1. LCC Use Case 2.0 Paragraph As the number of Health Concerns increases, the health care of that individual becomes more complex. Often this complexity is manifested by acute and chronic issues that intertwine and create management dilemmas, care in multiple sites by multiple care team members and an increased risk of care plan failure resulting in admissions and readmissions. Each additional problem, team member and site of care increases the complexity of care. Recent Medicare data (2012 Chartbook) showed that of individuals with six or more chronic conditions, two thirds were hospitalized and 16% were hospitalized 3 or more times in 2010. Of the 1.9 million readmissions in 2010, 98% occurred in individuals with two or more chronic conditions, and 14% of Medicare beneficiaries with six or more chronic conditions accounted for 70% of all readmissions. Only 1% of beneficiaries with 0-1 chronic conditions received care in PAC settings (SNF, LTAC, IRF and Home Care), while 41% of those with six or more chronic conditions received PAC care. Nearly half of these individuals had 13 or more PCP office visits in 2010; and 70% had at least one ER visit and 27% had three or more visits. In order to avoid gaps in care, conflicting interventions and duplicate services, these individuals with complex medical, behavioral and functional issues require a care plan that can be shared across sites and teams. This use case examines the requirements for two high volume exchanges: the transfer of a care plan between a Hospital-based Team to a Home Health Agency based team and the individual’s Primary Care Team (PCMH), between the Primary Care Team and the full Community Based Care Team.

2. Assumptions: Although there may be some overlap in the Home Health-Based and Community-Based Teams, these are treated as separate teams 1A and 1B could occur at the same time Discussion: A patient can be discharged from the hospital to home health, primary care, community based, meals on wheels, transportation, etc. Discharge orders and referrals may or may not go from the hospital to the receiving care provider. The only certainty is that it goes to the physician and patient. The community based team members may not even be recognized by the hospital or physician. We will not focus on the technology (Direct, fax, e-fax, etc) for the exchange of information between teams. We will only focus on the information flow, functional requirements, and content. This diagram does not reflect our previous discussion of 2 types of exchanges. 1). medically complex patient (high risk) 2). general patient Open Question: Is there any form of electronic exchange between Hospital and Community-based Non-Medical Team? Need to include a statement in the Background section of the Use Case stating that several of the information exchanges between teams is not / may not be electronic

3. Scenario 1A Exchange of care plan from hospital team to PCP/Primary Care team. The team members listed are a subset of the potential team members.

4. Scenario 1B The exchange of a care plan from the Hospital Team to the Home Health Agency-based Team.

5. Scenario 2 Exchange of a care plan between the Primary Care Team and the Community-based team.

6. Patient Stories Two patient stories, same patient with different degrees of complicating issues.

7. Hospital-Based Care Team Community-based care Medical Team Community-Based Care Non-Medical Team Primary Care Team Home Health Care Team Nursing Home DME provider Hospice Other DME provider Labs Pharmacy Out-patient therapy Meals on Wheels Housing Services Transportation Other Patient 1 1 2 2A A Lines1: Current state. Note: This obfuscates (and thus allows for variation in) the current state of HIE between the hospital and the community based medical team. E.g.: Do hospital exchange info with: only the CB doc? The HHA? The OPT provider? Do CB doc exchange info w/ other members of the CB medical team? Can we for purposes of this UC state that the current state of affairs is diverse and varies. Lines2: Use Case Scenarios

8. Hospital-based Care Team Community-based Care Team (Non-Medical) Patient Community-based Care Team (Medical) Primary Care Team Home Health Care Team Nursing Home DME Provider Hospice Out-Patient Therapy DME Provider Pharmacy Labs Meals on Wheels Housing Services Transportation Other

9. Hospital- based Care Team Community- based Care Team (Non-Medical) Community-based Care Team (Medical) Primary Care Team Home Health Care Team Nursing Home DME Provider Hospice Out-Patient Therapy DME Provider Pharmacy Labs Meals on Wheels Housing Services Transportation Other Primary Care Team Home w/ No Services Home w/ Services Home Health Agency Home w/ Services Other Certifying Physician Patient

10. Priority/Frequency of Exchange of Care Plans

11. Hospital-based Care Team to PCMH only HHA Team PCMH Team Specialist CBO Team

12. Hospital-based Care Team to HHA HHA TeamPCMH TeamSpecialist CBO Team

13. Hospital-based Care Team to PCMH and Specialist HHA Team PCMH TeamSpecialist CBO Team Communication on discharge to PCMH and Specialist Then: PCMH to HHA and CBO Then HHA to CBO