electronic Long-Term Services & Supports (eLTSS) Initiative All-Hands Workgroup Meeting April 23,

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 o Hold = Elevator Music = frustrated speakers and participants This meeting is being recorded o 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. o Send comments to All Panelists so they can be addressed publically in the chat, or discussed in the meeting (as appropriate). o 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 2

3 Agenda TopicPresenterTimeframe Welcome Announcements eLTSS Roadmap Lynette Elliott10 mins Use Case Working Session: User Story: Base Flow Activity Diagram Sequence Diagram Functional Requirements Becky Angeles Sweta Ladwa eLTSS Community 45 mins Homework / Next StepsBecky Angeles5 mins Concert Series Presentation: Care At HandDr. Andrey Ostrovsky Dr. Lori O’Connor 30 mins

Announcements HHS, CMS and ONC announced the release of the following on March 20, 2015: – Stage 3 Notice of Proposed Rulemaking (NPRM) for the Medicare and Medicaid Electronic Health Records (EHRs) Incentive Program Stage 3 Notice of Proposed Rulemaking (NPRM) for the Medicare and Medicaid Electronic Health Records (EHRs) Incentive Program specifies new criteria that EPs, EHs, and CAHs must meet to qualify for Medicaid EHR incentive payments proposes criteria that providers must meet to avoid Medicare payment adjustments based on program performance beginning in payment year 2018 – 2015 Edition Health IT Certification Criteria 2015 Edition Health IT Certification Criteria aligns with the path toward interoperability identified in ONC's draft shared Nationwide Interoperability Roadmap builds on past editions of adopted health IT certification criteria, includes new/updated IT functionality and provisions that support the EHR Incentive Programs care improvement, cost reduction, and patient safety across the health system – Comment period ends May 29,

Announcements (continued) PUBLIC COMMENTS: You may submit comments, identified by RIN 0991-AB93, by any of the following methods (please do not submit duplicate comments). Because of staff and resource limitations, we cannot accept comments by facsimile (FAX) transmission. Federal eRulemaking Portal: Follow the instructions for submitting comments. Attachments should be in Microsoft Word, Microsoft Excel, or Adobe PDF; however, we prefer Microsoft Word. Regular, Express, or Overnight Mail: Department of Health and Human Services, Office of the National Coordinator for Health Information Technology, Attention: 2015 Edition Health IT Certification Criteria Proposed Rule, Hubert H. Humphrey Building, Suite 729D, 200 Independence Ave, S.W., Washington, D.C Please submit one original and two copies. Hand Delivery or Courier: Office of the National Coordinator for Health Information Technology, Attention: 2015 Edition Health IT Certification Criteria Proposed Rule, Hubert H. Humphrey Building, Suite 729D, 200 Independence Ave, S.W., Washington, D.C Please submit one original and two copies. (Because access to the interior of the Hubert H. Humphrey Building is not readily available to persons without federal government identification, commenters are encouraged to leave their comments in the mail drop slots located in the main lobby of the building.) 5

Announcements (continued) 2015 Long Term Post Acute Care (LTPAC) & HIT Summit – What: The LTPAC HIT Summit is the premiere health IT conference for individuals within and working with the LTPAC industry for over 10 years. As the key conference of HIT leaders, policy makers, providers, vendors and professionals, the Summit continues to advance initiatives facing the long term, post acute care industry and priorities from the latest Roadmap for Health IT in LTPAC. – When: June 21-23, 8am-5pm ET – Where: Baltimore, MD in the Baltimore Hilton – To register: 6

Concert Series Presentations 7 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?

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: 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 ) and Lynette Elliott A pre-planning meeting will be scheduled prior to any public demonstration 8

Upcoming Concert Series Presentations 9 April 30 th : State of Colorado May 7 th : Inofile / Kno2 May 14 th : State of Minnesota May 21 st : Harmony Information Systems May 28 th : (available)

Timelines for Consideration: Two Pilot Phases, SDO Ballot Cycles eLTSS Initiative Roadmap Q3 ‘14Q4 ‘14Q1 ‘15Q2 ‘15Q3 ‘15Q4 ‘15Q4 ‘17 Phase 4: Pilots & Testing Pilot site readiness Implementation of solution Test User Stories and Scenarios Monitor Progress & Outcomes Utilize Requirements Traceability Matrix Phase 5: Evaluation Evaluate outcomes against Success Metrics and Criteria Update Implementation Guidance Develop, review, and finalize the Use Case and Functional Requirements Pre-Planning Call for Participation Conduct Environmental Scan Success Criteria Stakeholder Engagement Finalize Candidate Standards Standards Gap Analysis Technical & Standards Design Develop Requirements Traceability Matrix Develop Implementation Guide Launch initiative Review and Finalize Charter Review initial Candidate Standards 10 Initiative Kick Off: 11/06/14 Phase 1: Pre-Discovery Phase 2: Use Case Development & Functional Requirements Phase 3: Standards & Harmonization

Scope 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. 11

Project Charter and eLTSS Glossary FINAL Published Project Charter located here: Term+Services+and+Supports+%28eLTSS%29+Charter Term+Services+and+Supports+%28eLTSS%29+Charter eLTSS Glossary posted here: – 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 12

Wk. Target Date (2015) All Hands WG Meeting Tasks Review & Comments from Community via Wiki page due following Tuesday by 8 P.M. Eastern 1-51/22-2/19 Use Case Kick-Off & UC Process Overview Use Case Value Framing Discussions Review and Answer Value Framing Questions on wiki 62/26 Review: Consolidated UC Value Framing Introduce: Context Diagram & User Stories Review: Context Diagram & User Stories 73/12Finalize: Context Diagram & User StoriesReview: User Stories 83/19Review: User Stories CommentsReview: User Stories, Glossary 93/26 Review: User Stories Introduce: Actors & Roles Review: User Stories, Actors & Roles 104/2 Finalize: Actors & Roles Introduce: In/Out of Scope Review: In/Out of Scope 114/9 Finalize: In/Out of Scope Introduce: Assumptions & Pre/Post Conditions Review: Assumptions & Pre/Post Conditions 124/16 Finalize: Scope, Assumptions & Pre/Post Conditions Introduce: Activity Diagram & Base Flow Review: Activity Diagram & Base Flow 134/23 Finalize: Activity Diagram & Base Flow Introduce: Functional Requirements & Sequence Diagram Review: Functional Requirements & Sequence Diagram 144/30 Finalize: Functional Requirements & Sequence Diagram Introduce: Data Requirements Review: Data Requirements 155/7Review: Data Requirements 165/14 Finalize: Finalize Data Requirements Introduce: Risks & Issues Review: Risks & Issues 175/21 Finalize: Risks and Issues Begin End-to-End Review End-to-End Review by community 185/28End-to-End Comments Review & dispositionEnd-to-End Review ends 196/4Finalize End-to-End Review Comments & Begin ConsensusBegin casting consensus vote 206/11Consensus Vote*Conclude consensus voting Proposed Use Case Development Timeline 13

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: Term+Services+and+Supports+%28eLTSS%29+Use+Case Term+Services+and+Supports+%28eLTSS%29+Use+Case – Or Becky Angeles directly at with edits, comments or Discussions moving forward will be more technically (systems information and functionality, data sets/data elements, etc.). We encourage tech savvy individuals and teams to participate and provide input. 14

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Next Steps HOMEWORK – Due by COB Tuesday, April 28th: –Review Use Case Content posted on the eLTSS Use Case –Utilize Comment Form at Term+Services+and+Supports+%28eLTSS%29+Use+Casehttp://wiki.siframework.org/electronic+Long- Term+Services+and+Supports+%28eLTSS%29+Use+Case – feedback / comments to or NEXT WEEK: –Functional Requirements and Sequence Diagrams –Dataset Requirements Join the eLTSS Initiative: –Included on the eLTSS distribution list –Committed Members can vote on artifacts 16

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Andrey Ostrovsky, MD CEO | Co-Founder | Care at Hand Lori O’Connor, RN Director of Nursing | Elder Services of Merrimack Valley Using Quality Improvement to Experiment with Interoperability

> 50% of Medicare spending will be value-based by 2018

AHA. Issue Brief. Moving Toward Bundled Payment

Before Care at Hand – communication breakdowns between nurse and nonclinical coach Non-clinical coach Nurse Care Coordinator Primary Care Provider Visit Emergency Dept/ Admission Home Visit by Nurse Care coordination 21 We were missing opportunities to detect decline without nurse oversight

Non-clinical coach Nurse Care Coordinator Primary Care Provider Visit Emergency Dept/ Admission Home Visit by Nurse Care coordination Alerts triggered by Care at Hand technology 22 Digitizing the “hunch” of non-clinical workers to detect early decline

23 Same community Same education level Same language Same cultural background Care Coordination Med rec Red flags education f/u appointments Health CoachNurse Care Coordinator For 800 patients per month, need 20 health coaches ($30k/yr) + 1 nurse* Care management Communication with physicians Triage Sick vs Not Sick Education of coach AHRQ. Service Delivery Innovation: Community-Based Health Coaches and Care Coordinators Reduce Readmissions Using Information Technology To Identify and Support At-Risk Medicare Patients After Discharge. Rockville, MD

© Care at Hand - Confidential Over the past month, has the client had more difficulty paying for their food than most other months? Does the client have a fever or feel more warm today compared to most other days? Did the client sleep on more pillows last night than most other nights? Smart surveys predict hospitalizations using observations of non-clinical workers US Patent Serial No. 61/936459

25 Non-clinical workers reduce costs, improve outcomes AHRQ. Service Delivery Innovation: Community-Based Health Coaches and Care Coordinators Reduce Readmissions Using Information Technology To Identify and Support At-Risk Medicare Patients After Discharge. Rockville, MD Estimated Net Savings $2.57 net savings for every $1 invested $109 savings per member per month 39.6% 30 day readmissions

26 Interoperability PDSA: Information sent to CBO upon d/c from hospital

27 Interoperability took a back seat to…..snow!

PDSA 1

PDSA 2

Back to interoperability…PDSA 3: Access to community data Plan: (Hypothesis) Providing hospital access to CBO real-time data would enable hospital care management to be more comfortable sending patients to community rather than institutional care Do: Provide hospital care management staff access to CBO dashboards through Care at Hand. Study: …

Discharge location unchanged prior to providing dashboard access +12% -19% +10% Percent of all discharges from hospital PDSA 1 PDSA 2

Decreased SNF, increased home after access to dashboards +12% -19% +10% Percent of all discharges from hospital PDS A 1 PDS A 2 PDS A 3

Timely completion of decision support assigned tasks improved after education PDSA

Individual staff contribution to outcomes enables real-time targeted promotion and capacity building, decreasing turnover

Prevented ED visits used to calculate ROI of transition program, daily rather than quarterly

Granular hotspotting of highest utilizing and highest projected risk patients

37 2 MCO contracts 4 hospital contracts 1 bundled payment contract Expanding to chronic disease self management Next steps… Success with hospitals/MCOs made them want more…

Current PDSA: Determining which individual parts of a care plan to be shared bidirectionally rather than single direction glorified PDFs (cCDA)

Non-clinical coach Nurse Care Coordinator Primary Care Provider Visit Emergency Dept/ Admission Home Visit by Nurse Care coordination Current PDSA: Pre-admission ED diversion alerts 39

Time to first visit continues to improve PDSA 1 PDSA 2 PDSA 3

Thank you! Andrey Ostrovsky, MD CEO | Co-Founder | Care at Hand Lori O’Connor, RN Director of Nursing | Elder Services of Merrimack Valley

eLTSS Initiative: Project Team Leads ONC Leads – Elizabeth Palena-Hall – Patricia Greim CMS Lead – Kerry Lida Federal Lead – Jennie Harvell Community Leads – Andrey Ostrovsky – Nancy Thaler – Terry O’Malley Initiative Coordinator – Evelyn Gallego-Haag Project Management & Pilots Lead – Lynette Elliott Use Case & Functional Requirements Development – Becky Angeles Standards Development Support – Angelique Cortez Harmonization – Atanu Sen 42

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Scope Further defines the scope of the Use Case itself and NOT the scope of the Initiative Diagrams and other supplemental data / examples help provide context and clarify the basis for the Use Case 44

Scope Subsections Background – describes the relevance of the Use Case in relation to what gaps currently exist within the healthcare industry. Includes all policy and/or regulatory issues/dependencies that may impact the Use Case In Scope – indicates what is in scope for the Use Case. For example, the type of transactions, the information/data to be exchanged, and specific aspects that need to be in place to enable the information to be sent, received and understood the same at both ends of the transmission. Out of Scope – indicates what is out of scope for the Use Case. These points may highlight dependencies on the feasibility, implementability, and usability that result in limitations of the Use Case. At a high level, whatever is not declared “In Scope” is by definition, “Out of Scope”. – Note: Items that are out of scope for the Use Case, Functional Requirements and Standards Harmonization activities can be still be part of a Pilot. Communities of Interest 45

Assumptions Outlines what needs to be in place to meet or realize the requirements of the Use Case (i.e. the necessary privacy and security framework) Functional in nature and state the broad overarching concepts related to the Initiative Serve as a starting point for subsequent harmonization activities 46

Pre-Conditions Conditions that must exist for the implementation of the eLTSS Plan creation and sharing Describe the state of the system, from a technical perspective, that must be true before an operation, process, activity or task can be executed Lists what needs to be in place before executing the information exchange as described by the Functional Requirements and Dataset requirements 47

Post-Conditions Describe the state of the system, from a technical perspective, that will result after the execution of the operation, process activity or task 48

Activity Diagram An Activity Diagram is a action state transition diagram – An action state represents the fulfillment of associated responsibilities in response to the communication received from the previous step – Most transitions are triggered by completion of activities in the source states The Activity Diagram illustrates the Use Case flows events and information between the actors Displays the main events/actions that are required for the data sharing and the role of each system in supporting the sharing 49

Base Flow The Base Flow is the step by step process of the information sharing depicted in the activity diagram Indicates the actor who performs the action, the description of the event/action, and the associated inputs (records/data required to undertake the action) and outputs (records/data produced by actions taken) 50

Sequence Diagram Shows the interactions between objects in the sequential order that they occur Communicates how the sharing works by displaying how the different components interact Transition from requirements expressed as use cases to the next and more formal level of refinement 51

Information Interchange Requirements Define the system’s name and role Specify the actions associated with the actual sharing of information from the sending system to the receiving system 52

System Requirements Lists the requirements internal to the system necessary to participate successfully in the sharing of information May detail a required workflow that is essential to the use case 53