Longitudinal Coordination of Care WG LCC All Hands Meeting

Agenda Introductions/ Announcements Use Case Recap Next Steps 2

Baseline Transaction and Build Master Longitudinal Care Use Case Version 1: Baseline Developed with HHA/ SNF Creates base LCC Use Case Structure and focuses on HHA/ SNF as the starting point that gives the best overall coverage of data elements. Version 1: Baseline Developed with HHA/ SNF Creates base LCC Use Case Structure and focuses on HHA/ SNF as the starting point that gives the best overall coverage of data elements. Version 2: (IRF, Behavioral Health, CBO, ???) White Paper Roadmap lays out priority order to incrementally add requirements of other trading partners Version 2: (IRF, Behavioral Health, CBO, ???) White Paper Roadmap lays out priority order to incrementally add requirements of other trading partners Version 3: (IRF, Behavioral Health, CBO, ???) Version 4: (IRF, Behavioral Health, CBO, ???) Version …: Other trading partners Round out full longitudinal picture Version …: Other trading partners Round out full longitudinal picture Now: Foundation Future: Full LCP Support Building Incrementally 3

S&I Process: Foundation and Build in Parallel HHA/ SNF UC Next LTPAC UC HHA/ SNF Harmonization Next LTPAC Harm HHA/ SNF Pilots Other LTPAC Pilots Next LTPAC UC Continue to develop and refine requirements in parallel with developing implementation guidance and pilots 4

Use Case Scope 5 The Use Case describes “Transitions of Care” as an overarching concept that encompasses “transfers of care summary”, “consultation request clinical summary” and “shared care encounter summary”. The Use Case employs the phrase “Transitions of Care” when broadly referring to any transaction that facilitates a permanent or temporary transfer. With this in mind, the Use Case is comprised of 4 Scenarios: Scenario 1: Provider to Provider data exchanges for Transfer of Care and Referral that support the following interactions: Acute Care Hospital to LTPAC site (Transfer of Care Summary); LTPAC Site to Emergency Department/ Consultant (Consultation Request Clinical Summary); Emergency Department/ Consultant to LTPAC Site (Shared Care Encounter Summary). Scenario 2: Provider to Provider data exchanges for the HH-POC including the following user stories: HH-POC (Initial and Recertification): Home Health Agency (HHA) to Physician, Physician to HHA; Interim Changes to HH-POC: HHA to Physician, Physician to HHA. Scenario 3: Provider to Patient data exchanges that provide a copy of the Provider to Provider data to the patient/ delegate for the transitions of care data exchanges described in Scenario 1. Scenario 4: Provider to Patient data exchanges that provide a copy of the Provider to Provider data to the patient/ delegate for the HH-POC data exchanges described in Scenario 2.

Transfer and Consult Transactions 6

Plan of Care Transaction 7

Activity Diagram: Scenario 1 - User Story 1 8

Activity Diagram: Scenario 1 - User Story 2 9

Activity Diagram: Scenario 2 - User Story 10

Activity Diagram: Scenario 3 - User Story 1 11

Activity Diagram: Scenario 3 - User Story 2 12

Activity Diagram: Scenario 4 - User Story 13

Robust Consensus 21 Yes or Yes with Comments Votes 0 No Votes Broad representation: 14 Larry Garber, MD, Reliant Medical Group Elizabeth Milton, Optimus EMR Karen Utterback, McKesson Gerry McCarthy, HealthMEDX Rosemarie Namisato, VNSNY Teresa Mota BSN RN, Healthcentric Advisors Paul Burnstein, LeadingAge CAST NAHC Richard Brennan, HCTAA/NAHC, Association Jim Brennan, Massachusetts eHealth Institute Terry O'Malley, Partners Healthcare Susan E. Campbell, Care Management Professionals Larry Wolf, Kindred Healthcare Russell Leftwich, State of Tennessee Bill Russell Lester Keepper, Jr., SHAPE HITECH LLC Rhonda York, HCR Eric Thul, BAYADA Home Health Care Teresa Lee, Executive Director, Alliance for Home Health Quality & Innovation Jennie Harvell, HHS/ASPE Sue Mitchell

Next Steps Complete the LCC WG White Paper Begin Harmonization process for the LCC Use Case 1 15

Questions 16