electronic Long-Term Services & Supports (eLTSS) Initiative All-Hands Workgroup Meeting March 12, 2015 DRAFT: Not for distribution

Meeting Etiquette Remember: If you are not speaking, please keep your phone on mute Do not put your phone on hold. If you need to take a call, hang up and dial in again when finished with your other call Hold = Elevator Music = frustrated speakers and participants This meeting is being recorded Another reason to keep your phone on mute when not speaking Use the “Chat” feature for questions, comments and items you would like the moderator or other participants to know. Send comments to All Panelists so they can be addressed publically in the chat, or discussed in the meeting (as appropriate). Please DO NOT use the Q&A—only the presenter sees Q&A, not necessarily the person facilitating the discussion From S&I Framework to Participants: Hi everyone: remember to keep your phone on mute  All Panelists

Agenda Welcome Announcements eLTSS Roadmap Lynette Elliott 10 mins Topic Presenter Timeframe Welcome Announcements eLTSS Roadmap Lynette Elliott 10 mins Use Case Working Session: Review Context Diagram Comments Present User Story Submissions Evelyn / Community 45 mins Homework / Next Steps Evelyn 5 mins Concert Series Presentation: State of Maryland Kale Sweeney Rebecca Van Amburg David Wertheimer 30 mins

Announcements ONC issued the Connecting Health and Care for the Nation: A Shared Nationwide Interoperability Roadmap Version 1.0 The draft Roadmap is a proposal to deliver better care and result in healthier people through the safe and secure exchange and use of electronic health information. Includes Person-Centered Planning and eLTSS initiative ONC is accepting public comments until 5pm ET April 3, 2015: http://www.healthit.gov/policy-researchers- implementers/interoperability-roadmap-public-comments HIMSS Interoperability Showcase is being held April 12-15, 2015 in Chicago, IL Live interactive demonstration where health IT solution providers collaborate to maximize the collective impact of their technologies Highlight seamless health information exchange in multiple care settings

New Funding Announcement Advance Interoperable Health Information Technology Services to Support Health Information Exchange Funding Opportunity Announcement Letters of Intent Due: March 2, 2015; Application Deadline: April 6, 2015 Leverages investments and lessons learned from HITECH State HIE Program to accelerate widespread adoption and use of HIE infrastructure Grantees MUST select at least one eligible care provider and at least two non-eligible care providers for their target populations:

Concert Series Presentations Organizations are invited to present on an existing project or initiative that is related to the eLTSS scope of work and/or will help inform the eLTSS target outcomes and deliverables These projects do not have to be technically-focused Criteria for consideration: Has solution, whether it is technical or process driven, been implemented in a one or more of the eLTSS settings: home and community-based setting or clinical setting? Does solution incorporate existing or emerging standards and/or other relevant guidance? DRAFT: Not for distribution

Concert Series Presentations: Logistics Presentations will be scheduled as part of the weekly eLTSS Community Meetings and will occur the last 30 mins of the call Duration: 15-20 mins webinar (or demo); 5-10 mins Q&A eLTSS Workgroup activities will always take precedence over concert series presentations If you have an interest in participating, please contact Evelyn Gallego (evelyn.gallego@siframework.org ) and Lynette Elliott (lynette.elliott@esacinc.com) A pre-planning meeting will be scheduled prior to any public demonstration DRAFT: Not for distribution

Upcoming Concert Series Presentations March 19th: Colorado Regional Health Information Exchange (CORHIO) March 26th: NASDDDS National Core Indicators April 2nd: Person-Centered Planning Tools April 9th: PeerPlace April 16th: MyDirectives.com / A|D Vault, Inc. April 23rd: Care at Hand April 30th: (available) May 7th: (available) May 14th: State of Minnesota DRAFT: Not for distribution

eLTSS Initiative Roadmap Q3 ‘14 Q4 ‘14 Q1 ‘15 Q2 ‘15 Q3 ‘15 Q4 ‘15 Q4 ‘17 Initiative Kick Off: 11/06/14 Pre-Planning Call for Participation Conduct Environmental Scan Success Criteria Stakeholder Engagement Phase 4: Pilots & Testing Pilot site readiness Implementation of solution Test User Stories and Scenarios Monitor Progress & Outcomes Utilize Requirements Traceability Matrix Phase 2: Use Case Development & Functional Requirements Develop, review, and finalize the Use Case and Functional Requirements Launch initiative Review and Finalize Charter Review initial Candidate Standards Finalize Candidate Standards Standards Gap Analysis Technical & Standards Design Develop Requirements Traceability Matrix Develop Implementation Guide Phase 5: Evaluation Evaluate outcomes against Success Metrics and Criteria Update Implementation Guidance Phase 1: Pre-Discovery Phase 3: Standards & Harmonization Timelines for Consideration: Two Pilot Phases, SDO Ballot Cycles DRAFT: Not for distribution

Goals for the eLTSS Initiative Identify key assessment domains and associated data elements to include in an electronic Long-term Services & Supports (eLTSS) plan Create a structured, longitudinal, person-centered eLTSS plan that can be exchanged electronically across and between community- based information systems, clinical care systems and personal health record systems. We will use Health IT to establish a person-centered electronic LTSS record, one that supports the person, makes him or her central to the process, and recognizes the person as the expert on goals and needs.* * Source: Guidance to HHS Agencies for Implementing Principles of Section 2402(a) of the Affordable Care Act: Standards for Person-Centered Planning and Self-Direction in Home and Community-Based Services Programs DRAFT: Not for distribution

Project Charter and eLTSS Glossary FINAL Published Project Charter located here: http://wiki.siframework.org/electronic+Long-Term+Services+and+Supports+%28eLTSS%29+Charter eLTSS Glossary posted here: http://wiki.siframework.org/eLTSS+Glossary The eLTSS Glossary is a working document containing eLTSS-relevant terms, abbreviations and definitions as defined by stakeholders We are looking for your feedback and comments Discussion Thread available Submit any change requests via the Change Request Form located on the wiki Reminder: the Glossary is a living document and content may change as the initiative progresses DRAFT: Not for distribution

Proposed Use Case & Functional Requirements Development Timeline Week Target Date (2015) All Hands WG Meeting Tasks Review & Comments from Community via Wiki page due following Tuesday by 8 P.M. Eastern 1-5 1/22-2/19 Use Case Kick-Off & UC Process Overview Use Case Value Framing Discussions Review and Answer Value Framing Questions on wiki 6 2/26 Review: Consolidated UC Value Framing Introduce: Context Diagram & User Stories Review: Context Diagram & User Stories 7 3/12 Finalize: Context Diagram & User Stories Review: User Stories 8 3/19 Finalize: User Stories Introduce: In/Out of Scope Review: In/Out of Scope 9 3/26 Finalize: Assumptions & Pre/Post Conditions Introduce: Activity Diagram & Base Flow Review: Assumptions & Pre/Post Conditions, Activity Diagram & Base Flow 10 4/2 Finalize: Activity Diagram & Base Flow Introduce: Functional Requirements & Sequence Diagram Review: Functional Requirements & Sequence Diagram 11 4/9 Finalize: Functional Requirements & Sequence Diagram Introduce: Data Requirements Review: Data Requirements 12 4/16 13 4/23 Finalize: Finalize Data Requirements Introduce: Risks & Issues Review: Risks & Issues 14 4/30 Finalize: Risks and Issues Begin End-to-End Review End-to-End Review by community 15 5/7 End-to-End Comments Review & disposition End-to-End Review ends 16 5/14 Finalize End-to-End Review Comments & Begin Consensus Begin casting consensus vote 17 5/21 Consensus Vote* Conclude consensus voting

We Need YOU! In order to stick to our timeline and to ensure that the artifacts we develop fit the need of our stakeholders (you), we need your feedback, comments and participation Each week, please review the use case content and provide comments via the wiki at: http://wiki.siframework.org/electronic+Long-Term+Services+and+Supports+%28eLTSS%29+Use+Case Thank you for providing input for our eLTSS Use Case Framing Questions (via the wiki, live discussions or email). We have consolidated the responses and posted the document on the eLTSS wiki at: http://wiki.siframework.org/electronic+Long+Term+Services+and+Supports+Use+Case+Value+Framing+Questions This document and YOUR responses will be used as input for various sections of the eLTSS Use Case Artifact

Use Case Development Working Session: Review Context Diagram and User Stories DRAFT: Not for distribution

eLTSS Plan Future Creation and Sharing Other IT Standard System Beneficiary & Caregiver Owner of plan; contributes personal story, demographic data Standard Assessment(s) Service Team Other IT System Generates, updates and displays eLTSS Plan; stores/transmits service-related data Community-based setting Care Team IT System Clinical Institutional setting Updates and displays eLTSS Plan; stores/submits medical, clinical, advance directive data Extract, Transform, & Load financial data Systems Payer & Other Accountable Component 1 Component 2 Component n eLTSS Plan Move from Patient-Centered to Person-Centered Planning and Information Sharing Collects assessment data for eligibility determination and to inform plan of service

Context Diagram Feedback Comment (from Mark Pavlovich): I think we have disharmony between the Out Of Scope bullet points and the Use Case Context Diagram Generally, I don’t see how we can achieve our stated goal, “To fully realize the benefit of health IT” if integration of eLTSS plan into an EHR or other Clinical System is Out of Scope. Specifically, the Use Case Diagram shows direct links between the eTLSS plan and: Clinical IT System integration. The lower right quadrant of the diagram Standards Assessment(s). The upper left quadrant. Response: The diagram shows that there needs to be an interaction/exchange of data between the eLTSS plan and the IT System - to store/submit relevant data, but that doesn't mean that the eLTSS plan will be integrated into the IT System.

User Story Description: User Stories summarize the interaction between the actors of the Use Case Specify what information is exchanged from a contextual perspective Describe the real world application as an example of the Scenario Provide clinical context User Stories will be displayed on screen as working draft Word documents to capture updates and comments during the working session. These will be posted on the wiki Use Case page: http://wiki.siframework.org/electronic+Long-Term+Services+and+Supports+%28eLTSS%29+Use+Case

Next Steps and Homework DRAFT: Not for distribution

Next Steps HOMEWORK – Due by COB Tuesday, March 17th: NEXT WEEK: Review Use Case Scope section Utilize Comment Form at http://wiki.siframework.org/electronic+Long-Term+Services+and+Supports+%28eLTSS%29+Use+Case Email feedback / comments to becky.angeles@esacinc.com or evelyn.gallego@siframework.org NEXT WEEK: Assumptions Pre Conditions Post Conditions Concert Series Presentation: CORHIO Join the eLTSS Initiative: http://wiki.siframework.org/eLTSS+Join+the+Initiative Only Committed Members can vote on artifacts

Maryland’s LTSS System March 12, 2015

Medicaid’s Rebalancing Vision Improving access to home and community-based services (HCBS) Eliminate barriers to receiving HCBS Improve collaboration between agencies Enhance person-centered focus Shift focus from institutional settings to HCBS Shift spending Increase self-direction options Take advantage of opportunities presented by the Affordable Care Act

Balancing Incentive Program (BIP) Offers an enhanced federal medical assistance percentage (FMAP) for all HCBS covered during the “balancing incentive period” through September 30, 2015 Maryland awarded a projected $106 million All enhanced federal payments must be used to fund new and expanded Medicaid community-based LTSS States must initiate the following “structural changes” to their LTSS systems: No Wrong Door / Single Entry Point system for LTSS Implement a Core Standardized Assessment Instrument Ensure Conflict-Free Case Management By the end of the BIP period states must: Increase HCBS to 50% of total Medicaid LTSS spending Implement required structural changes

No Wrong Door / Single Entry Point Maryland Access Point (MAP) Sites MAP initiative led by Maryland Department of Aging (MDoA) Formalized partnerships between Area Agencies on Aging (AAA), Centers for Independent Living (CILs), Local Health Departments (LHDs), Core Service Agencies and Departments of Social Services MAP sites will conduct the interRAI-MDScreen and use LTSSMaryland, a statewide, person-centered tracking system for HCBS BIP/MFP Expansion of MAP sites 1-800 number and website expansion Collaboration with other resource websites (substance abuse and mental health) Working with 211 to ensure coordination of calls and shared resources Increased funding and partnerships

BIP BIP Assessment Requirements Data captured Statewide for all populations seeking community LTSS Includes a Level I screen/Level II assessment process across populations Level I screen is available for completion in person or over the phone Level II assessment is completed in person by a qualified professional Used to determine eligibility, identify support needs, and inform service planning

Core Standard Assessment: interRAI Non-profit organization Full membership meets every 10-12 months Key interests: Science (e.g., cross-national comparisons) Instrument development Support implementation in other nations Holds copyright to assessment instruments Grants royalty-free licenses to governments and care providers License software vendors around the world www.interrai.org

Why are interRAI assessments different? Developed by international panel of experts on geriatrics, gerontology, assessment, and health services research Carefully tested psychometric properties Compatible systems across health care sectors Cover all relevant domains Individuals’ strengths and weaknesses Include items on caregivers, environment Tradeoff of breadth and length Not only self-report Use all possible sources of information Include full definitions, time delimiters, examples, exclusions Training manuals

interRAI interRAI-MDScreen – Screening tool during initial contact Completed in person or over the phone by Maryland Access Point staff Used to identify risk of institutionalization and need for services Participants will be prioritized by risk/need and date to ensure services get to the person as soon as possible interRAI-Home Care (HC) – Assessment tool for services Completed in person by a qualified professional Used to determine eligibility, identify support needs, and inform service planning Consistent data captured statewide allows for tracking service provision, quality and outcomes

interRAI (continued) The interRAI-Home Care (HC) assessment Clinical Assessment Protocols (CAPs) Pre-populated on the Plan of Service (from most recent assessment) Each CAP can be used to help interpret information collected through interRAI Flexible Budget Equitable allocation of services based on Activities of Daily Living (ADL) & Instrumental Activities of Daily Living (IADL) needs

interRAI-HC Sections Section A: Identification Information Section N: Treatment and Procedures Section B: Intake and Initial History Section O: Responsibility Section C: Cognition Section P: Social Supports Section D: Communication and Vision Section Q: Environmental Assessment Section E: Mood and Behavior Section R: Discharge Potential and Overall Status Section F: Psychosocial Well-Being Section G: Functional Status Section S: Discharge Section H: Continence Section T: Assessment Information Section I: Disease Diagnosis Section J: Health Conditions Section K: Oral and Nutritional Status Section L: Skin Conditions Section M: Medications

LTSS Populations Community Options (CO) Waiver Increased Community Service (ICS) Community First Choice (CFC) Medical Assistance Personal Care (MAPC) Brain Injury (BI) Waiver Coming soon: Medical Day Care & DDA

Plans of Service (POS) Target participants in need of support of activities of daily living Certain requirements apply to each program, however, each use the same Plan of Service (POS) to outline services The POS should capture all services that will be provided to the participant (under these programs or through other Medicaid or non-Medicaid programs)

Resource Utilization Group (RUG) Prior to Plan of Service Generates RUG score Score used to assign a recommended flexible budget interRAI-HC uses statistically validated algorithms to assign clients to 1 of 23 RUGs DHMH has assigned each RUG to 1 of 7 groups (and has developed budget for each group based on a scale of needs)

Personal Assistance Services Offered under the CFC and MAPC programs CO waiver and ICS participants are eligible for CFC personal assistance services if they are not residing in an assisted living facility

In-Home Supports Assurance System (ISAS) Both independent and agency personal assistance providers must be enrolled An automated time-keeping system that tracks clock-in and clock-out time of providers

Substitutes for Human Assistance Home-delivered meals Environmental assessments Environmental adaptations Technology

Client Eligibility Enrollments in waiver programs are indicated in the client profile in the ‘Eligibility’ section of the LTSSMaryland system Data under the Special Program Code section indicates current or prior enrollment in a waiver program, hospice, or REM Supports planners should review the eligibility to determine if other programs are available and work with the participant and any other case manager/service coordinator assigned

Activities of Daily Living (ADLs) Bathing/completing personal hygiene routines Dressing/changing clothes Eating Mobility, including: Transferring from a bed, chair, or other structure Moving, turning, and positioning the body while in bed or in a wheelchair Moving about indoors or outdoors Toileting, including: Bladder /bowel requirements Routines associated with the achievement of maintenance of continence Incontinence care

Instrumental Activities of Daily Living (IADLs) Preparing meals Performing light chores that are incidental to the personal assistance services provided to the participant Shopping for groceries Nutritional planning Traveling as needed Managing finances/handling money Using the telephone of other appropriate means of communication Reading Planning and making decisions

The Nine Sections in LTSS 1. Overview Information 2. Strengths 3. Goals 4. Risks 5. Self-Direction 6. Emergency Backup Plans 7. Services 8. Signatures 9. Review

Lessons Learned Many changes at once (merger of waiver programs and a new system) Individuals buying into the assessment tool and tracking system Appropriate individuals for requirements gathering Nurse monitoring frequency (modifying) LHDs (functions) ISAS Soft-lives and Hard-lives Compliance Exceptions processing

Maryland Current State (TEFT) Live, working LTSS/ISAS system Environmental scan, analysis, and selection of PHR solution Continued stakeholder engagement Continued participation in e-LTSS all-hands initiative to develop a charter and standard that aligns with ONC’s S&I Framework Goal: identify, evaluate, and harmonize standards without taking away from our current system

Maryland Future State (TEFT) Environmental scan of PHR capabilities and solutions includes: PHR and Patient Engagement Technology assessment Ongoing stakeholder engagement Assessing the current and future state of MD’s LTSS system Assessing MD’s ecosystem Discussion of feasibility/capability with statewide and regional HIEs Goal: PHR solution integrated with our LTSS/ISAS system and the HIE Utilize and potentially enhance current system

Kale Sweeney (kale.sweeney@maryland.gov) Questions? Kale Sweeney (kale.sweeney@maryland.gov)

eLTSS Initiative: Project Team Leads ONC Leads Elizabeth Palena-Hall (elizabeth.palenahall@hhs.gov) Patricia Greim (Patricia.Greim@hhs.gov) CMS Lead Kerry Lida (Kerry.Lida@cms.hhs.gov) Federal Lead Jennie Harvell (jennie.harvell@hhs.gov) Initiative Coordinator Evelyn Gallego-Haag (evelyn.gallego@siframework.org) Project Management & Pilots Lead Lynette Elliott (lynette.elliott@esacinc.com) Use Case & Functional Requirements Development Becky Angeles (becky.angeles@esacinc.com) Standards Development Support Angelique Cortez (angelique.j.cortez@accenture.com) Harmonization Atanu Sen (atanu.sen@accenture.com)

Background Slides DRAFT: Not for distribution

Use Case Outline Tailored for each Initiative 1.0 Preface and Introduction** 2.0 Initiative Overview 2.1 Initiative Challenge Statement** 3.0 Use Case Scope 3.1 Background** 3.2 In Scope 3.3 Out of Scope 3.4 Communities of Interest** 4.0 Value Statement** 5.0 Use Case Assumptions 6.0 Pre-Conditions 7.0 Post Conditions 8.0 Actors and Roles 9.0 Use Case Diagram 10.0 Scenario: Generic Provider Workflow 10.1 User Story 1, 2, x, … 10.2 Activity Diagram 10.2.1 Base Flow 10.2.2 Alternate Flow 10.3 Functional Requirements 10.3.1 Information Interchange Requirements 10.3.2 System Requirements 10.4 Sequence Diagram 11.0 Risks, Issues and Obstacles 12.0 Dataset Requirements Appendices Related Use Cases Previous Work Efforts References ** Leverage content from Project Charter

eLTSS Plan User Story Need We need your help: Draft 3 – 4 User Stories based on the list of most used services Assisted Living Personal Care Adult Day Services Case Management Transportation Medication Management Meal/Food Delivery Care / Support for Family / Friends Volunteers: Nancy/Mary: Payer perspective - habilitation Caroline: Beneficiary perspective with sharing to payer/provider David: Focus on elderly and support for the family (include healthcare provider) Kelly: Provider perspective on Medication Management Andrey: sharing of data between waiver system, IT systems, health technology Rachel: Beneficiary perspective