Unit of Service Type and Service Unit Frequency Value elements to form a full description of how often a service is provided. For example, a service being provided 7 units per week, the Service Frequency Type = "week". For a service being provided 8 hours a day, the Service Frequency Type = "day". Service Frequency Type Slide	CO: Frequency KY: Service Frequency, Total Prior Authorized Frequency, Total NOT Approved Frequency, PDS Service Frequency, Non-Waiver Frequency MD: Frequency Type MN: Frequency
6/16/2016	Service Provider Name and Other Identifiers	Support Planner Phone Number	The phone number of the support planner.	Number / 111-111-1111	Y	This element could accompany the Support Planner Signature elements set (signature, printed name, date) that is already included as a core element. The "name" elements below map to the Support Planner Signature Printed Name element already included as a core element. Support Planner Phone Number Slide	CO: Case Manager Name, Case Manager Phone GA: Care Coordinator Name, Care Coordinator Phone Number KY: Case Manager First name, MI, Last Name MN: Case Manager/Care Coordinator Name, Case Manager/Care Coordinator Phone Number FEI: Case Manager Name, Case Manager Phone
6/9/2016	Service Provider Name and Other Identifiers	Service Provider Phone Number	The phone number of the service provider.	Number / 111-111-1111	N	It was agreed that the beneficiary or support planner needs to decide when they want a phone number displayed for a service provider. It may only be needed or beneficial to have for certain service providers. Service Provider Phone Numbers Slide	GA: Provider Site Phone KY: PDS Provider Primary Phone Number, Non-Waiver Provider Primary Phone Number, CDO Representative Information
6/9/2016 6/2/2016	Service Provider Name and Other Identifiers	Service Provider Name	The name of the organization/agency or individual plus the relationship of the person providing the service.	String / Organization/Agency Name OR Individual Provider First Name Last Name + Relationship	N	For paid services use organization/agency name, for unpaid services use the individual’s first name, last name and relationship to the person receiving the service. Service Provider Name Slides Service Provider Contact Information Slides	CO: Provider (CO) CT: PCA Name, Name of the Support and Planning Coach KY: PDS Employee Name, Provider Name, PDS Provider Name, Non-Waiver Provider Name MD: Provider Name MN: Provider FEI: Provider Name
6/2/2016	Name of Service Provided	Service Name	Identifies the services provided to an individual.	Text / display name, code, modifier	Y	Name of Service Provided Slide	CO: Service CT: Available Service GA: Waiver Services, Service Type KY: Service Name MD: POS Service MN: Service FEI: Service
5/26/2016	Service Provider Preferences	Person Service Provider Choice Indicator	States whether or not the person was offered a choice of providers and made an informed choice in selecting the provider for each service.	Boolean / Yes, No	N	Person Service Provider Choice Indicator Slide	CO: Client has been offered or given a resource list of qualified providers, Client has been informed of the availability and right to select among qualified providers, Client has been informed of his/her right to change providers at any time, Client has been informed that providers have the right to accept or deny the request for services, Client has been informed of any potential conflict of interest KY: I certify that I have made an informed choice when selecting the providers/employees to provide each service, The Individual understands that under the waiver programs, they may request services from any Medicaid provider qualified to provide the service and that a listing of currently enrolled Medicaid providers may be obtained from Medicaid Services MN: I was offered a choice of providers for services I am receiving. (Yes/No), I agree with the services, supports, and providers in my plan. (Yes/No) FEI: As the person this Plan of Services and Supports is being developed for, I agree that by signing this I was presented with all of my service options under this program. I also acknowledge that for the services selected, I was provided with all of the available providers of those services and authorize that I have selected the providers listed in this Plan of Services and Supports.
5/26/2016	Service Preferences	Person Service Agreement Indicator	States whether or not the person was given a choice of services and participated in the selection of and agrees to the services outlined in the plan.	Boolean / Yes, No	N	Person Service Agreement Indicator	CO: I have participated in the development of this plan and I agree with the services outlined., Client/Guardian indicates that he/she is in agreement with the information in the Service Plan and agrees to receive services accordingly., Client has been informed of his/her choice of available long term care programs and services CT: If you are not interested in services in this section initial here: KY: This is to certify that Individual/Legal Representative have been informed of waiver services. Consideration for waiver program as an alternative to institutional placement is requested. MN: I was given choices of different types of services that could meet my assessed needs. (Yes/No), I agree with the services, supports, and providers in my plan. (Yes/No) FEI: As the person this Plan of Services and Supports is being developed for, I agree that by signing this I was presented with all of my service options under this program. I also acknowledge that for the services selected, I was provided with all of the available providers of those services and authorize that I have selected the providers listed in this Plan of Services and Supports.
5/19/2016 5/12/2016	Financial Information: Funding / Source of Payment	Plan Funding Source	The source(s) of payment for the plan.	String / Text	Y	Continued discussion from 5/12. The community agreed that this should be a core element. It was decided that the list of values will vary by state and implementation. The funding source at the specific service level (e.g., Funding Source (CO)) will be addressed when we discuss service-specific elements in a few weeks. Funding-Source of Payment Slide	KY: Source of Payment MN: Funding the Plan
5/19/2016	Plan Signatures	Support Planner Signature Date	The date the support planner signed the plan.	Date / MM/DD/YYYY	N	Every signature type on the plan will be accompanied by a date. Support Planner Signature Date Slide	CO: Signature of Case Manager Date CT: Universal Case Manager approval date KY: Case Manager E-Signature Date MD: Signature Date MN: Signature of Person Who Developed This Plan Date FEI: Signature Date
5/19/2016	Plan Signatures	Guardian / Legal Representative Signature Date	The date the guardian/legal representative signed the plan.	Date / MM/DD/YYYY	N	Every signature type on the plan will be accompanied by a date. Guardian - Legal Representative Signature Date Slide	CO: Signature of Legal Guardian Date MN: Signature of Person or Guardian / Legal Representative Date
5/19/2016	Plan Signatures	Person Signature Date	The date the person signed the plan.	Date / MM/DD/YYYY	N	Every signature type on the plan will be accompanied by a date. Person Signature Date Slide	CO: Signature of Client Date CT: Participant signature date KY: Individual E-Signature Date MD: Signature Date MN: Signature of Person or Guardian / Legal Representative Date FEI: Signature Date
5/12/2016	Financial Information	Total Plan Budget	The total allotment of funds for a plan.	Number / $	N	Grantees agreed that Total Plan Budget should be a core element. Each implementation will arrive at that total budget amount from calculating "miscellaneous budget elements". Total Plan Budget Slide	CT: Total Budget Allocation, For individuals that used a paid Support and Planning Coach to assist with care planning, enter the authorized total KY: Total Prior Authorized Amount
5/12/2016	Financial Information	Total Plan Cost	The total cost of all services and supports for a plan.	Number / $	N	Total Plan Cost Slide	CT: Sections 1-4 Total (plus totals from non-CFC services) KY: Total Prior Authorized Amount MD: Total POS Cost MN: Total Plan Cost FEI: Total PSS Cost
5/12/2016 5/5/2016	Plan Signatures	Person Printed Name	The printed or typed name of the person	String / Free Text	N	Printed Name Slides	MD: Signature Printed Name FEI: Signature Name
5/12/2016 5/5/2016	Plan Signatures	Guardian / Legal Representative Printed Name	The printed or typed name of the guardian/legal representative.	String / Free Text	Y	Printed Name Slides	MD: Signature Printed Name FEI: Signature Name
5/12/2016 5/5/2016	Plan Signatures	Support Planner Printed Name	The printed or typed name of the support planner.	String / Free Text	N	Printed Name Slides	MD: Signature Printed Name FEI: Signature Name
5/5/2016	Plan Signatures	Person Signature	The handwritten depiction of the person's name as proof of identity and intent for the plan.	String / Signature	N	Conforms to person-centered planning guidance regulations. Outstanding Question: What does Georgia capture? Plan Signatures Slide	CO: Client Signature CT: Participant Signature KY: Individual's Signature MD: Client Signature MN: Signature of Person or Guardian/Legal Representative FEI: Person Signature
5/5/2016	Plan Signatures	Guardian / Legal Representative Signature	The handwritten depiction of the guardian or legal representative's name as proof of identity and intent for the plan.	String / Signature	Y	Plan Signatures Slide	CO: Legal Guardian MN: Signature of Person or Guardian/Legal Representative, Other Signature
5/5/2016	Plan Signatures	Support Planner Signature	The handwritten depiction of the support planner's name as proof of identity and intent for the plan.	String / Signature	N	Plan Signatures Slide	CO: Case Manager Signature CT: Universal Case Manager Signature GA: Care Coordinator Signature KY: Case Manager Signature MD: Support Planner Signature MN: Signature of Person Who Developed This Plan FEI: Case Manager Signature
4/28/2016	Program Type	Program Name	The state-administered Medicaid funding source in which the person is enrolled.	String / Free Text	Y	Core element for the eLTSS Plan, but each implementation will have a different list of values specific to their state/pilot. Program Name Slides	CO: HCBS Waiver Program / Program GA: Recommendation KY: Program MD: Program Type MN: Program FEI: Person is Enrolled In
4/21/2016	eLTSS Plan Period / Plan Effective Dates	Plan Effective Date	The date upon which the plan comes into effect.	Interval of Dates / MM/DD/YYYY -MM/DD/YYYY	N	Start date is required, end date is optional. Plan Effective Date Slide	CT: Care Plan Effective Date GA: Care Plan Period KY: Proposed Start Date, Level of Care End Date MD: POS Effective Date MN: Time Period Covered by the CSSP Start Date, Time Period Covered by the CSSP Start Date FEI: Effective Date

Parking Lot Data Elements

Date put in Parking Lot	Core Component	Element Area	Elements of Interest	Discussion
8/11/2016	Risk	Risk Mitigation Plan Text	MN: Plan/agreement reached to address the identified risks	UPDATE: This element was included in the Core Dataset for Round 2. Draft Definition: An attached description of the options and actions to reduce the likelihood that a risk will occur and/or reduce the effect of a risk if it does occur. Discussed on 8/4/2016. It was decided that this should be included, however it was proposed that instead if a free text it should be a yes or no question. On 8/11 it was decided to put this element in the parking lot. Grantees do have a risk mitigation plan but only MN includes it inside the service plan. Other grantees include the risk mitigation plan as an addendum to the service plan. CMS did state that it is okay for the plan to just reflect that a rick mitigation plan exists somewhere and that an indicator would be sufficient. Risk Management Plan Text Slide
8/4/2016 07/28/2016	Goals & Strengths	Perceived Needs	MN: Description of need; Support Needed	A description of whatever the person believes is important to living in the community. On 7/28/2016 It was said that Perceived Needs should be a core element. After reviewing the recording and notes from the meeting, it was decided that we need to revisit this element. On 8/4 it was decided that since MN is the only grantee that has this element it will be placed in the parking lot. Perceived Needs Slides
6/23/2016	Service Planning and Coordination	Plan Recipients	MN: My CSP / CSSP can be shared with the following people and/or providers for planning and coordination and I have signed release(s) of information to allow this sharing	PCP regulations state the plan must “Be distributed to the individual and other people involved in the plan”. What does “other people involved in the plan” mean – who exactly? Does this mean the List of people who should receive the plan be listed on the plan? Or can this “list of recipients” be captured somewhere else? Amanda Hill believes it is in reference to those who are implementing the plan and signing an agreement but will do some researching on that. ACL Guidance states: “All persons directly involved in the planning process must receive a copy of the plan or portion of the plan, as determined by the participant or representative.“ Plan Recipients Slide
6/23/2016	Service Planning and Coordination	Plan Participants	CO: Plan Participant Name; Plan Participant Title	CO currently captures the names and titles (roles) of the people who helped develop the plan. MN has checkboxes indicating if the person was able to invite who they wanted to be involved in the planning process. It is understood that the PCP rules indicates that the person has a choice, but the rule is not prescriptive on how this should be captured in the plan. The Plan Participants could already be covered by the eLTSS core elements related to plan signatures. Plan Participants Slide
5/19/2016	Service Planning and Coordination	Plan Signatures	Provider Signature	UPDATE: This element was included in the Core Dataset for Round 2. This element is only captured by MD currently, so we will revisit when current harmonization phase is complete and additional Person Centered Planning elements are discussed. If Provider Signature is included as a core element, include Provider Signature Printed Name and Provider Signature Date to be consistent with other signature elements. We also need to discuss whether or not the Service that the Provider delivered needs to accompany the signature (MD currently does this). Provider Signature Slide
5/26/2016	Service Planning and Coordination	Person's Choice in Setting (residence)	N/A	UPDATE: This element was included in the Core Dataset for Round 2. This is not currently captured by Grantees, but is written in the Person Centered Planning regulations. This was briefly discussed in conjunction with service delivery preference elements, but since this element is not currently captured, we will revisit after this phase of harmonization. Grantees agreed that service delivery setting usually equals residence setting (since the eLTSS plan is for home and community based services). Setting Preferences Slide

Non-Core eLTSS Data Elements

Date Discussed	Element Name	Comments
8/4/2016	Measure to Minimize Risk	Precautionary steps used to reduce the likelihood, or to manage the severity of a possible risk to personal safety, health and behavioral risk. Maps to: Alternative measure that may be implemented (MN) Grantees decided that measures to minimize risk could be included in the risk mitigation plan and there was no need for two separate elements. Measures to Minimize Risk Slide
8/4/2016	Date the Risk was Created	The date the risk was put on the plan. Maps to: Date Created (Risks) (MD)(FEI) This date is pre-populated based on the date that InterRai assessment was performed or the date the is added to the plan which would be the same as the Plan Created Date. Date Risk was Created Slide
7/21/2016	Goal Completed Date	The date on which the goal was achieved. Maps to: Target /Actual Objective Completed Dates (KY), Target Date (MN) This is not core since the majority of the grantees did not track or capture the completion of the goal. Currently, grantees’ plans are static in nature. If a goal is completed before the annual plan review date, most grantees will create a new plan with new goals. Goal Completed Date Slide
7/21/2016	Goal Created Date	The date on which the goal was created by the person. Maps to: Date (CT ), Date Objective Developed (KY), Date Created (MD, FEI) This is not core since the grantees that do collect this date state that the date the goal is created is usually the same as the date the plan was created. Goal Created Date Slide
7/21/2016	Goal Status	The condition or state of a goal at a particular time. Maps to: Status (GA), Objective Status (KY), Progress (FEI) This is not core since the status of goals is not captured directly in the plan by all grantees. Currently, grantees’ plans are static in nature. If there is a change in status, a new plan is generated rather than a status being updated. Goal Status Slide
7/21/2016	Outcome	The actual endpoint of the goal. Maps to: Outcomes (CT) This is not core since the majority of the grantees currently do not have this level of “case management tracking” in their service plans. Some grantees collect this information at the end of the plan and is not captured directly on the plan. Outcome Slide
6/23/2016	Service Reason	Need to follow-up with MD and what is typically included for their Reason for Service/Details element. In the meantime, this element is being marked as not core. KY uses their reason elements for internal tracking purposes only and are specific to delays in services being provided. Maps to: Reason for Service/Details (MD), Specify reason for delay, Delay Reason Comments, Specify Reason Service End (KY), Support Needed (MN) Service Reason
6/23/2016	Service Status	KY and MN are the only grantees who currently capture the status of each service being provided. They both mentioned that they see this as something that is important for their planning process, but should not be listed as a core eLTSS element. Maps to: Service Status (KY), Status (MN) Service Status Slide
6/16/2016 6/9/2016	Service Provider Qualifications	Service Provider Qualifications will not be a core element on the eLTSS Plan. There is nothing specifically stated in the PCP regulations that Provider Qualifications need to be captured in the plan. Currently only CT captures qualfications of service providers in their plan. CT requires that providers have certain qualifications and this is a criteria based on certification. This information collected is similar to what would be found on a resume. MN no longer captures "qualifications" in their plan, but instead the individual states their needs in a "Support Instructions" field and then providers are selected (from provider enrollment information) based on those needs. Maps to: PCA Qualifications, Documentation of how employee (PCA) meets qualification (CT), Qualifications of staff implementing the support plan, Support Instruction (MN) Service Provider Qualifications Slide
6/16/2016	Service Delivery Days of the Week	Service Delivery Day should not be included as a core element. This information is negotiated between the provider and beneficiary and may change frequently which would make plan management and revisions impossible to maintain. Maps to: Days of Service Delivery (KY), Mon, Tue, Wed, Thu, Fri, Sat, Sun (GA) Service Delivery Days Slide
6/9/2016	Service Provider Identifier	The Grantees currently use Service Provider Identifier for billing and service authorization purposes. It is not something needed for sharing the plan. Maps to: Provider DMA No. (GA), Provider Number (KY) (MD), Provider NPI (MN) Service Provider Identifier
6/9/2016	Service Provider Address	Service Provider Address will not be a core element on the plan. KY states this information is pre-populated for traditional (paid) services. MD captures the provider's address for their emergency back-up plans only. MN's county of service is brought over from the assessment and not considered core to the plan. Maps to: County of Service, PDS Employee Address (KY), COS (MN) Service Provider Address Slide
6/2/2016	Exceptions for Service	Each Grantee who captured Exceptions for Service had a unique way of capturing and displaying this element on their plan. It was agreed that these elements could not be harmonized as a core component. Maps to: Requested One Time Expense (CT), Exceptional Rate Request, Exceptional Rate per Unit, Reason for Exceptional Rate Request (KY), Personal Assistance, Home-Delivered Meals, Other Items that Substitute for Human Assistance, Reason for Exceptional Rate Request (MD), EW Conversion Request (MN) Exception for Services Slide
6/2/2016	Type of Service Provided	The 3 Grantee / Pilot who utilized the element service type captured data that was very different and state specific. There were no commonalities in the values for this element. It was agreed that these elements could not be harmonized as a core component. Maps to: Service type ( GA) (KY) (MD) Type of Service/Category Provided Slides
6/2/2016	Service Category	Each Grantee / Pilot has a unique way of capturing and displaying service category on their plan. It was agreed that these elements could not be harmonized as a core component. Maps to: Natural Supports, Third Party Resources, State Plan Benefits, Home Health, Long Term Care Service Plan (CO), CFC Services for assistance with hands-on Care/Cueing/Supervision, CFC Services to assist with managing budget, service planning etc., CFC Service to Support Back Up Systems, CFC Service to assist with increasing independence in health related tasks… (CT), Cognition, Functional, Client, Clinical, Social (GA), Cognitive and Behavioral Supports, Prevention of Abuse and Neglect, Supportive Services, Home Management, Caregiver/Parent Support, Personal Assistance, Communication, Health-Related/Medical, Training/Skill Building, Personal Security, Case Management, Other Informal Supports (MN) Type of Service/Category Provided Slides
5/26/2016	Address to Receive Services - Miscellaneous Elements	These miscellaneous elements related to the address or setting where services are delivered are assessment in nature. They are important to know, but are not be core to the eLTSS plan. Maps to: Current Living Situation (CO), Lives with Family, Home Type, Home Setting (MD), Number of People in Home, Lives with? (FEI) Address to Receive Services - Miscellaneous Slide
5/26/2016	Service Delivery Setting Type	Services under the eLTSS plan will be delivered in a home or community setting. Some Grantees do not distinguish between home and community, they are treated as the same. Grantees/Pilots agreed that services will be received in the individual’s home or community setting. Many grantees see home = community so there is no need for a distinction. Maps to: Will this service be provided at the individual's home?, Setting (KY), Address Type (MD) Service Delivery Setting Slide
5/26/2016	Service Delivery Location Preferences	Services under the eLTSS plan will be delivered in a home or community setting. It is understood that is where the individual prefers to receive services (rather than in an institution-based setting). Maps to: Is Setting Chosen by the participant?, Is setting chosen by Guardian of Person? (MD), I was given a choice between received services in the community or in an institution. (MN), Is Setting Chosen by the participant?, Is setting chosen by Guardian of Person? (FEI) Service Delivery Location Preferences Slide
5/26/2016	Service Delivery Address	Services under the eLTSS plan will be delivered in a home or community setting. Some Grantees do not distinguish between home and community, they are treated as the same. KY stated that the address for delivery of services will most likely vary. For example, a community club may meet at various locations each week. MN captures the person's address as the "service delivery location". GA captures the service delivery location as the person's address or from the DMA No. CT is not prescriptive on where services are completed, just so that they are delivered in a home or community setting. Maps to: Service Delivery Address, Address Line 1, Address Line 2, City, State, Zip, Zip +, County (KY), Service Delivery Address (MD), County (MN), Service Delivery Address (FEI) Service Delivery Address Slide
5/26/2016	Emergency Contact Information	Elements related to a general emergency contact (i.e., contact this person if something happens to the individual) are collected at the assessment level and will not be eLTSS core components. Any contact information that is collected specifically for an Emergency Backup or Contingency Plan will be discussed later this summer. Maps to: Emergency Contact Name, Emergency Contact Relationship (CO), Guardian of Person (MD), Emergency Contact Name, Emergency Contact Phone Number, Emergency Contact Relationship, Parent/Guardian Name and Phone Number, Physician/Healthcare Provider Name and Phone Number (MN), Guardian of Person (FEI) Emergency Contact Information Slides
5/12/2016	Financial Information: Miscellaneous Budget Elements	Each Grantee / Pilot has a unique way of capturing and displaying various budgets on their plan. It was agreed that these elements could not be harmonized as a core component. Maps to: CFC Total Budget Allocation, CFC Monthly Budget Allocation (CT), CDPSS Budget (Monthly), Liability (GA), CFC Fixed Budget Total, CFC Flexible Budget Total (MD), EW/AC Case Mix Monthly Maximum Budget, EW/SIS Waiver Obligation, CDCS Annual Budget, Participant Contributions (Waiver Obligation / AC Fee), Authorized Daily Amount for CAC, CADI, BI, or DD Waiver, Authorized Monthly Amount for CAC, CADI, BI, or DD Waiver (MN), Cost Neutrality Limit (FEI) Miscellaneous Budget Elements Slide
5/12/2016	Financial Information: Miscellaneous Cost Elements	Each Grantee / Pilot has a unique way of capturing and displaying various costs on their plan. It was agreed that these elements could not be harmonized as a core component. Maps to: Sections 1 - 4 Total Costs, Projected Annual Cost of Service, Annual Cost of All Waiver Services, Annual Cost of Husky Home Services (CT), Total Traditional Services Cost, Total Participant Directed Services Cost, Total Plan of Care Cost Requested (KY), Annual Waiver Services Total, Annual State Plan Services Total, Annual Non-Medicaid Services Total, MFP Flexible Funds Total (MD), AC Fee (MN), Waiver Services Total Cost (FEI) Miscellaneous Cost Element Slide
5/12/2016	Plan Signatures: Signature Type/Signature on File	These are administrative in nature and should not be a core component of the eLTSS Plan. Maps to: Legal Guardian Signature on file, Clients Signature on file, Additional Legal Guardian Signature on file, Case Manager Signature on file (CO), Individual, authorized Rep, and/or legal guardian has signed the plan signature sheet, The Case Manager has signed the plan signature sheet (KY), Signature Type (FEI) Signature Type/Signature on File Slide
5/5/2016	Plan Signatures	Other optional or state-specific signatures. Maps to: DSS CO Staff (CT), Care Coordinator Collaborator Signature (GA), Emergency Backup Signature (MD), Backup Provider Signature (FEI) Plan Signatures Slide
4/28/2016	Plan Comments/Narrative Text	Grantees/pilots currently use this field for administrative purposes or any items from assessments that can't be put in another field. Maps to: Overall Comments (KY), Narrative (MD), Overview Comments (FEI) Overall Plan Comments Slide
4/28/2016	Plan Status	These elements are administrative in nature and are largely used for internal purposes. Maps to: Plan Status (KY), POC Status (MD) Plan Status Slide
4/28/2016	Plan Type/Category	These elements are administrative in nature and are largely used for internal purposes. Maps to: Service Plan Type (CO), Care Plan Type (GA), Category of Plan (KY), Plan of Service Type (MD), PSS Type (FEI) Plan Type/Category Slide
4/21/2016	eLTSS Plan Created Date	Include as an Optional element. This is an administrative element (mostly used for audit and tracking purposes) and is defined differently via the Grantees and Pilots. This could be the date the plan was entered into a system or the date the plan is considered complete (or both). Maps to: Date (CT), Date Entered (CO), Care Plan Visit Date (GA), Created Date (MD), Date Support Plan was mailed/given on (MN), Created Date (FEI) Plan Created Date Slide

eLTSS Use Case Resources

Link or Download	Description
Use Case: Beneficiary Requests the Latest eLTSS Data from the Care Coordinator	This use case, developed by Altarum for use in eLTSS testing at the September 2019 HL7 Connectathon, describes the automated generation and transmission of the eLTSS data set utilizing the eLTSS FHIR resource between a beneficiary and a care coordinator using a portal or mobile app. It is intended to provide the beneficiary with a copy of his/her most recent long-term services and supports service plan.
Appendix C: Actors and Activities for establishing eLTSS Information Sharing Resource Matrix	The eLTSS information sharing resource contains a set of Actors and request and response Activities that must be established for the beneficiary/advocate and providers to share eLTSS information. The steps and process on establishing the eLTSS information sharing resource will vary between states and other payers. Some states can and may have multiple information sharing resources. An example set of activities performed to establish the information sharing resource can be found in this matrix.

Conference and Annual Meeting Presentations

Link or Download	Description
Combined ONC Annual Meeting	2015 ONC Annual Meeting LTPAC and LTSS Presentation Materials

Affordable Care Act (ACA) Program Reference Materials

Link or Download	Description
Money Follows the Person	The Money Follows the Person (MFP) Rebalancing Demonstration Grant helps states rebalance their Medicaid long-term care systems by increasing the use of home and community-based services (HCBS) and reduce the use of institutionally-based services. This is an ACA Program included in the Deficit Reduction Act (DRA) and Extended through ACA, Section 2403.
Community First Choice	The "Community First Choice Option" lets States provide home and community-based attendant services to Medicaid enrollees with disabilities under their State Plan (ACA, Section 2401).
Person-Centered Planning and Self-Direction in Home and Community-Based Services	ACA, Section 2402(a) requires the Secretary to ensure all states receiving federal funds develop service systems that are responsive to the needs and choices of beneficiaries receiving home and community-based long-term services (HCBS), maximize independence and self-direction, provide support coordination to assist with a community-supported life, and achieve a more consistent and coordinated approach to the administration of policies and procedures across public programs providing HCBS.
No Wrong Door/Single Entry Point (NWD/SEP) Information System	ACA BIP requirement that establishes a Statewide system to enable consumers to access all long-term services and supports through an agency, organization, coordinated network, or portal, in accordance with such standards as the State shall establish and that shall provide information regarding the availability of such services, how to apply for such services, referral services for services and supports otherwise available in the community, and determinations of financial and functional eligibility for such services and supports, or assistance with assessment processes for financial and functional eligibility.
Balancing Incentive Program (BIP)	The Balancing Incentive Program authorizes grants to States to increase access to non-institutional long-term services and supports (LTSS) as of October 1, 2011. (ACA, Section 10202)

Home and Community Based Services and Supports (HCBS) /

Long-Term Services and Supports (LTSS) Reference Materials

Link or Download	Description
Risk Management and Quality in HCBS: Individual Risk Planning and Prevention, System-Wide Quality Improvement	This document is a great reference for work relating to identifying and managing risk in HCBS. The document is prepared by Te MEDSTAT Group, Inc.and the Human Services Research Institute (February 15, 2005).
Health Policy Brief: Rebalancing Medicaid Long-Term Services and Supports, //Health Affairs//, September 17, 2015	Expenditures for Medicaid long-term services and supports (LTSS) expenditures are shifting away from primary dependence on institutional care and focusing more on long-term home and community based services. This brief explores the balance between expenditures in home and community versus institutional settings and whether those system expectations should vary by state, by age, or by other population characteristics. It also addresses the discussion of how federal policies influence the use of LTSS by different populations. Health Policy Briefs are produced under a partnership of Health Affairs and the Robert Wood Johnson Foundation.
Serving Low-Income Seniors Where They Live: Medicaid's Role in Providing Community-Based Long-Term Services and Supports	To better understand the low-income population with LTSS needs, including those covered by Medicaid and those who are not, this issue brief examines the need for LTSS among seniors who live in the community and need LTSS.

Centers for Medicare & Medicaid (CMS) Standards and Guidance

Link or Download	Description
Post-Acute Care Interoperability (PACIO) Project	The PACIO Project is a collaborative effort to advance interoperable health data exchange between post-acute care (PAC) and other providers, patients, and key stakeholders across health care and to promote health data exchange in collaboration with policy makers, standards organizations, and industry through a consensus-based approach.
Functional Assessment Standardized Items (FASI)	The Centers for Medicare & Medicaid Services (CMS), as part of the Testing Experience and Functional Tools (TEFT) demonstration, tested the use of the Functional Assessment Standardized Items (FASI) measures among individuals receiving home and community-based services (HCBS), aligning with national efforts to create exchangeable data across Medicare and Medicaid programs.
The HCBS Taxonomy: A New Language for Classifying Home- and Community-Based Services	A description of the HCBS taxonomy, explanation of the construction of a crosswalk to map procedure codes to taxonomy categories, and descriptive statistics on state-, service-, and person-level HCBS expenditures based on 28 states whose 2010 MAX data files had been approved by June 1, 2013.
Outcome and Assessment Information Set (OASIS) dataset for use in Home Health Agencies (HHAs)	Policy and technical information related to OASIS (the Outcome and Assessment Information Set) data set for use in home health agencies (HHAs), State agencies, software vendors, professional associations and other Federal agencies in implementing and maintaining OASIS.
Minimum Data Set (MDS) dataset for use in Nursing Homes	The Minimum Data Set (MDS) is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes.
Continuity Assessment Record and Evaluation (CARE) Item Set	Provided standardized information on patient health and functional status, independent of site of care, and examined resources and outcomes associated with treatment in each type of setting
Program for All-Inclusive Care for the Elderly (PACE) Assessment and Care Planning Tools	Regulatory requirements for the Interdisciplinary Team (IDT) as defined by the PACE regulations
Balancing Incentives Program Tools	BIP Work Plan and Deliverables guidance
Home and Community-Based Services (HCBS) Taxonomy	Describes the HCBS taxonomy and presents findings on HCBS waiver expenditures and users

Other Standards and Guidance

Link or Download	Description
Standards Catalog	Includes the HL7 Consolidated Clinical Document Architecture (C-CDA) Release 2.0 Implementation Guide, BlueButton Plus, and the emerging HL7 FHIR Profile
Structured Data Capture	HL7 FHIR Profile Implementation Guide for Structured Data Capture (SDC)
Data Access Framework	HL7 FHIR Profile Implementation Guide for Data Access Framework (DAF)
ONC Direct Project	Transport Standard
Recommended Social and Behavioral Domains and Measures for Electronic Health Records	Institute of Medicine's work to identify domains and measures that capture the social determinants of health to inform the development of recommendations for Stage 3 meaningful use of electronic health records (EHRs)
National Core Indicators	National Association of State Directors of Developmental Disabilities Services (NASDDDS) and Human Services Research Institute (HSRI) program
Standards for Social Work Practice	National Association of Social Workers (NASW) Standards
Standards of Practice for Case Management	Case Management Society of America (CMSA) Standards
Guidelines for Uniform Assessment	American Medical Association (AMA) and American Academy of Home Care Physicians (AAHCP) guidance
Standardized Data Collection Tools	Administration of Aging (AoA) guidance
One Care Early Indicators Projects (EIP)	MassHealth, One Care Implementation Council, and UMass Medical School collaboration reports
National Information Exchange Model (NIEM)	NIEM domains contain mission-specific data components that build upon NIEM core concepts and add additional content specific to the community supporting that mission. A NIEM domain represents both the governance and model content oriented around a community’s business needs. A NIEM domain manages their portion of the NIEM data model and works with other NIEM domains to collaboratively to identify areas of overlapping interest.
National Association of State Directors of Developmental Disabilities Services (NASDDDS)	NASDDDS represents the nation's agencies in 50 states and the District of Columbia providing services to children and adults with intellectual and developmental disabilities and their families. NASDDDS promotes systems innovation and the development of national policies that support home and community-based services for individuals with disabilities and their families. NASDDS, in collaboration with the Human Services Research Institute (HSRI) has developed National Core Indicators (NCI), a program to support state member agencies to gather a standard set of performance and outcome measures that can be used to track their own performance over time, to compare results across states, and to establish national benchmarks.
National Quality Forum 2014 Input on Dual Eligible Beneficiaries	Report developed by the Measure Applications Partnership (MAP) for the Department of Health & Human Services (HHS) on the use of performance measures to evaluate and improve care provided to dual eligible beneficiaries. The report includes an updated Family of Measures for Dual Eligible Beneficiaries and outlines a basic rational for engaging stakeholders using measures in learning more about their experience to inform MAP's future decision making.

Other Care Assessment Tool Projects

Link or Download	Description
Guided Care	Johns Hopkins University program (Comprehensive Primary Care for Complex Patients)
Case Management Information System	Community Care of North Carolina program (Case Management Information System)
Community Health Needs Assessment	Eastern Maine Healthcare Systems program

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Round 2 Pilot Activities:

Core eLTSS Data Elements (Round 2 Pilots)

Round 1 Pilot Activities:

eLTSS Harmonized Data Elements

Parking Lot Data Elements

eLTSS Use Case Resources

Conference and Annual Meeting Presentations

Affordable Care Act (ACA) Program Reference Materials

Home and Community Based Services and Supports (HCBS) /

Long-Term Services and Supports (LTSS) Reference Materials

Centers for Medicare & Medicaid (CMS) Standards and Guidance

Other Standards and Guidance

Other Care Assessment Tool Projects

Link or Download

Description

Guided Care

Johns Hopkins University program (Comprehensive Primary Care for Complex Patients)

Case Management Information System

Community Care of North Carolina program (Case Management Information System)

Community Health Needs Assessment

Eastern Maine Healthcare Systems program

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Archive of eLTSS References

Table of Contents

Round 2 Pilot Activities:

Core eLTSS Data Elements (Round 2 Pilots)

Round 1 Pilot Activities:

eLTSS Harmonized Data Elements

Parking Lot Data Elements

eLTSS Use Case Resources

Conference and Annual Meeting Presentations

Affordable Care Act (ACA) Program Reference Materials

Home and Community Based Services and Supports (HCBS) /

Long-Term Services and Supports (LTSS) Reference Materials

Centers for Medicare & Medicaid (CMS) Standards and Guidance

Other Standards and Guidance

Other Care Assessment Tool Projects

Link or Download

Description

Guided Care

Johns Hopkins University program (Comprehensive Primary Care for Complex Patients)

Case Management Information System

Community Care of North Carolina program (Case Management Information System)

Community Health Needs Assessment

Eastern Maine Healthcare Systems program