THE FINAL PROJECT CHARTER IS NOW AVAILABLE. (See download below)
Thank you to all eLTSS Committed Members for their valuable input.
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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 individual receiving community-based long-term services and supports (CB-LTSS). 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:
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. 2 However, EHR implementation and integration into service delivery has been limited for CB-LTSS. CB-LTSS is defined by CMS 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.” 3 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. 4 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 (Affordable Care Act, 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 5 , 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 and person-centered planning.
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; lack of consensus on the inter-relationships between a beneficiary’s plans across care, services and supports; and lack of evidence and understanding of how Health IT may benefit the beneficiary and encourage their adoption and use of Health IT.
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.
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 6 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. 7 The required Core Dataset domains for assessments include clinical and non-clinical data. 8 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:
The eLTSS Initiative will provide a framework to standardize the exchange of the eLTSS plan across and between institutionally-based and community-based information systems. In the short term, the initiative will introduce the concept of the eLTSS plan to the public, define the information model necessary to support its adoption, and inform future efforts to integrate institutional LTSS data with CB-LTSS data. In the longer term, specification of standards for the eLTSS plan will support and spur development and implementation of software and pilots that will inform refinement of these standards prior to their consideration for inclusion in future Federal regulations, which include Health IT certification requirements.
The value of this initiative will be measured through the attainment of the following outcomes:
Immediate Outcomes
Long-Term Outcomes
The eLTSS Initiative will leverage standardization efforts established by other projects, which may include but not be limited to the following:
Stakeholders and interested parties include but are not limited to the following:
This timeline represents notional estimates of planned activities and will be adjusted as work moves forward through the initiative phases.
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Centers for Medicare & Medicaid Services (CMS). (2014). State Balancing Incentive Payments Program: Initial Announcement. Retrieved from Medicaid.gov: https://www.medicaid.gov/medicaid-chip-program-information/by-topics/long-term-services-and-supports/balancing/balancing-incentive-program.html
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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.
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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
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