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

2. 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

3. 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

4. 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: 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

5. 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:

6. 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

7. 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
DRAFT: Not for distribution

8. 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

9. 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

10. 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

11. Project Charter and eLTSS Glossary
FINAL Published Project Charter located here:
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
DRAFT: Not for distribution

12. 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

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:
Thank you for providing input for our eLTSS Use Case Framing Questions (via the wiki, live discussions or ).
We have consolidated the responses and posted the document on the eLTSS wiki at:
This document and YOUR responses will be used as input for various sections of the eLTSS Use Case Artifact

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

15. 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

16. 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.

17. 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:

18. Next Steps and Homework
DRAFT: Not for distribution

19. Next Steps HOMEWORK – Due by COB Tuesday, March 17th: NEXT WEEK:
Review Use Case Scope section
Utilize Comment Form at
feedback / comments to or
NEXT WEEK:
Assumptions
Pre Conditions
Post Conditions
Concert Series Presentation: CORHIO
Join the eLTSS Initiative:
Only Committed Members can vote on artifacts

20. Maryland’s LTSS System
March 12, 2015

21. 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

22. 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

23. 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

24. 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

25. Core Standard Assessment: interRAI
Non-profit organization
Full membership meets every 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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)

32. 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)

33. 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

34. 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

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

36. 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

37. 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

38. 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

39. 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

41. 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

42. 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

43. 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

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

45. eLTSS Initiative: Project Team Leads
ONC Leads
Elizabeth Palena-Hall
Patricia Greim
CMS Lead
Kerry Lida
Federal Lead
Jennie Harvell
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

46. Background Slides
DRAFT: Not for distribution

47. 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
Base Flow
Alternate Flow
10.3 Functional Requirements
Information Interchange Requirements
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

48. 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