Longitudinal Coordination of Care Longitudinal Care Plan Sub Workgroup

Agenda Welcome LCC Introduction The LCC Challenge LCC Structure and Work-to-date Work Streams Timeline – High-level Use Case Scope White Paper

Introductions and Welcome Round-robin introductions Overall LCC F2F Agenda Time Agenda Topic Room Thursday 8:00 am – 10:00 am LCC Status and Introduction Edison E 10:30 am – 12:00 pm LTPAC Working Session 1:30 pm – 3:30 pm PAS Working Session 4:00 pm – 6:00 pm LCP Working Session Friday Use Case Working Session 10:30 am – 12:00 pm Use Case Working Session and Recap F2F Progress/ Next Steps

LCC Overview Longitudinal Coordination of Care Workgroup* Providing subject matter expertise and coordination of SWGs Developing systems view to identify interoperability gaps and prioritize activities Longitudinal Coordination of Care Workgroup* Longitudinal Care Plan Sub-Workgroup LTPAC Care Transition Sub-Workgroup Patient Assessment Summary Sub-Workgroup Near-Term: Developing an implementation guide to standardize the exchange of Form CMS-485 (Home Health Certification and Plan of Care) Long-Term: Identify and develop a longitudinal care plan spanning multiple care settings Identifying the key business and technical challenges that inhibit long-term care data exchanges Defining data elements for long-term and post-acute care (LTPAC) information exchange and using a single standard for LTPAC transfer summaries Establishing the standards for the exchange of patient assessment summary documents Inform the development of the Keystone Beacon Patient Assessment Summary Document Exchange. Inform HL7 balloting of LTPAC-specific enhancements to the C-CDA * 75 interested parties, including 28 active, committed members

Observations on progress to date Excellent progress: Keystone Feedback on PAS CCD RTI Data feedback Input on CMS HL7 Balloting Use Case – Gap Analysis, Scoping and Functional/ Data Requirements Complexity Broad view of trading partner community Many types of transitions and roles of receivers Focus Challenges External Drivers Multiple Demands Coordination Challenges Separate SWGs Lack of cohesive overall plan

Related Work Streams S&I Process - Use Case/ Requirements to Advance interoperability for the LTPAC community. Building on the ToC Initiative work and ToC V1.1 Use Case as a foundation for LCC S&I process (Use Case, Harmonization, IG) provides actionable implementation path for the LTPAC community LLC WG would like implementable specifications to support pilots before the end of 2012 Influence and impact ongoing policy discussions LCC WG has a strong set of LTPAC interoperability policy stakeholders at the table White paper would allow for the articulation of a vision and objectives that would be in a format that is familiar to policy-makers. Support specific WG objectives Continue to use LCC WG as the working forum to support the Challenge, Beacon and VNSNY project objectives Project-specific deliverables based on Challenge, Beacon and other requirements Serve as a platform for responding to important and related standards activities Care/ CMS collaboration with HL7 and S&I LCC WG Standardization of Content for Functional Status, Cognitive Status and Pressure Ulcer work (C-CDA structure review, Data Elements Review) Impacting a variety of Assessment Instruments (MDS, OASIS, CARE, etc…) All LCC SWGs as well as the LTPAC community at large, looks to leverage the standards work emerging from this collaboration Analysis-supporting deliverables

White Paper Detailed articulation of environment Detailed articulation of current efforts Vision for Longitudinal Coordination of Care - Roadmap Extend Baseline to other care settings Extend interoperability interchanges and system functions to more sophisticated care processes, e.g. CDS Articulate how S&I first LCC Use Case (HHA) supports overall vision and roadmap for incrementally building trading-partner specific Use Cases Standards-improvement roadmap NPRM response and implications Use White Paper to manage any unanticipated complexity What else??

Use Case Content Guidance Requirements document for use by business/ clinical analysts to hand-off to technical implementers Document designed for business and technical implementers (not policy makers) Get the best possible coverage of likely overall data elements with the least number of specifically defined transactions Use Baseline Use Case to replicate for other care settings, e.g., IRF, BH, and to add scenarios and more sophisticated process transactions and content

View of LTPAC Flow ACH to HHA/SNF Admission to HHA/SNF HHA/SNF Episode of Care Change in Condition Order for Skilled Care (HHA/SNF) Initial Assessment (Nsg, etc) OASIS MDS Order for referral to Acute Care ToC Data HHA- CMS 485 SNF- Start of Care Orders Comprehensive Plan of Care Scenario 1: Transitions of Care and Referral Representative Transitions Acute Care to LTPAC (as represented by HHA) #5: Initial PoC from HHA to Physician, Physician to HHA Ongoing PoC from HHA to Physician, Physician to HHA Recertification PoC from HHA to Physician , Physician to HHA Populate OASIS LTPAC (as represented by SNF/ NF reusing MDS and INTERACT) to ED #4 ED to LTPAC (as represented by SNF/ NF and populating MDS) #3 Scenario 2 –Patient Communications: Copy all ToC and PoC transactions to patient/care giver PHR Referral to specialist SNF- Initial Plan of Care PAS

Strawman Proposal for Use Case An evidence-based approach to supporting LTPAC needs

MA DPH Universal Transfer Form 4/22/2017 MA DPH Universal Transfer Form Started with DPH’s 3-pg Discharge Form Sought input from LTPAC “receivers” Reviewed existing forms and datasets: MDS OASIS IRF-PAI INTERACT Sought expert opinions Resulted in 7-page UTF

Massachusetts Paper UTF Pilot 4/22/2017 Massachusetts Paper UTF Pilot Too Long! Already done. Found to be too long. Need to define subsets for various transitions

UTF Data Element Survey 46 Organizations completing evaluation ~300 Data elements evaluated 1135 Transition surveys completed

11 Types of Organizations

4/22/2017 12 User Roles

Findings from UTF Survey Largest survey of Receivers’ needs Identified for each transitions which data elements are required, optional, or not needed Each of the 300+ data elements is valuable to at least one type of Receiver Many data elements are not valuable in certain care transition Paper form can’t represent these needs

11x11 Sender (left column) to Receiver (top) Sender-Receiver grid. 11x11. The sites across the top are the same as those down the left hand column. The result is a 121 cell grid. It includes the traditional PAC sites: LTACs, IRFs, SNFs, HHA, Hospice. And some “non-traditional” PAC sites including the PCP in the office, Community Based Service providers, the ASAPs, and most importantly, the Patient and Family at home. At the other end of the grid are three Acute Care Hospital sites that send the most patients to PAC and receive the most patients from PAC sites: the in-patient unit, ED and outpatient testing and treatment areas. The grid could have easily been enlarged to include outpatient therapy, pharmacists, ALFs, foster homes, and many other sites. We proceeded on the assumption that data sets identified for these high volume transitions would likely include the information required by the lower volume transitiions. Every site is both a “sender” and a “receiver” The next task was to prioritize among these 121 possible transitions. For this we applied three parameters, each ranked high, medium and low. The first was volume. The second, the clinical instability of the patient. And the third, the time-value or “Acuity” of the information. How quickly did the receiver need the information. These are clinical parameters. We could have gotten a different result using cost data. Applying these parameters results in my favorite grid where red is high, yellow medium and blue low. The transitions on this grid, then look like this. NEXT 17

Black circles = highest priority Green circles = high priority Prioritize Transitions by Volume, Clinical Instability and Time-Value of Information Cells with three “red” (=high) scores are highest priority. Those with two “high” scores are next. (Medium is “yellow” and “low” is blue). Using this approach, there are 16 highest priority transitions and 33 high priority transitions out of 121. The black and grey cells are very rare and not scored. I don’t expect to be able to read this grid but there are three priority areas: on the left are the transfers FROM PAC to the ACH, across the top are transitions FROM the ACH to PAC sites, and in the middle are transitions among PAC sites. Pulling the colors out gives the following grid with black as highest and green as next highest transitions. NEXT Black circles = highest priority Green circles = high priority 18

Prioritize Transitions by Volume, Clinical Instability and Time-Value of Information 49 Documents Is Too Many! Here are the priority transitions based on the criteria in the title. The individual scoring of each cell has been removed leaving only the “circle”. The next grid indicates the essential receiver “roll-groups” Black circles = highest priority Green circles = high priority 19

5 High-priority Transition Datasets Report from Outpatient testing, treatment, or procedure Referral to Outpatient testing, treatment, or procedure Shared Care Encounter Summary (Office Visit, Consultation Summary, Return from the ED to the referring facility) Consultation Request Clinical Summary (Referral to a consultant or the ED) Permanent or long-term transfer to a different facility or care team or Home Health Agency

5 High-priority Transition Datasets 4 2 3 1 Here are the priority transitions based on the criteria in the title. The individual scoring of each cell has been removed leaving only the “circle”. The next grid indicates the essential receiver “roll-groups”

5 High-priority Transition Datasets Type 3 Dataset: Office Visit to PHR Consultant to PCP ED to PCP, SNF, etc… 5 – Transfer of Care Summary 4 – Consultation Request Clinical Summary 3 – Shared Care Encounter Summary 2 – Test/Procedure Request 1 – Test/Procedure Report Type 4 Dataset: PCP to Consultant PCP, SNF, etc… to ED Type 5 Dataset: Hospital to SNF, PCP, HHA, etc… Hospital, SNF, etc… to HHA PCP to new PCP

Relationship to Other Transfer Forms Type 3 Dataset: Office Visit to PHR Consultant to PCP ED to PCP, SNF, etc… 5 – Transfer of Care Summary INTERACT 4 – Consultation Request Clinical Summary MA Universal Transfer Form 3 – Shared Care Encounter Summary 2 – Test/Procedure Request 1 – Test/Procedure Report Type 4 Dataset: PCP to Consultant PCP, SNF, etc… to ED Type 5 Dataset: Hospital to SNF, PCP, HHA, etc… Hospital, SNF, etc… to HHA PCP to new PCP

Relationship to Assessment Tools Continuity Assessment Record and Evaluation (CARE) Tool Minimum Data Set (MDS) OASIS IRF-PAI

Relationship to Plan of Care 5 – Transfer of Care Summary 4 – Consultation Request Clinical Summary 3 – Shared Care Encounter Summary Plan of Care 2 – Test/Procedure Request 1 – Test/Procedure Report

Relationship to Patient Instructions 5 – Transfer of Care Summary 4 – Consultation Request Clinical Summary 3 – Shared Care Encounter Summary Plan of Care 2 – Test/Procedure Request 1 – Test/Procedure Report Patient Instructions

Situation-specific Data Elements 5 – Transfer of Care Summary 5 – Transfer of Care Summary 4 – Consultation Request Clinical Summary Variable Base on Situations: Setting Diagnoses Medications Treatments Procedures 3 – Shared Care Encounter Summary Plan of Care 5 – Transfer of Care Summary 2 – Test/Procedure Request 1 – Test/Procedure Report Patient Instructions 5 – Transfer of Care Summary 5 – Transfer of Care Summary 5 – Transfer of Care Summary

Optionality of Data Elements 5 – Transfer of Care Summary 5 – Transfer of Care Summary 4 – Consultation Request Clinical Summary Optionality within each dataset: Shall Should May 3 – Shared Care Encounter Summary Plan of Care 5 – Transfer of Care Summary 2 – Test/Procedure Request 1 – Test/Procedure Report Patient Instructions 5 – Transfer of Care Summary 5 – Transfer of Care Summary 5 – Transfer of Care Summary

Plan of Care Permeates Datasets 5 – Transfer of Care Summary 4 – Consultation Request Clinical Summary 3 – Shared Care Encounter Summary Plan of Care 2 – Test/Procedure Request 1 – Test/Procedure Report Patient Instructions

Hospital Discharge Instructions is a subset of #5 Sometimes Subsets are Used Hospital Discharge Instructions is a subset of #5 5 – Transfer of Care Summary 4 – Consultation Request Clinical Summary Discharge Instructions 3 – Shared Care Encounter Summary Plan of Care 2 – Test/Procedure Request 1 – Test/Procedure Report Patient Instructions

CMS-485 is a subset of #5 CMS- 485 Sometimes Subsets are Used 5 – Transfer of Care Summary CMS-485 is a subset of #5 4 – Consultation Request Clinical Summary CMS- 485 3 – Shared Care Encounter Summary Plan of Care 2 – Test/Procedure Request 1 – Test/Procedure Report

Timing of Producing Datasets Transition of Care Workgroup recognized that the Patient Instructions may be generated independently and given to the patient prior to the full transition dataset. 5 – Transfer of Care Summary 4 – Consultation Request Clinical Summary Discharge Instructions 3 – Shared Care Encounter Summary Plan of Care 2 – Test/Procedure Request 1 – Test/Procedure Report Patient Instructions Sending a patient to the ED starts with #4, but upon admission, #5 should be sent

Original S&I ToC Use Case Scenario 1 - Provider to provider: User Story 1 - Hospital/ED to PCP Discharge Instructions Discharge Summary User Story 2 - Closed Loop Referral Consult Request Consult Summary Scenario 2 - Provider to patient: User Story 1 - Discharge Instructions and Discharge Summary to patient’s PHR User Story 2 - Closed Loop Referral where copies of Consult Request and Consult Summary are sent to patient’s PHR

Relationship to S&I ToC Scenarios 5 – Transfer of Care Summary Type 3 Dataset: Scenario 1 & 2/User Story 2 Consult Summary 4 – Consultation Request Clinical Summary 3 – Shared Care Encounter Summary Plan of Care 2 – Test/Procedure Request 1 – Test/Procedure Report Patient Instructions Type 4 Dataset: Scenario 1 & 2/User Story 2 Consult Request Type 5 Dataset: Scenario 1 & 2/User Story 1

CMS- 485 LTPAC “Poster Child” Scenarios Type 3 Dataset: Scenario 1 & 2/User Story 2 Consult Summary ED to SNF 5 – Transfer of Care Summary 5 – Transfer of Care Summary 4 – Consultation Request Clinical Summary CMS- 485 3 – Shared Care Encounter Summary Plan of Care 2 – Test/Procedure Request 1 – Test/Procedure Report Patient Instructions Type 4 Dataset: Scenario 1 & 2/User Story 2 Consult Request SNF to ED Type 5 Dataset: Scenario 1 & 2/User Story 1 Hospital to Home Health Agency HHA  PCP (CMS-485 Subset)

LCC - Timeline for Phase 2 LCC Work Stream 1: Indirect to S&I Process

LCC - Timeline for Phase 2 LCC Work Stream 2: S&I Process

LCC - Timeline for Phase 2 LCC Work Stream 3: Vision/ Policy/ Roadmap

Baseline Transaction and Build Master Longitudinal Care Use Case Future: Full LCP Support Version …: Other trading partners Round out full longitudinal picture Version 4: (IRF, Behavioral Health, CBO, ???) Version 3: (IRF, Behavioral Health, CBO, ???) Building Incrementally Version 2: (IRF, Behavioral Health, CBO, ???) White Paper Roadmap lays out priority order to incrementally add requirements of other trading partners 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. Now: Foundation

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

Baseline Use Case Transactions Scenario 1: Transitions of Care and Referral Representative Transitions Acute Care to LTPAC (as represented by HHA) #5: LTPAC (as represented by SNF/ NF) to ED #4 ED to LTPAC (as represented by SNF/ NF) #3 Scenario 2 –Patient Communications: Copy all ToC and PoC transactions to patient/care giver PHR Scenario 3 – HHA Plan of Care: Initial PoC from HHA to Physician, Physician to HHA Ongoing PoC from HHA to Physician, Physician to HHA Recertification PoC from HHA to Physician , Physician to HHA

Baseline Use Case Transactions Scenario 1: Transitions of Care and Referral Representative Transitions Acute Care to LTPAC (as represented by HHA) #5: Note post-condition populating POC and OASIS LTPAC (as represented by SNF/ NF) to ED #4: Note pre-condition reusing MDS and INTERACT ED to LTPAC (as represented by SNF/ NF) #3: Note post-condition populating MDS Scenario 2 –Patient Communications: Copy all ToC and PoC transactions to patient/care giver PHR Scenario 3 – HHA Plan of Care: Initial & Recertification PoC from HHA to Physician, Physician to HHA Interim Changes to PoC from HHA to Physician, Physician to HHA Requirements for all PoC transactions to consider date stamp/ versioning requirement

PAS SWG Standards and Data Analysis Determine next steps with Harmonization Team

Structuring WG Activities to meet our challenge Do we have the right structure? How might we modify to better fit current and future needs? Re-engaging the LCC WG-level to build out White Paper

Schedule Reminder Time Agenda Topic Room Thursday 8:00 am – 10:00 am LCC Status and Introduction Edison E 10:30 am – 12:00 pm LTPAC Working Session 1:30 pm – 3:30 pm PAS Working Session 4:00 pm – 6:00 pm LCP Working Session Friday Use Case Working Session 10:30 am – 12:00 pm Use Case Working Session and Recap F2F Progress/ Next Steps

Confirm Meeting Actions Confirm objectives for the F2F?