electronic Long-Term Services and Supports (eLTSS) Pilots Template Insert the Name of Your Pilot / Organization Here MM/DD/YYYY

Pilot Team Identify the members of your organization who will be supporting this pilot. If possible include the role he/she will play in the pilot and contact information Name Role Email

Full Disclosure?

Goal of the Pilot Please include a write up or create a Visio diagram of what you intend to show/prove/support during the pilot process. Make this an actionable statement with specifics. Also include in this description what you hope to gain from this pilot.

Which of the eLTSS Pilot Tiers will guide your pilot? Please use this section to document which of the eLTSS Pilot Tiers you intend to pilot. Please be as specific as possible. Tier / Description Specifics to Pilot Notes Sample: Tier 1 Data Sharing Sample: Validates target eLTSS Use Cases. Determines possible data use/sharing legal needs. Evaluates benefit and utility of sharing eLTSS data. Sample: ONC/TEFT Program guidance on desired output formats (report and file formats, if available)

What Relevant Story (from the Use Cases) does your Pilot support? User Story 1: LTSS Eligibility Determination, Plan Creation and Approval User Story 2: Sharing a Person-Centered eLTSS Plan Other: ____(Please specify) Link to download Use Case: http://wiki.siframework.org/electronic+Long-Term+Services+and+Supports+%28eLTSS%29+Use+Case

Identify the Use Case Actors/Systems Involved: A pilot may involve the following participants from the longitudinal coordination of care ecosystem: Sending Entity Care Team Receiving Entity Care Team Sending Entity Information System (EHR) Receiving Entity Information System (EHR) Patient and/or Caregiver Home Health Agency (HHA) Care Team Home Health Agency (HHA) Information System (EHR) PHR Application

Minimum Configuration What is your current technical / infrastructure set up? What systems / applications will you be using to conduct the pilot? Examples: Electronic Health Record (EHR) system Health Information Exchange (HIE) External database (which one/type) Existing interfaces New interfaces (to be developed as part of the pilot)

Timeline Milestone Target Date Responsible Party What is your proposed timeline Guidance: ~6 months minimum / ~1 year maximum Evaluation: starts @ 6-9 months / final evaluation when pilot is complete Example Timeline September – Kickoff and Logistics October – Start Pilots November – Continue with Pilots March – Conclude Pilots Milestone Target Date Responsible Party

Success Criteria What will you/your organization use to determine the success of this pilot? This needs to be quantitative and not subjective in as much as possible. Examples: X% reduction in readmission rate X% Increase in number of unique patient transfers between sites with complete set of eLTSS data elements

Example: MA IMPACT Performance Metrics Target Outcome Target Value Target Population Data Source Numerator Denominator Reduce hospital readmission rate 5% decrease in 30 day hospital readmission rates from baseline Unique FCHP patient discharges from St. Vincent Hospital and UMass Memorial Hospital that are readmitted to any hospital from IMPACT Pilot Sites Fallon Community Health Plan’s claims data via Reliant Medical Group Number of unique patient discharges from St. Vincent Hospital and UMass Memorial Hospital that are readmitted to any hospital from IMPACT Pilot Sites within 30 days during measurement period Number of unique patient discharges from St. Vincent Hospital and UMass Memorial Hospital during measurement period Reduce Hospital Admission Rate 5% decrease in Hospital Admission Rate from baseline Unique FCHP members seen in St. Vincent Hospital and UMass Memorial Hospital ER that had been under the care of an IMPACT Pilot Site during the measurement period, that are subsequently admitted to the hospital from the ER Number of unique FCHP members in an IMPACT Pilot Site’s care during measurement period that are transferred to the St. Vincent Hospital or UMass Memorial Hospital ER that are subsequently admitted to the hospital Number of unique FCHP members in an IMPACT Pilot Site’s care during measurement period that are transferred to the St. Vincent Hospital or UMass Memorial Hospital ER Increase overall completeness of data included in transition process 70% of patients transferred with complete set of required data elements included in electronic Universal Transfer Form (UTF) Unique patient transfers between IMPACT pilot sites LAND and SEE data Number of unique patient transfers between IMPACT Pilot Sites during measurement period with complete set of required data elements in electronic UTF Number of unique patient transfers between IMPACT Pilot Sites during measurement period

In Scope / Out of Scope If you already know what will be in and out of scope for your pilot (beyond the Pilot Guide or the Use Case) please document it here. Example:

Risks & Challenges Identify any risks or challenges

Questions / Needs Please include those items you wish to consider any questions you have or hope the pilot addresses. Additionally, please include those items you need in order to succeed. We will try to accommodate as many of these needs as possible within the scope of ONC, S&I and eLTSS (and resource availability).

Useful Links eLTSS Wiki Main Page: http://wiki.siframework.org/electronic+Long-Term+Services+and+Supports+%28eLTSS%29 eLTSS Use Case: http://wiki.siframework.org/electronic+Long-Term+Services+and+Supports+%28eLTSS%29+Use+Case Pilots Wiki Page: http://wiki.siframework.org/electronic+Long-Term+Services+and+Supports+%28eLTSS%29+Pilots