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

2. 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

3. Full Disclosure?

4. 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.

5. 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)

6. 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:

7. 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

8. 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)

9. Timeline Milestone Target Date Responsible Party
What is your proposed timeline
Guidance: ~6 months minimum / ~1 year maximum
Evaluation: 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

10. 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

11. 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

12. 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:

13. Risks & Challenges
Identify any risks or challenges

14. 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).

15. Useful Links
eLTSS Wiki Main Page:
eLTSS Use Case:
Pilots Wiki Page: