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This page provides reference materials for the eLTSS Initiative. For project related reference materials from federal fiscal year 2017 and earlier please see the eLTSS References Archive. 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.
Table of Contents
eLTSS Use Case Resources
| Link or Download | Description |
| Draft Use Case and Test Architecture: PACIO-eLTSS HL7 FHIR Connectathon 25 | A draft use case for testing the aggregation, exchange, updating, and display of PACIO and eLTSS data expressed using FHIR for the HL7 September 2020 Connectathon. This test case was developed by the PACIO Project in coordination with the eLTSS Project and other stakeholders. |
| Use Case: PACIO-eLTSS HL7 FHIR Connectathon 24 Use Case | A use case for testing the aggregation, exchange, updating, and display of PACIO and eLTSS data expressed using FHIR. This test case was developed by the PACIO Project in coordination with the eLTSS Project and other stakeholders |
| 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
| Event | Description and Download Link |
| Session 235, February 14, 2019 | "Electronic Long-Term Services and Supports (eLTSS) Standards" presented by Elizabeth Palena Hall, ONC and Bonnie Young, GA Department of Community Health |
HL7 May 2019 International Working Group Meeting Joint Working Group Session May 6 | "eLTSS Project Overview" presented by Johnathan Coleman |
| ONC Interoperability Forum 2019 September 22, 2019 11:00-12:30pm | "Bridging the Health IT Divide between Physical, Behavioral and Human Service Providers" panelists include: Liz Palena Hall, ONC; Evelyn Gallego, EMI Advisors; Krissy Celentano, EMI Advisors; Adam Goldman, CMS; Shawn Terrell, Administration for Community Living (ACL); Greg White, Security Risk Solutions; Erin Holve, DC Department of Health Care Finance; Jennie Harvell, Washington State Health Care Authority |
| State Healthcare IT Connect Mini Series July 9, 2020 | Care Continuum, Interoperability: If We Build It, Will They Come? panelist include: Arun Natarajan ONC; Jim Kamp Altarum Institute; Dave Hill MITRE; Damon Terzaghi ADvancing States. Watch a recording of this important discussion exploring the demonstrated use of FHIR across the health care continuum in support of social services data exchange, alignment with other FHIR based initiatives, and what it will take to attract industry participants and deliver robust eLTSS solutions for state HHS agencies, HCBS providers as well as to engage the patient and their care team throughout. |
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 |
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 |