Dynamic Care Team Management IHE Patient Care Committee (PCC)

Profile Concepts The Dynamic Care Team Management (DCTM) Profile provides the means for sharing care team information about a patient’s care teams that meet the needs of many users, such as providers, patients and payers. Supports HL7 Care Coordination Service Functional Model Sub- capabilities: Discovering Care Teams Creating/updating Care Teams Listing Care Teams http://wiki.ihe.net/index.php/Dynamic_Care_Team_Management#See_Also

Care Team Concepts Patient centered care teams with the overarching goal to support collaborative care. Care teams can be made up of a single individual, a single group of individuals or multiple groups of individuals providing various types of services. Care teams can be discipline and or condition specific. Uses LHS Classification of types of care teams: Encounter-focused Care Team; Episode-focused Care Team; Condition- focused Care Team; Care-coordination focused Care Team; Research-focused Care Team.

DCTM Volume 1

DCTM Actor Diagram

Basic Process Flow

Interaction Diagram

DCTM Use Case Reuses the HL7 Care Plan Domain Analysis Model specification storyboard 2: Chronic Conditions Slight modifications made to depict care team management needed for chronic disease management as well as transition of care episodes Use case is sub-divided to reflect HL7 LHS Care Team Definition Project’s classification of types of care teams

DCTM Volume 2

Transaction: Update Care Team A CareTeam resource is submitted to a Care Team Service where the update or creation is handled Update uses HTTP or HTTPS PUT of a CareTeam resource See FHIR update interaction - http://hl7.org/fhir/http.html#update Create uses HTTP or HTTPS POST of a CareTeam resource See FHIR create interaction - http://hl7.org/fhir/http.html#create You go to update but if the resource does not exist then you create.

Transaction: Search for Care Team Care Team Contributor initiates Search for Care Team in order to locate a CareTeam resource of interest. Care Team Service responds to the Search Search uses FHIR search operation using REST platform constrained to HTTP or HTTPS GET See FHIR CareTeam search parameters - http://build.fhir.org/careteam.html#search

Transaction: Retrieve Care Team Care Team Contributor requests a specific CareTeam resource Initiates retrieve request using HTTP or HTTPS GET Care Team Service returns the requested CareTeam resource (or an error if the requested resource does not exist) Care Team Service responds according to FHIR GET specification See FHIR read interaction http://hl7.org/fhir/http.html#read

Transaction: Subscribe to Care Team Updates Care Team Contributor subscribes to updates based upon changes to a CareTeam resource Care Team Service evaluates the involved resources of the Subscription and uses the defined channel to notify a Care Team Contributor about changes Care Team Contributor inspects the response from the Care Team Service See FHIR CareTeam create interaction http://hl7.org/fhir/http.html#create Care Team Contributor can update an existing subscription Update uses HTTP or HTTPS PUT of a Subscription resource See FHIR update interaction - http://hl7.org/fhir/http.html#update

Transaction: Provide Care Team Care Team Service provides updated CareTeam resources to subscribed Care Team Contributors Provide uses HTTP or HTTPS POST of a CareTeam resource Care Team Contributor that has Subscribed to Care Team Updates receives updates of changed CareTeam resources

PCC Volume 3 FHIR Content Module

dctmCareTeam StructureDefinition See section 6.6.1 Profiled the following Identifier Identifier value Status Name Subject (patient) context Period Start participant

dctmSubscription StructureDefinition See section 6.6.2 Profiled the following type (rest-hook) Endpoint payload