eLTSS Use Case End-to-End Review

The End-to-End Review period for the eLTSS Plan Use Case will ended on Thursday, May 28th.

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Use Case Document for End-to-End Review:

 eLTSS_Use_Case_End-to-End_Review_2015-05-21.docx

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eLTSS Use Case End-to-End Review Response Form

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Submitted Documents with Comments

1.0 Preface and Introduction

To fully realize the benefits of health IT, the Office of the National Coordinator for Health Information Technology (ONC) in conjunction with Centers for Medicare and Medicaid Services (CMS) are developing Use Cases that define the interoperability requirements for high priority health care data sharing; maximize efficiency, encourage rapid learning, and protect patients’ privacy in an interoperable environment. These Use Cases address the requirements of a broad range of Communities of Interests including; patients, their significant others and family members, providers, payers, vendors, standards organizations, public health organizations, and Federal agencies.

These Use Cases describe:

• The operational context for the data sharing
• The stakeholders with an interest in the Use Case
• The information flows that must be supported by the data sharing
• The types of data and their specifications required in the data sharing

The Use Case is the foundation for identifying and specifying the standards required to support the data sharing and developing reference implementations and tools to ensure consistent and reliable adoption of the data sharing standards.

2.0 Initiative Overview

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 shared 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 sharing 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.

2.1 Initiative Challenge Statement

The adoption and use of Health IT and quality measurement for community-based long-term services and supports is limited. Limitations include: insufficient business and/or financial incentives for service providers to acquire and use Health IT to support coordination of services; minimal national standards for quality measurement in LTSS outcomes; lack of uniformity in the terminology and definitions of data elements, including those important to the beneficiary, needed for assessments and service plans used across and between community-based information systems, clinical care systems and personal health record systems; and lack of consensus on the inter-relationships between an individual’s plans across care, services and supports.

3.0 Use Case Scope

The scope of this Use Case is to define the necessary requirements that will drive the identification and harmonization of standards needed for the creation, sharing and re-use of:

• key domains and associated data elements of CB-LTSS person-centered planning assessment and services
• interoperable, accessible person-centered service plans for use by providers and beneficiaries, accountable entities and payers

The person-centered eLTSS plan will be led by the beneficiary and includes individuals chosen by the beneficiary to participate in his or her services and supports. The eLTSS plan will be specific to LTSS information collected for home and community-based services; however the eLTSS plan may contain relevant clinical data needed to support the continuum of beneficiary care, supports and services.

3.1 Background

Section 2701 of the Patient Protection and Affordable Care Act (ACA) of 2010 calls for the Secretary of the Department of Health and Human Services (DHHS) to identify and publish an initial voluntary core set of health care quality measures for adults eligible for Medicaid. In response to this provision, the Centers for Medicare and Medicaid Services (CMS) recognized that a significant quality measurement gap exists in the ability to collect standardized information about the experience and outcomes of care for people receiving community-based long-term services and supports (CB-LTSS). Information collected in different sectors and populations that pertain to CB-LTSS can be shared across sectors. CMS established the Testing Experience and Functional Tools (TEFT) in community based long-term services and supports Planning and Demonstration Grant Program to support selected, eligible State applicants to accomplish the following:

1. Test and evaluate new measures of functional capacity and individual experience for populations receiving CB-LTSS;
2. Identify and harmonize the use of health information technology (Health IT); and
3. Identify and harmonize electronic LTSS (e-LTSS) standards.

Health Information Technology (Health IT), which includes the meaningful use of Electronic Health Records (EHRs), is increasingly being recognized as a tool with the highest potential to provide timely and relevant data in a form that is quickly usable for research, public health, quality improvement and consumer engagement. However, EHR implementation and integration into service delivery has been limited for CB-LTSS. CB-LTSS (as with home and community-based services (HCBS)) is defined by CMS for this project as “assistance with activities of daily living and instrumental activities of daily living provided to beneficiaries (elderly and adults with disabilities) that cannot perform these activities on their own due to a physical, cognitive, or chronic health condition.” The limited use of Health IT and EHRs to access and capture data for these services is partly due to the fact that incentives put in place through the American Recovery and Reinvestment Act of 2009 (ARRA) target “eligible professionals and hospitals” for using electronic health technology. These eligible groups do not include CB-LTSS providers or accountable entities. Similarly the value proposition for exchanging electronic information between institutional and non-institutional providers is not well understood by providers or beneficiaries. The integration of clinical care and/or institutional care with CB-LTSS service data is also compounded by the fact that social and behavioral determinants of health and quality of life indicators are often not included in a beneficiary’s health record regardless of whether it is paper-based or electronic. There is no consensus on what information should be included in a beneficiary’s LTSS record, even though the record itself may contain a combination of clinical care, client assessment, service plan data and other information.

The Affordable Care Act introduces approaches to health care delivery that encourage the formation of more coordinated systems and person-centered planning, many of which can be supported by Health IT. Relevant Affordable Care Act programs include Money Follows the Person (included in the Deficit Reduction Act (DRA) and Extended through ACA, Section 2403), Community First Choice (ACA, Section 2401), the Balancing Incentives Program (ACA, Section 10202) and Oversight and Assessment of the Administration of Home and Community-Based Services. (ACA, Section 2402(a)). These programs target diverse beneficiary populations, some of which are eligible for Medicaid-funded CB-LTSS provided by the states. In addition, recent changes to the regulations governing Medicaid-funded LTSS provide increased clarity related to the characteristics and requirements of LTSS, home and community-based services and person-centered planning.

This Use Case will identify key assessment domains that will inform the creation of a structured, longitudinal, interoperable, person-centered electronic LTSS plan for CB-LTSS beneficiaries. The eLTSS plan will be designed in such a way that it can be shared 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.

3.2 In Scope

The following list outlines what is in scope for the Use Case to include the type of transactions, the information/data to be exchanged, and specific aspects that need to be in place to enable the eLTSS plan information to be shared and understood the same at both ends of the transmission.

• Identify key domains and associated data elements of CB-LTSS person-centered planning assessment and services
• Identify candidate standards needed for the creation, sharing (mobile access, exchange of documents, exchange of data, etc.) and re-use of an interoperable, accessible person-centered service plan for use by providers and beneficiaries, accountable entities and payers
• Identify eLTSS plan content or data elements that are specific to the types of services rendered and information collected for CB-LTSS
• Define the actors contributing to an eLTSS plan that is led by the beneficiary and includes individuals chosen by the beneficiary to participate in his or her care
• Define the actors involved in the sharing of an eLTSS plan
• Identify candidate standards to support consistent data collection and interoperable sharing 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.)
• Identify domains of the eLTSS plan to be shared electronically across multiple CB-LTSS settings (e.g., adult day services, beneficiary homes, group homes, foster homes, assisted living, supportive housing, home health, hospice, etc.), institutional settings (e.g. hospitals, nursing homes, primary care, post-acute care) and with beneficiaries and payers
• Identify candidate standards to support revisions to the eLTSS plan as the beneficiary receives services
  • Beneficiary will contribute and request corrections, changes, and additions to their eLTSS plan

3.3 Out of Scope

The following list outlines what is out of scope for the Use Case. These points may highlight dependencies on the feasibility, implementability, and usability that result in limitations of the Use Case. At a high level, whatever is not declared “In Scope,” is by definition, “Out of Scope.” Note: There may be some items that are out of scope for the Use Case and Functional Requirements Development, as well as the Standards Harmonization activities, that can be included as part of a Pilot.

• Harmonization of state and setting-specific assessment templates, tools and instruments
• Resolve potential gaps in beneficiary assessment content collected across states
• Harmonization of assessment domains and data elements that do not directly drive care and service planning (e.g., functionality eligibility, rate setting or budgeting)
• Harmonization or integration of various forms of plans (care plans, plan of treatment, etc.) with the eLTSS plan. However, the eLTSS plan will include relevant domains across those plans.
• Full integration of eLTSS plan into an EHR or other clinical IT system (e.g., eLTSS Plan is part of the EHR)
• Full integration of eLTSS plan into a PHR system
• Transmission protocols describing the most efficient means of transport of eLTSS plan information from sender to receiver
• The packaging of eLTSS data elements into a specified form or template for submission from one EHR system to another health information system
• Standardization of data elements to be included in all queries for clinical health information, and to be used to link clinical health information from disparate systems
• Identification of privacy and security consent standards
• Configuration of systems to alert providers to the presence of relevant information from other sources and make it conveniently available to the provider(s)
• Define process by which states authorize, access, approve and pay for service delivery
• Development of state-autonomous policy to support interoperability
• Identification of eLTSS record information (non-planned data)

3.4 Communities of Interest

Communities of Interest are relevant stakeholders who are directly involved in the business process, in the development and use of interoperable implementation guides, and/or in actual implementation. Communities of Interest may directly participate in the sharing; that is, they are business actors or are affected indirectly through the results of the improved business process.

4.0 Value Statement

The eLTSS Initiative, as driven by the requirements of the CMS TEFT Program and other HHS Initiatives (e.g. National Quality Forum HCBS Quality Measures), provides an opportunity for states to leverage and integrate initiatives available under the Affordable Care Act, the Health Information Technology for Economic and Clinical Health Act of 2009 (HITECH), the Social Security Act and the Improving Post-Acute Care Transformation Act of 2014 (IMPACT). The Affordable Care Act Balancing Incentive Program, in particular, includes requirements for the development of a Core Standardized Assessment (CSA) that generates a beneficiary service plan based on assessment data. The required Core Dataset domains for assessments include clinical and non-clinical data. In addition, through the No Wrong Door (NWD) System requirement, participating states must develop a coordinated and streamlined eligibility determination and program enrollment process, where data on functional and financial assessments are shared across participating agencies. The NWD system approach entails engaging the beneficiary and, as appropriate, their caregivers, in facilitating the development of the beneficiary’s person-centered service plan. The CSA and NWD System requirements provide a foundation for how states can access, capture, and share longitudinal LTSS data (institutional and community-based) across provider types and accountable entities. For example, the Administration of Community Living (ACL) investments with ACA funding, in partnership with CMS and the VHA, are building person-centered planning into Aging and Disability Resource Centers (ADRC) that function as a NWD of access to LTSS for all populations and all Payers.
States may maximize the use of health information technology by leveraging existing health information exchange (HIE) infrastructure to collect and share eLTSS plan data across CB-LTSS providers—who are not eligible for Meaningful Use (MU) incentives—CB-LTSS beneficiaries and other institutional based or clinical provider types (to include those eligible for MU incentives). This initiative will not only enable states to demonstrate how CB-LTSS providers and beneficiaries can benefit from the use of Health IT, but it will also ensure data captured for LTSS can be shared electronically with other clinically and institutionally-based provider types as the beneficiary chooses to share such information.
The identification and harmonization of standards for an eLTSS plan will improve efficiencies and promote collaboration across provider groups and beneficiaries by:

• Identifying an agreed upon set of data elements for the capture and sharing of eLTSS plan information
• Improving provider workflows by enabling secure, single-point data entry for eLTSS plan development and sharing including authentication and tracking of changes and approvals
• Integrating beneficiary priorities, preferences and goals identified in the CB-LTSS setting with those goals and outcomes included in the beneficiary care plan generated in a clinical/institutional setting
• Improving timeliness for collecting and sharing LTSS information between provider types, between providers and beneficiaries, and between providers and State Medicaid Agencies and/or payers, and other entities
• Reducing data collection burden processes (e.g. paper based, manual and/or other electronic) placed on providers/beneficiaries/payers by enabling the reuse of previously collected data
• Supporting the timely transition of relevant eLTSS plan information at the start of care and service delivery and as the beneficiary’s preferences and goals change
• Enabling sending and receiving provider types to initiate changes for beneficiary interventions more promptly
• Enabling beneficiaries to lead decision making regarding appropriate care and services to be received
• Increasing beneficiary engagement in preventative services and wellness activities
• Identifying critical gaps and unnecessary overlaps in the care and services needed and delivered to a beneficiary
• Enabling beneficiaries to share important care and service plan information across provider groups and with accountable entities and other parties

5.0 Use Case Assumptions

The Use Case Assumptions section outlines what needs to be in place to meet or realize the requirements of the Use Case (i.e. the necessary privacy and security framework). These points are more functional in nature and state the broad overarching concepts related to the Initiative. The Use Case assumptions will serve as a starting point for subsequent harmonization activities.

The Assumptions for this Use Case are the following:

• The eLTSS plan is longitudinal and dynamic in nature – beneficiaries are able to update information as needed when needed
• Beneficiary populations will be able to access the eLTSS plan through their beneficiary system, including the option of a state-identified PHR
• 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)
• Beneficiary is approved to receive LTSS benefits
• Beneficiary leads the creation and approval of an eLTSS plan
• Beneficiary has ability to grant consent to eLTSS plan for selected care team members
• Beneficiary has ability to define notifications and designate notification recipients
• Send and receipt of notifications depend on the capability of the beneficiary’s system, service provider’s managed care/LTSS system, and the EHR
• Change in service needs need to be communicated from clinical EHR system to beneficiary system
• The system(s) used for sharing the eLTSS plan is capable of equipment/device tracking
• There will be an individual assigned as the eLTSS plan facilitator/steward who is responsible for reviewing and reconciling all proposed modifications (with consensus and approval from beneficiary) to the eLTSS plan
• The beneficiary can directly modify eLTSS plan components (e.g., preferences, goals, outcomes, personal story, etc.) that do not affect LTSS resource allocation
• Each state may vary in the process or order of steps required for the creation and sharing of an eLTSS plan
• eLTSS information sharing resource foundation(s) are operational
• All interested parties are capable of providing input toward the eLTSS plan
• Clinical providers approve services/care delivery based on their designation or authorization by the payer (always consistent with engaging the beneficiary at every level)

6.0 Pre-Conditions

Pre-conditions are those conditions that must exist for the implementation of the eLTSS plan interoperability information sharing. These conditions describe the state of the system, from a technical perspective, that must be true before an operation, process, activity or task can be executed. It lists what needs to be in place before executing the information sharing as described by the Functional Requirements and Dataset requirements.

• Beneficiary’s eligibility determination forms have been completed, submitted and approved
• PHR and/or other relevant systems for data sharing are in place
• The system to coordinate and provide LTSS services must be capable of sharing data bi-directionally with the EHR, PHRs and other relevant data management platforms
• The beneficiary, advocate(s)s and provider(s) establish the eLTSS information sharing resource foundation
• Consent is established to govern information sharing of the eLTSS plan
• A system-determined way to establish and verify identity for all entities involved in the sharing of the eLTSS plan needs to be in place to facilitate sharing of information across entities
• The original eLTSS plan is generated in a state-defined LTSS system

7.0 Post Conditions

Post Conditions describe the state of the system, from a technical perspective, that will result after the execution of the operation, process activity or task.

• The eLTSS plan is successfully shared between intended entities
• eLTSS plan information is displayed in a human readable format
• eLTSS plan information is accessible via EHR/PHR and other relevant systems
• Sending and receiving entities have the capability to receive, view, modify, process, incorporate, download and share structured data
  
  

8.0 Use Case Diagram

9.0 User Stories

9.1 User Story 1: LTSS Eligibility Determination, eLTSS Plan Creation and Approval

Following the admission of a beneficiary with developmental disabilities to a hospital, it is determined by the beneficiary advocates and hospital-based care team that an eLTSS plan will be required at discharge to manage the various services needed by the beneficiary and advocates at home. There are a few activities that need to accompany the creation of an eLTSS plan. These activities can occur at any time in the process of creating an eLTSS plan. The beneficiary needs to be approved for long-term services and supports (LTSS) coverage, create a brief person-centered profile and work with their service team to establish an eLTSS information sharing resource.

An eligibility determination form submitter is assigned to the beneficiary who, with their consent, completes and submits the eligibility determination forms electronically to the Payer system for community-based long-term services and supports.

The beneficiary develops their brief person-centered profile. The brief person-centered profile is a summary of what the beneficiary/advocate wants his/her service providers to know about them as an individual regardless of the services he or she needs. The beneficiary/advocates define the relationships that they are seeking with service providers and what people and activities matter most and are most important to them.

The eLTSS plan developer then works with the beneficiary and his/her advocates, and service providers to establish an eLTSS information sharing resource. The eLTSS information sharing resource contains a set of 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. 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 Appendix C (Actors and Activities table).

The eLTSS plan developer meets with the beneficiary and advocates, and together they assemble the person-centered eLTSS plan within the case manager’s information system. Information from the eligibility determination forms, brief person-centered profile and eLTSS information sharing resource is used as input for the eLTSS plan. The eLTSS plan also captures the goals, preferences, service and formal /informal support needs, etc. of the beneficiary electronically. The eLTSS plan developer provides the beneficiary/advocate with information on available service providers. The beneficiary/advocate selects from available provider(s) with assistance from the plan developer as needed. The plan developer then makes a referral to the provider(s). The plan developer updates the plan as providers are finalized. The beneficiary reviews and approves the eLTSS plan. The plan developer submits the person-centered eLTSS plan to the LTSS payer agency for authorization. Once authorized by the payer agency, the eLTSS plan is updated in the case manager’s information system.
The eLTSS plan is sent to the beneficiary’s system. Depending on the specific beneficiary information system, the beneficiary and/or advocate may receive a notification to access the system as there is new information available.

The eLTSS plan exchange message is received into the beneficiary’s system. The beneficiary/advocate accesses the system to view the eLTSS plan.

9.1.1 Actors and Activities - User Story 1: LTSS Eligibility Determination, eLTSS Plan Creation and Approval

9.1.2 Base Flow - User Story 1: LTSS Eligibility Determination, eLTSS Plan Creation and Approval

9.1.3 Activity Diagram - User Story 1: LTSS Eligibility Determination, eLTSS Plan Creation and Approval

9.1.4 Information Interchange Requirements - User Story 1: LTSS Eligibility Determination, eLTSS Plan Creation and Approval

9.1.5 System Requirements - User Story 1: LTSS Eligibility Determination, eLTSS Plan Creation and Approval

9.1.6 Sequence Diagram - User Story 1: LTSS Eligibility Determination, eLTSS Plan Creation and Approval

9.2 User Story 2: Sharing a Person-Centered eLTSS Plan

A beneficiary has an eLTSS plan that represents her goals, preferences, daily plan and formal and informal support systems to help provide a successful home-life within a community. The eLTSS plan also states that the beneficiary must see a doctor immediately upon any sign of fever, cough, or abnormal balance due to a causal relationship with a rapid-spreading systemic infection. The beneficiary’s daily plan includes a scheduled phone call every day at 11 AM with her advocate. The beneficiary requires assistance from the assigned home care assistant (HCA) to dial the phone.

While meeting with the beneficiary and her advocate, the plan facilitator notices that the beneficiary seems agitated and looks somewhat unkempt. During the conversation the beneficiary states that she does not like and is dissatisfied with her current agency provided home care assistant (HCA). She feels that the HCA tends to rush when helping her with dressing, bathing, etc. and does not take time to talk to her or focus on what is important to her. The beneficiary also states that she would prefer more assistance and company in the evening.

The beneficiary advocate admits that she has not been able to call the beneficiary every day at 11am and knows this causes the beneficiary to be depressed. The advocate states that she would be more able to make these daily calls if they were scheduled for after 8:00pm.

After further discussion, the beneficiary states that her neighbor has recently retired and may be willing to support her with some daily living tasks. The beneficiary provides contact details for her neighbor.

After the meeting the plan facilitator documents an overview of the meeting in the beneficiary’s contact notes. The beneficiary and her advocate update her daily plan to reflect the change in the preferred call time and notates the preference changes for what she feels are important to her. Since these are purely functional changes the plan is not shared with the payer for authorization but alerts of the updates are sent to the beneficiary, beneficiary advocate, plan facilitator and the agency providing daily living services. All recipients have the ability to acknowledge that they have seen and agree to the changes.The updated plan is also shared with the beneficiary’s PCP so they can be referenced as needed in the ongoing medical care of the beneficiary.

At a follow-up meeting, the beneficiary, advocate (via phone), plan facilitator, and the neighbor discuss the planned changes to the beneficiary’s supports. The neighbor has agreed to spend several hours each evening with the beneficiary to assist her with her daily living activities and will also stop by periodically in the morning. The neighbor will be hired as an attendant under the self-directed personal assistance model, with the beneficiary signing off on time sheets and developing schedules with her advocate’s assistance as necessary. A fiscal intermediary will pay the neighbor and any applicable taxes and insurances. The beneficiary will be provided a new HCA. The agency provider will work with the beneficiary to establish a new protocol for ensuring the HCA understands and adheres to the beneficiary’s preferences as documented in her eLTSS plan. To help ensure her health and safety during the afternoon (and overnight) the plan facilitator recommends that a PERS (Personal Emergency Response System) be installed and the beneficiary agrees.

The plan facilitator updates the beneficiary’s eLTSS plan to note the changes in services and the details around why these changes are being made and how they support what is important to the beneficiary. The neighbor is also added as a contact for the beneficiary. Access to the functional components of the beneficiary’s plan is granted to the neighbor and, after some discussion with the beneficiary and her advocate, the neighbor is given access to medical information as well. All changes are reviewed with the team at the conclusion of the meeting and the beneficiary’s approval is documented.

The plan facilitator submits/shared the updated plan to the beneficiary’s payer (or their designee) for review and service authorization. The payer reviews the changes and the detail related to the reasons for the changes and confirms that they support what is important to the beneficiary while accounting for her health and welfare. The changes are also reviewed to ensure that they meet the payer’s fiscal prudency standards. The services are authorized and alerts are sent to the beneficiary, beneficiary advocate, the neighbor, the fiscal agent and the agency provider of daily living services. All recipients have the ability to acknowledge that they have seen and agree to the changes. (Note that the PERS provider does not have access to the plan.) The changes are also shared with the beneficiary’s PCP so that they can be referenced in her ongoing medical care.

A few days later, the beneficiary has a fever requiring a visit with a PCP. The beneficiary’s HCA schedules transportation services for the beneficiary to get to the doctor’s office, based on the available units of transportation service the beneficiary has available.

The beneficiary sees the PCP, who performs an exam and prescribes new medication. The PCP reviews relevant eLTSS plan components with the beneficiary and recommends additional assistance be provided to the beneficiary for meal preparation and medication administration. The beneficiary agrees with the PCP recommendation and the PCP adds proposed modifications to the beneficiary’s clinical documentation within their EHR system. The PCPs EHR System sends the relevant portion of the beneficiary’s medical record containing the notes pertaining to proposed modifications to the eLTSS plan to the eLTSS Plan Facilitator’s Information System. 

The eLTSS plan facilitator receives the proposed modifications and makes updates to the beneficiary’s eLTSS plan. The plan facilitator sends the updated plan to the beneficiary for approval. If the plan is not approved by the beneficiary, the plan facilitator notifies the PCP of the disapproval. The PCP may have to revise their recommendations and re-send the plan to the plan facilitator for further update, using the same process as outlined previously. If the plan is approved by the beneficiary, the plan facilitator sends the modified eLTSS plan to the accountable entity, which receives, reviews, and executes the modified eLTSS plan. Notifications of the modifications are sent to affected parties. In preparation for the next visit, the HCA accesses the beneficiary’s modified eLTSS plan to review the list of new medications/administration instructions as well as change in meal preparation duties.

9.2.1 Actors and Activities - User Story 2: Sharing a Person-Centered eLTSS Plan

9.2.2 Base Flow - User Story 2: Sharing a Person-Centered eLTSS Plan

9.2.3 Activity Diagram - User Story 2: Sharing a Person-Centered eLTSS Plan

9.2.4 Information Interchange Requirements - User Story 2: Sharing a Person-Centered eLTSS Plan

9.2.5 System Requirements - User Story 2: Sharing a Person-Centered eLTSS Plan

9.2.6 Sequence Diagram - User Story 2: Sharing a Person-Centered eLTSS Plan

10.0 Risks, Issues and Obstacles

• Failure to engage key stakeholders in contributing to, learning from, and committing to the eLTSS process in an accessible, productive, efficient manner early in the eLTSS process
• Failure to adequately train staff on appropriate and effective person-centered assessment process
• Content models for standards that overlap or compete with existing or developing models
• Identification and implementation of eLTSS standards that are misaligned with the nationwide health IT infrastructure standards
• Insufficient funding and/or financial incentives to implement eLTSS standard and supporting policies and programs
• Insufficient engagement and participation by vendor communities; lack of product adoption
• Insufficient engagement and participation by beneficiary populations; lack of PHR adoption
• Insufficient focus by stakeholders on the care and service planning goals and preferences of beneficiaries
• Insufficient participation by various vendors and organizations (including non-TEFT state grantees) in eLTSS Pilots
• Lack of consensus from non-participating groups on eLTSS key assessment domains and the definition of an eLTSS plan
• Solutions for eLTSS plan data capture and reporting may vary; one standard solution may not apply
• Standard and solutions may not scale to small vendors and service providers, including those in rural areas
• Proposed project timeline may not reflect actual deadlines in relevant standards or regulatory bodies
• Proposed project timeline may not reflect readiness of participating pilots (exchange entities and solution providers) to support implementation of standard
• Lack of clarity around legal issues (e.g. patient consent, data sharing, etc.) surrounding the new eLTSS plan and associated new data types may cause significant implementation delays for organizations that have not already addressed these issues internally
• The eLTSS standard identified may not be applicable to all LTSS populations
• Harmonization and timing of quality measures and other regulatory items that affect both eLTSS and other providers

11.0 Dataset Requirements

The Dataset Requirements for the eLTSS Plan Content is currently being developed by the eLTSS Plan Content SWG. This section provides a draft set of domains identified by the SWG at this time. The final set of domains, sub-domains and a sample set of data elements will be a final artifact of the SWG. Please keep in mind that the content below is draft and may change as the SWG activities evolve.

The following tables list the DRAFT domains that will be available within an electronic LTSS plan.

11.1 eLTSS Plan Content Domains (DRAFT)

Appendices

Appendix A: Related Use Cases

• ONC Longitudinal Coordination of Care (LCC) Care Plan Exchange
• Blue Button Plus
• ONC Data Segmentation for Privacy (DS4P)
• ONC Data Provenance
• ONC Structured Data Capture
• ONC Data Access Framework

Appendix B: Previous Work Efforts

• CMS Medicaid Money Follows the Person (MFP) Rebalancing Demonstration Grant
• CMS Medicaid Community First Choice Option
• CMS Medicaid Balancing Incentives Program
• Institute of Medicine (IOM) Capturing Social and Behavioral Domains in Electronic Health Records
• The Improving Medicare Post-Acute Care Transformation Act of 2014
• National Core Indicators (NCI)
• Administration for Community Living (ACL), Centers for Medicare & Medicaid Services (CMS), Veterans Health Administration (VHA) Transforming State LTSS Access Programs and Functions into A No Wrong Door System for All Populations and All Payers
• National Quality Forum (NQF) Patient Reported Outcomes (PROs) in Performance Measurement
• National Quality Forum (NQF) HCBS Quality Measures Project
• ONC Direct Project
• Institute of Medicine’s Committee on Approaching Death: Key End-of-Life Issues
• Standards identified through the 2015 Interoperability Standards Advisory to include the HL7 Consolidated Clinical Document Architecture (C-CDA) Release 2.0 Implementation Guide as updated through the Longitudinal Coordination of Care (LCC) Initiative, Data Provenance, Data Segmentation for Privacy (DS4P), BlueButton Plus, and the emerging HL7 FHIR Profile Implementation Guides for Structured Data Capture (SDC) and Data Access Framework (DAF)
• ONC Direct Project (as a transport standard)
• Substance Abuse and Mental Health Services Administration (SAMHSA) and Veterans Administration (VA) Joint Pilot under Data Segmentation For Privacy Initiative
• Standards identified through the National Information Exchange Model (NIEM) Human Services Domain
• HL7 Personal Health Record System Functional Model Release 1
• HL7 Implementation Guide for CDA Release 2: Patient Generated Document Header Template
• HIMSS Healthstory Project
• Openmhealth.org
• Centers for Medicare & Medicaid (CMS) Standards and Guidance:
  • Outcome and Assessment Information Set (OASIS) dataset for use in Home Health Agencies (HHAs)
  • Minimum Data Set (MDS) dataset for use in Nursing Homes
  • Continuity Assessment Record and Evaluation (CARE) Item Set
  • Program for All-Inclusive Care for the Elderly (PACE) Assessment and Care Planning Tools
  • Balancing Incentive Program
  • Home and Community-Based Services (HCBS) Taxonomy
  • Person-Centered Planning Tools
  • Post-Acute Care (PAC) Data Element Library
• Administration for Community Living
  • The Aging and Disability Resource Center Program/No Wrong Door System for All Populations and All Payers Initiative
  • Guidance to implement Person-Centered Planning
• Other projects using assessment tools (for example):
  • Guided Care by Johns Hopkins University
  • Case Management Information System by Community Care of North Carolina
  • Community Health Needs Assessment by Eastern Maine Healthcare Systems
  • Ohio Person Centered Planning Technology Tools
• Person-Centered Planning Tools
  • PATH
  • Making Action Plans (MAPS)
  • Essential Lifestyle Learning (ELP)
  • PACER
  • Wraparound Service
• National Association of Social Workers (NASW) Standards for Social Work Practice
• Case Management Society of America (CMSA) Standards of Practice for Case Management
• American Medical Association (AMA) and American Academy of Home Care Physicians (AAHCP) Guidelines for Uniform Assessment
• MassHealth, One Care Implementation Council, and UMass Medical School One Care Early Indicators Projects (EIP)
• Standards of Practice for Registered Dietitians
• International Classification of Functioning, Disability, and Health (WHO)
• Standard Terminologies and Taxonomies adopted by ONC: SNOMED CT, LOINC
  • HITSP Nursing Terminology Overlap Resolution
    
    

Appendix C: Actors and Activities for establishing eLTSS Information Sharing Resource

Actors and Activities Table 2015-05-11.xlsx

Appendix D: Resources

• Centers for Medicare & Medicaid Services (CMS). (2014). State Balancing Incentive Payments Program: Initial Announcement. Retrieved from: https://www.medicaid.gov/medicaid-chip-program-information/by-topics/long-term-services-and-supports/balancing/downloads/bip-manual.pdf
• Centers for Medicare & Medicaid Services. (2013, June 27). Planning and Demonstration Grant for Testing Experience and Functional Tools in Community-Based Long Term Services and Supports. Funding Opportunity Number: CMS-1H1-13-001. Baltimore, MD: Centers for Medicare & Medicaid Services.
• Friedman, C. P. (2013). Toward a National Learning Health System. Retrieved from:https://www.networkforphl.org/_asset/0xhnys/PPT-Toward-a-National-LHS-Friedman.pdf
• Institute of Medicine. (2014). Capturing social and behavioral domains in electronic health records: Phase 1. Washington, DC: The National Academies Press.
• Mission Analytics Group. (2013, February). The Balancing Incentive Program: Implementation Manual. Retrieved from: https://www.medicaid.gov/medicaid-chip-program-information/by-topics/long-term-services-and-supports/balancing/downloads/bip-manual.pdf