Scope Statement
To identify, evaluate and harmonize standards needed for the creation, exchange and re-use of: (i) key domains and associated data elements of CB-LTSS person-centered planning, assessment and services; and (ii) interoperable, accessible person-centered service plans for use by providers and beneficiaries, accountable entities and payers.
This initiative will identify key assessment domains that will inform the creation of a structured, longitudinal, person-centered electronic LTSS plan for CB-LTSS beneficiaries. The eLTSS plan will be designed in such a way that it can be exchanged electronically across multiple CB-LTSS settings (e.g., adult day services, beneficiary homes, group homes, foster homes, assisted living, supportive housing, home health and hospice), institutional settings (e.g. hospitals, nursing facilities, primary care, post-acute care) and with beneficiaries and payers. The person-centered eLTSS plan is led by the beneficiary and includes individuals chosen by the beneficiary to participate in his or her care. The standards identified for the eLTSS plan will support consistent data collection and interoperable exchange with various information systems to include clinical information systems, State Medicaid and Health Information Exchange (HIE) systems, Personal Health Record (PHR) systems, and other information systems (e.g. case management, legal, justice, education, protective services, etc.). Information will be shared and accessed in compliance with policy, regulation, and Patient Consent Directives (e.g., 42 C.F.R Part 2 Confidentiality of alcohol and drug abuse patient records; and 38 USC § 7332-Confidentiality of certain medical records, Section 508 of the Rehabilitation Act). These standards will also support revisions to the eLTSS plan as the beneficiary receives services.
The content or data elements of the eLTSS plan will be specific to the types of services rendered and information collected for CB-LTSS, including person-centered quality of life goals, social determinants, and other relevant information essential to person-centered planning and quality CB-LTSS delivery. Beneficiary populations will be able to access the eLTSS plan through a supported PHR system, including the option of a state-identified PHR.
For the purposes of this initiative, the eLTSS plan will center on LTSS information collected for community-based services. The eLTSS plan may contain relevant clinical data needed to support the continuum of beneficiary care, support and services.
Out of Scope
This initiative will not focus on harmonizing state assessment templates per se, including resolving potential gaps in client assessment content collected across states. Nor will it harmonize assessment domains and data elements that do not directly drive care and service planning (e.g. functionality eligibility, rate setting or budgeting). However, standardizing the domains and elements of an eLTSS plan will provide the states the opportunity outside of this initiative to further evaluate and standardize their data needs, including assessment templates, to align with the eLTSS plan.