1. electronic Long-Term Services & Supports (eLTSS) Initiative All-Hands Workgroup Meeting February 19, 2015 1

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 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). From S&I Framework to Participants: Hi everyone: remember to keep your phone on mute All Panelists 2

3. 3 Agenda TopicPresenterTimeframe Welcome Announcements eLTSS Roadmap Lynette Elliot5 mins Use Case FramingEvelyn Gallego5 mins Use Case Working Session: Service Provider and Payer Perspective Community45 mins Homework / Next StepsBecky Angeles5 mins Concert Series Presentation: IMPACT ActStella Mandl30 mins

4. Announcements REMINDER - Join the eLTSS Initiative: http://wiki.siframework.org/eLTSS+Join+the+Initiative. Only Committed Members can vote on artifacts. http://wiki.siframework.org/eLTSS+Join+the+Initiative ONC issued the Connecting Health and Care for the Nation: A Shared Nationwide Interoperability Roadmap Version 1.0Connecting 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: http://www.healthit.gov/policy-researchers- implementers/interoperability-roadmap-public-comments http://www.healthit.gov/policy-researchers- implementers/interoperability-roadmap-public-comments 4

5. New Funding Announcement Advance Interoperable Health Information Technology Services to Support Health Information Exchange Funding Opportunity 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: 5 Upcoming Webinar: Feb 24 th at 3pm ET: https://attendee.gotowebinar.com/register/3398558919765946881 https://attendee.gotowebinar.com/register/3398558919765946881 Upcoming Webinar: Feb 24 th at 3pm ET: https://attendee.gotowebinar.com/register/3398558919765946881 https://attendee.gotowebinar.com/register/3398558919765946881

6. 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 6 Initiative Kick Off: 11/06/14 Phase 1: Pre-Discovery Phase 2: Use Case Development & Functional Requirements Phase 3: Standards & Harmonization

7. 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 7

8. Project Charter and eLTSS Glossary FINAL Published Project Charter located here: http://wiki.siframework.org/electronic+Long- Term+Services+and+Supports+%28eLTSS%29+Charter http://wiki.siframework.org/electronic+Long- Term+Services+and+Supports+%28eLTSS%29+Charter eLTSS Glossary posted here: http://wiki.siframework.org/eLTSS+Glossary http://wiki.siframework.org/eLTSS+Glossary – 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 8

9. Concert Series Presentations 9 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?

10. 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: 15-20 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 (evelyn.gallego@siframework.org ) and Lynette Elliott (lynette.elliott@esacinc.com)evelyn.gallego@siframework.orglynette.elliott@esacinc.com A pre-planning meeting will be scheduled prior to any public demonstration 10

11. Upcoming Concert Series Presentations Feb 19 th : Improving Post-Acute Care Transformation (IMPACT) Act March 5 th : Right Care Now Project 11

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13. PhaseTypical Activities 1.Pre-Discovery  Development of Initiative Synopsis  Development of Initiative Charter  Definition of Goals & Initiative Outcomes 2.Discovery  Creation/Validation of Use Cases, User Stories & Functional Requirements  Identification of interoperability gaps, barriers, obstacles and costs  Review of Vocabulary 3.Implementation  Evaluation of candidate standards  Development of Standards Solution Plan  Creation of Implementation Guidance 4.Pilot  Validation of aligned specifications, testing tools, and reference implementation tools  Revision of documentation and tools  Development and presentation of Pilot Proposals 4.Evaluation  Measurement of initiative success against goals and outcomes  Identification of best practices and lessons learned from pilots for wider scale deployment  Identification of hard and soft policy tools that could be considered for wider scale deployments S&I Framework Deliverables 13 Use Case focused on “what” the requirements should be rather than “how”…but we still need to work on the “why”.

14. Week Target Date (2015) All Hands WG Meeting Tasks Review & Comments from Community via Wiki page due following Tuesday by 8 P.M. Eastern 1-51/22-2/19 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: In/Out of Scope Review: In/Out of Scope 73/5 Review: In/Out of Scope Introduce: Context Diagram & User Stories Review: Context Diagram & User Stories 83/12Review: Context Diagram & User StoriesReview: Continue Review of User Stories 93/19 Review: Finalize User Stories Introduce: Assumptions & Pre/Post Conditions Review: Assumptions & Pre/Post Conditions 103/26 Review: Assumptions & Pre/Post Conditions Introduce: Activity Diagram & Base Flow Review: Activity Diagram & Base Flow 114/2 Review: Activity Diagram & Base Flow Introduce: Functional Requirements & Sequence Diagram Review: Functional Requirements & Sequence Diagram 124/9 Review: Functional Requirements & Sequence Diagram Introduce: Data Requirements Review: Data Requirements 134/16 Review: Finalize Data Requirements Introduce: Risks & Issues Review: Risks & Issues 144/23 Review: Risks and Issues Begin End-to-End Review End-to-End Review by community 154/30End-to-End Comments Review & dispositionEnd-to-End Review ends 165/7Finalize End-to-End Review Comments & Begin ConsensusBegin casting consensus vote 175/14Consensus Vote*Conclude consensus voting Proposed Use Case & Functional Requirements Development Timeline 14

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16. What we learned so far / What questions need answered Work from eLTSS Use Case Framing Questions Results.doc located on the eLTSS wiki: http://wiki.siframework.org/file/view/eLTSS%20Use%20Case%20Framing%20Questions%20Consolidated%20Resul ts%202015-02- 19.docx/541482334/eLTSS%20Use%20Case%20Framing%20Questions%20Consolidated%20Results%202015-02- 19.docx http://wiki.siframework.org/file/view/eLTSS%20Use%20Case%20Framing%20Questions%20Consolidated%20Resul ts%202015-02- 19.docx/541482334/eLTSS%20Use%20Case%20Framing%20Questions%20Consolidated%20Results%202015-02- 19.docx 16

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18. Next Steps HOMEWORK – Due by COB Tuesday, February 24th: –Review and Provide feedback on the Use Case Value Framing Questions either using the form or word document located here: http://wiki.siframework.org/electronic+Long+Term+Services+and+Supports+Use+Case+Value+Frami ng+Questions http://wiki.siframework.org/electronic+Long+Term+Services+and+Supports+Use+Case+Value+Frami ng+Questions What is missing? –Provide feedback, comments, etc. to becky.angeles@esacinc.com and evelyn.gallego@siframework.orgbecky.angeles@esacinc.com evelyn.gallego@siframework.org NEXT WEEK: –Overview of Common Themes from Value Framing Questions –Dive into the In Scope and Out of Scope section of the Use Case Join the eLTSS Initiative: http://wiki.siframework.org/eLTSS+Join+the+Initiative http://wiki.siframework.org/eLTSS+Join+the+Initiative –Only Committed Members can vote on artifacts 18

19. IMPACT ACT OF 2014 Concert Series Presentation: Stella Mandl, RN – Deputy Director – The Division of Chronic & Post Acute Care 19

20. Data Element Uniformity, Assessment Domain Standardization and the IMPACT ACT OF 2014 Stella Mandl, RN Deputy Director The Division of Chronic & Post Acute Care

21. 2000: Benefits Improvement & Protection Act (BIPA) – mandated standardized assessment items across the Medicare program, to supersede current items 2005: Deficit Reduction Act (DRA) – Mandated the use of standardized assessments across acute and post-acute settings – Established Post-Acute Care Payment Reform Demonstration (PAC-PRD) which included a component testing the reliability of the standardized items when used in each Medicare setting 2006: Post-Acute Care Payment Reform Demonstration requirement: – Data to meet federal HIT interoperability standards Data Standardization: PAC-PRD and the CARE Tool: Background 21

22. Assessment Data that is Uniform : Reusable Informative Can help achieve data use that can: Communicate in the same language across settings Ensure data transferability of clinically relevant information forward and backward allowing for interoperability, ensuring care coordination Data Uniformity Increases reliability and validity Allows data to follow the person Facilitates patient centered care, care coordination Goals that standardization can enable: Fostering seamless care transitions Measures that can follow the patient Evaluation of longitudinal outcomes for patients that traverse settings Assessment of quality across settings Improved outcomes, and efficiency Reduction in provider burden PAC PRD & the Care Tool: Informed Concepts 22 Guiding Principles and Goals:

23. More About CARE Data collection using the CARE Item Set occurred as part of the Post Acute Care Payment Reform Demonstration and included 206 acute and PAC providers http://www.cms.gov/Medicare/Quality-Initiatives-Patient- Assessment-Instruments/Post-Acute-Care-Quality- Initiatives/CARE-Item-Set-and-B-CARE.html 23

24. Facilities are able to transmit electronic and interoperable Documents and Data Elements Provides convergence in language/terminology Data Elements used are clinically relevant Care is coordinated using meaningful information that is spoken and understood by all Measures can evaluate quality across settings and evaluate intermittent and long term outcomes Measures and data can follow the person Incorporates needs beyond healthcare system Keeping in Mind, the Ideal State 24

25. Data Elements: Standardization IRF-PAI LTCH CARE Data Set OASIS-C MDS 3.0 Data Elements HCBS CARE Uniformity

26. CMS Data Element Library: HIT Exchange Standards 26 Standardized Detailed Reusable QIC Presentation: O’Malley/Garber May 20, 2014 Please Pass the Legos :

27. CMS Framework for Measurement Measures should be patient- centered and outcome-oriented whenever possible Measure concepts in each of the six domains that are common across providers and settings can form a core set of measures Patient experience Caregiver experience Preference- and goal- oriented care Efficiency and Cost Reduction Cost Efficiency Appropriateness Care Coordination Patient and family activation Infrastructure and processes for care coordination Impact of care coordination Clinical Quality of Care Care type (preventive, acute, post-acute, chronic) Conditions Subpopulations Population/ Community Health Health Behaviors Access Physical and Social environment Health Status All-cause harm HACs HAIs Unnecessary care Medication safety Safety Person- and Caregiver- Centered Experience and Outcomes Function 27

28. Standardization: Future State 28 Data Follows the Person Long Term Care Institutional and Home and Community- Based Services (HCBS) Duals/Medicaid/Medicare/All Other Payers Acute Care Post-Acute Care TCP CMMI Home Health Person PCP EMR EHR

29. Bi-partisan bill introduced in March, U.S. House & Senate; passed on September 18, 2014 and signed into law by President Obama October 6, 2014 Requires Standardized Patient Assessment Data that will enable: – Assessment and QM uniformity – Quality care and improved outcomes – Comparison of quality across PAC settings – Improve discharge planning – Interoperability – Facilitate care coordination Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014 29

30. Definitions Applicable PAC settings and Prospective Payment Systems (PPS): – Home health agencies (HHA) under section 1895 – Skilled nursing facilities (SNF) under section 1888(e) – Inpatient rehabilitation facilities (IRF) under section 1886(j) – Long-term care hospitals (LTCH) under section 1886(m) 30

31. Definitions (continued) Applicable PAC assessment instruments – HHA: Outcome and Assessment Information Set (OASIS) or any successor regulation – SNF: assessment specified under section 1819(b)(3) – IRF: any Medicare beneficiary assessment instrument established by the Secretary for purposes of section 1886(j) – LTCH: any Medicare beneficiary assessment instrument used to collect data elements to calculate quality measures, including for purposes of section 1886(m)(5)(C) 31

32. Requirements for Standardized Assessment Data IMPACT Act added new section 1899(B) to Title XVIII of the Social Security Act (SSA) Post-Acute Care (PAC) providers must report: – Standardized assessment data – Data on quality measures – Data on resource use and other measures The data must be standardized and interoperable to allow for the: – Exchange of data using common standards and definitions – Facilitation of care coordination – Improvement of Medicare beneficiary outcomes PAC assessment instruments must be modified to: – Enable the submission of standardized data – Compare data across all applicable providers 32

33. Standardized Assessment Data Elements 33 One Question: Much to Say

34. One Response: Many Uses 34 Care Planning/ Decision Support Care Planning/ Decision Support Payment Quality Reporting QI Care Transitions Data Element and Response Code

35. Specified Application Dates by Quality Measure Domains Functional status, cognitive function, and changes in function and cognitive function Skin integrity and changes in skin integrity Medication reconciliation Incidence of major falls Communicating the existence of and providing for the transfer of health information and care preferences 35

36. Standardized Patient Assessment Data Requirements for reporting assessment data: – Providers must submit standardized assessment data through PAC assessment instruments under applicable reporting provisions – The data must be submitted with respect to admission and discharge for each patient, or more frequently as required Data categories: – Functional status – Cognitive function and mental status – Special services, treatments, and interventions – Medical conditions and co-morbidities – Impairments – Other categories required by the Secretary 36 Use of Standardized Assessment Data: HHAs: no later than January 1, 2019 SNFs, IRFs, and LTCHs: no later than October 1, 2018

37. Resource Use and Other Measures – Resource use and other measures will be specified for reporting, which may include standardized assessment data in addition to claims data. – Resource use and other measure domains include: Total estimated Medicare spending per beneficiary Discharge to community Measures to reflect all-condition risk-adjusted potentially preventable hospital readmission rates 37

38. (1)Measurement Implementation Phases (A)Initial Implementation Phase (i) measure specification (ii)data collection (B) Second Implementation Phase – feedback reports to PAC providers (C) Third Implementation Phase – public reporting of PAC providers' performance (2) Consensus-based Entity (3) Treatment of Application of Pre-Rulemaking Process (e) Measurement Implementation Phases; Selection of Quality Measures and Resource Use and Other Measures 38

39. SNFs - amends section 1888(e) of the SSA to add paragraph (6) — – (A) Reduction in Update for Failure to Report A SNF will receive a 2 percentage point reduction in its APU for failure to report data beginning with FY 2018 – The result may be less than 0.0 for the FY and/or less than the preceding – The reduction will only apply to the FY involved SNF QRP Established 39

40. eLTSS Initiative: Project Team Leads ONC Leads – Elizabeth Palena-Hall (elizabeth.palenahall@hhs.gov)elizabeth.palenahall@hhs.gov – Patricia Greim (Patricia.Greim@hhs.gov)Patricia.Greim@hhs.gov CMS Lead – Kerry Lida (Kerry.Lida@cms.hhs.gov)Kerry.Lida@cms.hhs.gov Federal Lead – Jennie Harvell (jennie.harvell@hhs.gov)jennie.harvell@hhs.gov Initiative Coordinator – Evelyn Gallego-Haag (evelyn.gallego@siframework.org)evelyn.gallego@siframework.org Project Management & Pilots Lead – Lynette Elliott (lynette.elliott@esacinc.com)lynette.elliott@esacinc.com Use Case & Functional Requirements Development – Becky Angeles (becky.angeles@esacinc.com)becky.angeles@esacinc.com Standards Development Support – Angelique Cortez (angelique.j.cortez@accenture.com)angelique.j.cortez@accenture.com Harmonization – Atanu Sen (atanu.sen@accenture.com)atanu.sen@accenture.com 40

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42. Use Case Outline Tailored for each Initiative 42 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 o 10.2.1 Base Flow o 10.2.2 Alternate Flow – 10.3 Functional Requirements o 10.3.1 Information Interchange Requirements o 10.3.2 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

43. LTSS Information Sharing: As-Is Workflow Transport Emergency Services Personal Care Meals Caregiver Support Housing Home Maintenance & Repair Behavioral Health Employment Education Legal Services Criminal Justice Acute Care Primary Care Specialty Care Long-Term Care Post-Acute Care Emergency Care Intensive Care Person-Centered Patient-Centered

44. eLTSS Plan Future Sharing Options Generates, updates and displays eLTSS Plan; stores/transmits data Updates and displays eLTSS Plan; stores/submits data Extract, Transform, & Load eLTSS Plan Data Move from Patient-Centered to Person-Centered Planning and Information Exchange Updates and displays eLTSS Plan; stores/transmits data