1. electronic Long-Term Services & Supports (eLTSS) Initiative All-Hands Workgroup Meeting October 29, 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). 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. 3 Agenda TopicPresenterTimeframe Welcome Announcements eLTSS Roadmap Evelyn Gallego10 mins eLTSS Pilot Plan Presentations MN Department of Human Services (Tom Gossett) Georgia Department of Community Health (Bonnie Young) Care At Hand (Andrey Ostrovsky) Meals on Wheels (Allison Thompson) 80 mins

4. Announcements ONC Webinar on the 2015 Edition Health IT Certification Criteria – What: The webinar will provide an overview of the components of the 2015 Edition final rule; the differences between the proposed and final rules; previous editions of certification criteria and certification policies and the 2015 Edition rule and important milestones and timelines related to the final rule. – When: Thursday, October 29, 2015 at 3:30 p.m. ET – To register: https://attendee.gotowebinar.com/register/67294810235290910 73 https://attendee.gotowebinar.com/register/67294810235290910 73 – Presentation slides (scroll down, last link in the Resources box): https://www.healthit.gov/sites/default/files/onc2015editionfinal rulepresentation_10-9-15.pdf https://www.healthit.gov/sites/default/files/onc2015editionfinal rulepresentation_10-9-15.pdf 4

5. Announcements, cont’d Fall 2015 HIMSS Health Story Project Roundtable: Using CDA Documents to Share a Person’s Health Story and the Data Within – What: This online presentation given by Lisa Nelson will explain the mechanisms available in standard CDA documents to share human readable information and the associated machine processable data using common language for a non-technical audience. – When: November 2, 2015 from 12:00pm-1:00pm ET – Virtual Event Registration: http://www.himss.org/Events/EventDetail.aspx?ItemNumber=44 641&utm_source=commepush&utm_medium=email&utm_term =text_link&utm_content=fall_hsp_event&utm_campaign=hie http://www.himss.org/Events/EventDetail.aspx?ItemNumber=44 641&utm_source=commepush&utm_medium=email&utm_term =text_link&utm_content=fall_hsp_event&utm_campaign=hie 5

6. Announcements, cont’d.. Long Term Quality Alliance (LTQA) Summit: “LTSS Pioneers: Pathways to the Future for LTSS Innovation” – What: The Summit is a day-long program starting with a keynote address by Dr. Atul Gawande. Hear LTSS innovators and leaders discuss new models, successful approaches and challenges to LTSS integration. – When: November 2, 2015 – Where: Boston Convention and Exposition Center ~ Boston, MA – Agenda: http://ltqa.us2.list- manage.com/track/click?u=985bf81d21e051e0affed6804&id=7 8f6014df1&e=d9aa5cc810http://ltqa.us2.list- manage.com/track/click?u=985bf81d21e051e0affed6804&id=7 8f6014df1&e=d9aa5cc810 – To register: http://ltqa.us2.list- manage1.com/track/click?u=985bf81d21e051e0affed6804&id= 4a57fada34&e=d9aa5cc810http://ltqa.us2.list- manage1.com/track/click?u=985bf81d21e051e0affed6804&id= 4a57fada34&e=d9aa5cc810 6

7. Announcements, cont’d... Connecting Health and Care for the Nation: A Shared Nationwide Interoperability Roadmap version 1.0 – What: This draft interoperability roadmap lays out a clear path to catalyze the collaboration of stakeholders who are going to build and use the health IT infrastructure. These documents include all the public comments that were submitted during the public comment period. – Roadmap Website: https://www.healthit.gov/policy-researchers- implementers/interoperabilityhttps://www.healthit.gov/policy-researchers- implementers/interoperability – Rules: https://www.federalregister.gov/articles/2015/10/16/2015-25595/medicare- and-medicaid-programs-electronic-health-record-incentive-program----stage- 3-and https://www.federalregister.gov/articles/2015/10/16/2015-25597/2015- edition-health-information-technology-certification-criteria-2015-edition- base-electronic 7

8. Announcements, cont’d… Common Clinical Data Set Renamed the “Common MU Data Set.” This does not impact 2014 Edition certification. Includes key health data that should be accessible and available for exchange. Data must conform with specified vocabulary standards and code sets, as applicable. 8 Patient nameLab tests SexLab values/results Date of birthVital signs (changed from proposed rule) RaceProcedures EthnicityCare team members Preferred languageImmunizations ProblemsUnique device identifiers for implantable devices Smoking StatusAssessment and plan of treatment MedicationsGoals Medication allergiesHealth concerns 2015-2017 Send, receive, find and use priority data domains to improve health and health quality ONC Interoperability Roadmap Goal Red = New data added to data set Blue = New standards for data

9. Announcements, cont’d… mHealth Summit – What: The 2015 mHealth Summit explores what is new in mobile, telehealth and connected health—from the impact on healthcare delivery, clinical care and patient/consumer engagement to new technologies, research, investment activities, policy and shifts in the business environment. – When: November 8 –11, 2015 – Where: Gaylord National Resort and Convention Center ~ Washington, D.C. – To register: http://www.mhealthsummit.org/registrationhttp://www.mhealthsummit.org/registration 9

10. Announcements, cont’d… National Call for Applications Opens: Community Health Peer Learning Program – What: In July 2015 the Office of the National Coordinator for Health Information Technology (ONC) has awarded AcademyHealth $2.2 million to lead the Community Health Peer Learning Program (CHP). Throughout this two-year program, AcademyHealth will work in partnership with ONC to establish a national peer learning collaborative for 15 competitively-awarded communities to address specified population health management challenges through increased sharing and use of data. – When: Application Due Date November 10, 2015 ~ Anticipated Award Date January 8, 2016 – For more information: http://www.academyhealth.org/Programs/ProgramsDetail.cfm?ItemNumber= 16918&navItemNumber=17093 http://www.academyhealth.org/Programs/ProgramsDetail.cfm?ItemNumber= 16918&navItemNumber=17093 – To apply: http://www.academyhealth.org/Programs/content.cfm?ItemNumber=17238 http://www.academyhealth.org/Programs/content.cfm?ItemNumber=17238 10

11. Announcements, cont’d.. Aging 2.0’s AgeTech Expo – Charting the Course: Innovations in Aging – What: The Aging2.0 AgeTech Expo brings together aging services providers and tech companies for cross-sector innovation insights and collaboration opportunities. The 2-day conference and technology exposition features innovation tours and workshops, inspiring keynotes, practical education panels, technology exhibits and the live “Pitch-for-Pilots (P4P)” session. – When: November 19-20, 2015 – Where: Hyatt Regency Hotel ~ San Francisco, CA – For more information: http://www.aging2.com/expo/http://www.aging2.com/expo/ – To register: http://www.aging2.com/expo/#registrationhttp://www.aging2.com/expo/#registration 11

12. eLTSS Initiative Timeline 12 Phase 1 Pilots & Testing … Pilot Guide Development Use Case & Functional Requirements Pre-Discovery DEC 14JUNJAN FEBMAYJULAUGSEPOCTNOV Kick Off 11/06/14 Evaluation... Content Work Stream Content Work Stream eLTSS All-Hands Work Group Use Case 1. eLTSS Use Case eLTSS Plan Content SWG 1.eLTSS Plan Domains & Data Elements Pilot Guide Development 1.Candidate Standards & Technologies 2.Three-tiered implementation Approach 3.Functional Requirements Matrix MARAPRDEC 15JAN 16 Pilot Execution

13. 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. 13

14. eLTSS Artifacts Final published Project Charter: 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: 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 Final published Use Case: http://wiki.siframework.org/electronic+Long- Term+Services+and+Supports+%28eLTSS%29+Use+Case http://wiki.siframework.org/electronic+Long- Term+Services+and+Supports+%28eLTSS%29+Use+Case Pilot Artifacts – Pilot Starter Kit: http://wiki.siframework.org/electronic+Long- Term+Services+and+Supports+%28eLTSS%29+Pilots#Pilot Starter Kithttp://wiki.siframework.org/electronic+Long- Term+Services+and+Supports+%28eLTSS%29+Pilots#Pilot Starter Kit The Pilot Starter Kit includes the Pilot Guide (consisting of a ReadMe overview, Functional Requirements Matrix/FRM and Tiered Approach), the Requirements Traceability Matrix (RTM), and Pilot Plan Templates – Pilot Resource Materials: http://wiki.siframework.org/electronic+Long- Term+Services+and+Supports+%28eLTSS%29+Pilots#Pilot Resource Materialshttp://wiki.siframework.org/electronic+Long- Term+Services+and+Supports+%28eLTSS%29+Pilots#Pilot Resource Materials Pilot Resource Materials include overview documentation, design process documentation, and the Domain Harmonization Matrix 14

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16. Pilot Plan Presenters – Contact Information MN Department of Human Services – Tom Gossett ~ tom.l.gossett@state.mn.ustom.l.gossett@state.mn.us Georgia Department of Community Health – Bonnie Young ~ Bonnie.young@dch.ga.govBonnie.young@dch.ga.gov Care At Hand – Andrey Ostrovsky ~ Andrey@careathand.comAndrey@careathand.com Meals on Wheels – Allison Thompson ~ allison.thompson@freshmealsonwheels.org allison.thompson@freshmealsonwheels.org 16

17. Tentative Presentation Schedule DATEORGANIZATIONTEFT/NONPoint of Contact 10/15/2015Janie AppleseedNon TEFTLisa Nelson 10/22/2015National Disability InstituteNon TEFTMary Lynn Revoir FEi SystemsNon TEFTChirag Bhatt Kno2Non TEFTDane Meuler ADvaultNon TEFTScott Brown 10/29/2015MN Department of Human ServicesTEFTTom Gossett GA Department of Community HealthTEFTBonnie Young Care at HandNon TEFTAndrey Ostrovsky Meals on WheelsNon TEFTAllison Thompson 11/05/2015KY Office of Administrative & Technology ServicesTEFTSheena Batts MD Department of Health & Mental HygieneTEFTKale Sweeney CT Department of Social Services Division of Health Services TEFTMinakshi Tikoo CO Department of Health Care Policy & FinancingTEFTKelly Wilson

18. Minnesota Department of Human Services 18 10/29/2015

19. Agenda Introduction Goal of Pilot Tier Piloting Activity to Pilot Role of MN Department of Human Services in the pilot Standards and Technologies Under Consideration Logistics Ecosystem Defining Success Resources/References

20. Introduction: Pilot Team NameRoleEmail Rolf Hage Project ExecutiveRolf.hage@state.mn.us Tom GossettProject ManagerTom.l.gossett@state.mn.us Rick Bagley DHS Technical Architect rick.bagley@state.mn.us Greg Linden Contractor Resource GLINDEN@stratishealth.org PHR Community Collaborative Provider/Payer/Ben eficiary stakeholders Others as appropriate

21. Introduction: Organization Who we are: MN Department of Human Services, TEFT Grantee What we do: Serve as payer for Medical Assistance (Medicaid) funded services in MN How involved in services and support: We oversee County and Managed Care Organizations who provide certified assessment and case management services to beneficiaries of MA and MA Waiver services Current process: Certified Assessors conduct MnCHOICES assessment, Counties work with the state to determine financial eligibility. Registered providers bill the state for services covered under MA. Collaborative: MN DHS is in final negotiations with a Collaborative made up of County Public Health and Human Services, primary, acute, post-acute and long term service and support providers. We’re unable to provide further details about the Collaborative until the contract is finalized. The Collaborative has agreed to participate in piloting the eLTSS plan.

22. Pilot Introduction: Business Drivers Business Drivers: – Comprehensive assessment and re-assessment of beneficiaries – Person-centered services provided to beneficiaries Business Use Case: – Create and prototype new means of sharing LTSS data electronically with Beneficiaries and an array of LTSS Service Providers and stakeholders, and evaluate the value of the data and methods of exchange. 22

23. Goal of the Pilot Our pilot will be using User Story 2: Sharing a Person- Centered eLTSS Plan

24. Pilot Workflow 24 Case Manager Community Collaborative Services Provider LTSS Data eLTSS Pilot

25. Which Tier are you piloting? We will be piloting Tier 1 - Basic non-Electronic Information Exchange in Round One We will be piloting Tier 2 in Round 2

26. What are you intending to pilot Pick which one(s) apply – Access, View, Review Plan – Update Plan Have you identified a Service provider with which to work, if so who? – Yes, or PHR Collaborative Grantee – we cannot disclose until we have a finalized contract in place Do you know if they have an electronic system? – We cannot disclose until we have a finalized contract in place Do you know which sub-domains from the FR document will you pilot: – This will be determined with the members of the Collaborative once the contract is in place

27. What role do you play in the pilot MN DHS Role - Payer: Our role will be to work with the PHR Community Collaborative to: Identify and recruit providers in the CB-LTSS continuum Train/educate providers on the pilot and objectives Inventory existing Provider technology Assess readiness of Provider to work with eLTSS data Map data elements in plan to the eLTSS dataset Share data elements among partners Develop Use cases of mutual interest Document and implement changes to provider workflow Test secure exchange of data

28. Standards Under Consideration: Tier 1 – Non-Electronic – paper documents – Electronic –.pdf or export files such as CCDs Tier 2 – eHealth secure exchange methods (HISPs, HIEs, etc.)

29. Pilot Logistics: Timeline – – Tentative – actual dates will be determined with the Collaborative after Pilot Kick off in November Kick off: November 2015 Identification of Partners/Providers- December 2016 Completion of Partner Data Use/Sharing Agreements – January 2016 Inventory and Characterize participating Provider technology and readiness – January 2016 Develop methods to produce eLTSS data appropriate for sharing – February 2016 Exchange eLTSS data via paper, fax or other secure method – March 2016 Completion of Pilots: April 2016 Challenges: – Identification of common data elements across providers

30. Pilot Ecosystem Partners: – MN DHS is in final negotiations with a Collaborative made up of County Public Health and Human Services, primary, acute, post-acute and long term service and support providers. We’re unable to provide further details about the Collaborative until the contract is finalized. Systems: – Partner systems cannot be disclosed until our contract is in place – DHS systems include MMIS and MAXIS (financial eligibility determination), as well as the MnCHOICES comprehensive assessment system and Social Services Information System (SSIS) for Case Management.

31. How do you define success We will develop specific success criteria linked to the Goals and objectives outlined on previous slides These success criteria will be developed in collaboration with the Community, early in the Pilot

32. Helpful References PHR for LTSS Demo Web Site: http://www.dhs.state.mn.us/main/dhs16_184574

33. Georgia Department of Community Health 33 October 29 th, 2015

34. Agenda Introduction Business Drivers Pilot Use Case Pilot Timeline and Process Ecosystem Defining Success Resources/References 34

35. Introduction: Pilot Team 35 NameRole Laura EllisProject Director Bonnie YoungProject Manager Waiver Program DirectorsSME Program Integrity ManagersSME Waiver Program IT SpecialistsSME Irina ConnellyGeorgia Tech Research Institute (GTRI) Technical Support

36. Mission The Georgia Department of Community Health We will provide Georgians with access to affordable, quality health care through effective planning, purchasing and oversight. We are dedicated to A Healthy Georgia 36 Georgia Department of Community Health (www.dch.georgia.gov)www.dch.georgia.gov

37. Pilot Introduction: Business Drivers 37 Georgia Business Drivers: Development of Health Information Technology (HIT) standards that: Support program monitoring and improvement of all waivers Support cross-waiver program information sharing Help bridge the gap between clinical and non-clinical data Support incremental adoption by members of the ecosystem

38. Support cross-waiver program information sharing Entities in Long Term Services and Support Transitions: Waiver programs, hospice care, nursing homes, hospitals, rehab facilities, etc. Lack of information sharing leads to… – Uncertainty in service eligibility – Delay in receiving eligible services – Lost productivity and time impact on case managers – Miscommunication between LTSS stakeholders 38

39. Use Case: Support cross-waiver program information sharing Transitioning between LTSS services: Pilot Focus – Beneficiary moving between CCSP and ICWP waivers Information currently flows within each waiver. Information flowing across waiver groups are not currently supported. Identifying and documenting the information and process needs across waiver groups will illuminate common/overlapping as well as distinct data components. 39

40. Overview of 2 Waiver Programs - Community Care Waiver Program (CCSP) - Independent Care Waiver Program (ICWP) CCSPICWP Population Size8,8661,375 Age RangeAny21-64 Impairment EligibilityFunctional impairment caused by physical limitations (including Alzheimer’s and dementia) Severe physical impairment and/or Traumatic Brain Injury Service Eligibility Determination Care Coordinators involved in eligibility determination subject to validation by External Quality Review Organization External Quality Review Organization involved in eligibility determination 40

41. Waiver Program Services ServicesCCSP (Any)ICWP (21-64) Team-based Care (i.e., jointly developed Plan of Care) Case Management Adult Day Health Alternate Living Services (24-hour personal/nursing supervision) Behavior Management Services Counseling Services Emergency Response System Home-delivered Meals Home-delivered Services (skilled nursing/therapy) Home Environment Modification Personal Support Services (e.g. personal care tasks and ADL) Respite Care Skilled Nursing Services Specialized Medical Equipment and Supplies Consumer Directed Care Option for Personal Support Services Financial Support Services Vehicle Adaptation 41 Both waivers serve different populations with some overlap Similar services provided by both Similar data needs Comparison between CCSP and ICWP Georgia’s Round 1 pilot focus Identifying data requirements (i.e., identify overlapping and distinct data) Georgia Waiver Programs (www.dch.georgia.gov/waivers)www.dch.georgia.gov/waivers

42. Georgia Pilot Timeline – Tier I OctNovDecJan ’16FebMarch April (round 1 complete) Kick-off & Pilot plan finalization Participant Identification/ Recruitment - conduct outreach activities - prepare materials for pilot participants Conduct Pilot -identify and validate data items via stakeholder interviews, focus group, town halls -identify and validate potential vocabulary standards for coded data items -solicit input for additional data items not in use today -capture qualitative feedback Results Analysis Based on input received -summarize findings on common data items and associated domains -summarize findings on unique data items and associated domains -identify potential candidate standards applicable to data items 42

43. Round I Pilot Details 43 GOAL 1: Develop a data profile for CCSP and ICWP – begin with Service Plans - Inputs (i.e., data collection) - Outputs (i.e., data sharing) - Data Format (semantics/syntax) - Identify Standards (i.e., data, forms, etc.) - Business Process Flows - Actors (i.e., internal and external) GOAL 2: Identify existing ecosystem problems HIT can help solve -Improve timely access to critical information -Reduce redundancy and burden of manual data input -Identify current barriers to eLTSS implementation

44. How do you define success Deliverables: 1.Identified and documented data that exists in both programs 2.Gap analysis 3.Identified and documented essential service plan data to share 44

45. Resources/References For more information: Georgia Department of Community Health, Division of Health IT https://dch.georgia.gov/health-information-technology Georgia Department of Community Health, Waiver Programs https://dch.georgia.gov/waivers Georgia Tech Research Institute http://www.gtri.gatech.edu/icl 45

46. Care at Hand 46 10/29/15

47. Agenda Introduction Goal of Pilot Tier Piloting Activity to Pilot Role of Care at Hand in the pilot Standards and Technologies Under Consideration Logistics Ecosystem Defining Success Resources/References

48. Introduction: Pilot Team. Care at Hand – Andrey Ostrovsky, MD – CEO – Lori O’Connor – Chief Nursing and Quality Officer Elder Services of Merrimack Valley – Joan Hatem-Roy – Assistant Executive Director Lawrence General Hospital – Robin Hynds – Senior Director

49. Introduction: Organization 1. 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. 2014.

50. Pilot Introduction: Business Drivers 50 2. Ostrovsky A, O’Connor L, Marshal O, et al. Predicting 30-120 day readmission risk among Medicare FFS patients using non-clinical workers and mobile technology. Perspectives in Health Information Management. 2015. In press. 3. Munevar D, Drozd E, & Ostrovsky A. Correlation between Medicare A spending and hospitalization risk score using mobile technology. Avalere Independent Analysis. 2015.

51. User Story 2 (Modified) 51

52. Pilot Workflow 52 Beneficiary SystemLTSS/Service Provider SystemEHR SystemCase Management SystemPayer System EHR sends d/c summary of care document AAA receives d/c SOC document and starts transition service MCO nurse care managers identify earlier opportunity to redetermine level of care Risk stratification each time interaction between coach and consumer Hospital care management staff given real-time line of site into community-based intervention State-mandated LTSS reporting system gets periodic data dump

53. Which Tier are you piloting? Tiers 1, 2, & 3, iteratively

54. What are you intending to pilot Pick which one(s) apply – Create Plan – Approve/Authorize Plan/Services – Access, View, Review Plan – Update Plan Have you identified a Service provider with which to work, if so who? Elder Services of Merrimack Vallery & LGH Do you know if they have an electronic system – If so which one? Care at Hand, Harmony Do you know which sub-domains from the FR document will you pilot: – Work, Community, Choice & Decision Making, Relationships, Self-Direction, Demographics, Person-Centered Profile, Medication, ADLs/IADLs, Safety, Behavioral Needs, Restrictions, Service, Financial/Payer Information, Service Information, Family Information, Community Connections, Access & Support Delivery, Information & Planning, Health, Other (specify) (from the FR document and the RTM document)

55. What role do you play in the pilot Beneficiary/Advocate, Beneficiary System, CB-LTSS Provider, Clinical and Institutional based provider, EHR system, Eligibility Determination Form Submitter, eLTSS plan developer, eLTSS plan facilitator/steward, LTSS/case management info, LTSS/Service Provider System, Payer, Payer System – Please describe the role you intend to play in the pilot: Predictive analytics platform with person- centered care plan as backbone

56. Standards Under Consideration: C-CDA; HL7v2.0; RxNorm; HCBS Taxonomy; Care Coordination Atlas; BARHII Health Determinants Direct; REST; SSL; FHIR; HTML5; JSON HL7; IETF; Peebles et al 2014; AHRQ; BARHII Exemplar Standards/Technologies Relevant SDOs/Vendors Content & StructureTransport & SecurityCross Category

57. Pilot Logistics: Timeline – (April 2016 is end date for round one pilots) Kick off: Feb 23, 2015 Identification of Partners/Providers- Sept-Dec 2015 Completion of RTM: March 2016 Completion of Pilots: April 2016 Challenges: – Business case is VERY hard to make: Why should hospitals outsource when “they can just build it themselves?” – HIE has limited attention span for “free connections” – community providers don’t get as much attention as “paying customers” – Maryland AND Mass HIEs are INCREDIBLY good and thoughtful, but business is business – Too many cooks in kitchen required to microwave a lean cuisine – Interface analysts, Senior directors, EMR vendor, admins, care coordination leadership, etc. (that’s just the hospital, there’s equal number of community organization reps “needed”) – Timeframes for operationalizing are so long that turnover starts to kick in – Hospital CIO changed and interoperability lead changed

58. Overcoming objections in MA 1. 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. 2014. 2. Ostrovsky A, O’Connor L, Marshal O, et al. Predicting 30-120 day readmission risk among Medicare FFS patients using non-clinical workers and mobile technology. Perspectives in Health Information Management. 2015. In press. 3. Munevar D, Drozd E, & Ostrovsky A. Correlation between Medicare A spending and hospitalization risk score using mobile technology. Avalere Independent Analysis. 2015.  39.6% 1 30-day readmissions 257% 1 ROI from prevented readmissions $4,591 3 Reduction in Medicare A & B spending per beneficiary per year Predict admissions up to 120 days 2

59. Overcoming objections in MD

60. How do you define success Run chart demonstrating improve outcomes associated temporally with incremental increase in interoperability Improve outcomes in terms of “payer/provider” and “consumer” – ED utilization – 30 day readmission rates – SNF LOS – NCI – Percent of goals of care met – Consumer confidence (activation subcomponent )

61. Care at Hand’s vision 61 Beneficiary System LTSS/Service Provider System EHR SystemCase Management System Payer System

62. Meals On Wheels of Sheboygan County Inc. 62 October 29, 2015

63. Agenda Introduction Goal of Pilot Tier Piloting Activity to Pilot Role of Meals On Wheels in the pilot Standards and Technologies Under Consideration Logistics Ecosystem Defining Success Resources/References

64. Introduction: Pilot Team NameRoleEmail Kelly HeynProject and IT oversight Kelly.heyn@freshmealsonwheels.org Allison ThompsonSpearheading pilot project Allison.thompson@freshmealsonwheels.org Connie KatchkeyBookkeeper, client communication Connie.katchkey@freshmealsonwheels.org Maureen FatlaClient services and support Maureen.fatla@freshmealsonwheels.org

65. Introduction: Meals on Wheels Organization Since 1970 Meals On Wheels of Sheboygan County (MOW) has been an independent, non-profit agency delivering meals to the homebound, elderly, and disabled residents of Sheboygan County. Long-term accredited agency through Meals On Wheels Association Clients come first. Recently built a new facility purposely designed to utilize fresh produce to enhance freshness, nutrition and flavor for our clients. Manage numerous gardens and hoop houses to maintain access to fresh produce. 17 years worth of electronic client data and a tech support team willing and able to adapt as needed At the forefront of the home-delivered meal industry. Intend to create an internal system which meshes well with CMS, to optimize client services Staff has complete access to our electronic data system, continually updating client information as needed to provide better service.

66. Pilot Introduction: Business Drivers We recognize that efficiency and integration with partnering agencies will ultimately provide better service for our clients. This pilot study aligns with our efforts to strengthen our partnerships with area healthcare providers. 66

67. Goal of the Pilot Because we are a community- based service provider we fall under both User Story 1 and 2 under Beneficiary System.

68. User Story 2 68

69. Pilot Workflow Deliver medically-tailored meals to the homebound, elderly and disabled. Clients are referred to us by: family, government agencies (such as ADRC), social workers, doctors, dieticians, hospitals and nursing homes. While most referrals are verbal, others are sent via email and fax. Client information is first gathered on paper and then is input into a custom-built ACCESS database. Hospitals/Doctors will fax diet restrictions. Initial client health assessments are done verbally over the phone and the information is put into the database. Ongoing assessments are done by staff and volunteers and information is updated as needed in our custom ACCESS database. 69

70. What are you intending to pilot – Create Plan – Approve/Authorize Plan/Services – Access, View, Review Plan – Update Plan Identify and prioritize value-based information requirements among participating partners (hospitals, doctors, social workers). Evaluate gaps in what data elements are needed and what data elements are available. Sub-domains include: Work, Community, Relationships, Demographics, Person- Centered Profile, Medication, ADLs/IADLs, Safety, Current Behavioral Needs, Restrictions, Service, Financial/Payer Information, Service Information, Family Information, Community Connections, Access & Support Delivery, Information & Planning, Health, Dietary Needs

71. Which Tier are you piloting? We plan to Pilot Tier 1 and 2 with likeliness of also participating in Tier 3. We continue to modify the plan to meet changes in needs of partnering agencies, and to better service clients and understand their changing needs. Reports are shared in various ways with case workers, clients and family via phone, fax and email.

72. What role do you play in the pilot CB-LTSS Provider eLTSS plan facilitator/steward LTSS/case management info With every new client MOW gathers the previously- mentioned data and monitors the client through regularly scheduled meal deliveries. Updates are made electronically and communicated verbally, via email and via fax with families/social workers/providers, as necessary.

73. Standards Under Consideration: Tier 1 – Non Electronic – Electronic – email, ACCESS database, have access to Drop Box if needed. Tier 2 – Create documents and template methodologies to standardize the content and structure for clinical care summaries. Tier 3: – Implement revised plans and templates to share the data and information electronically with partnering agencies.

74. Pilot Logistics: Timeline – (April 2016 is end date for round one pilots) Kick off: November 2015 Secure partner by December 2015 Match current questionnaire with use-case activities by January 2016 Completion of RTM: March 2016 Completion of Pilots: April 2016 Challenges: – Finding healthcare agencies/government programs willing to pilot with us – Changes in technology/modifying current database – Educating staff and volunteers as to what to look for/access based on provider needs – Creating/printing additional marketing pieces to help educate the healthcare community, staff and volunteers

75. Pilot Ecosystem Potential partners include local hospitals, healthcare providers, dieticians, social workers, government care facilities. MOW customized ACCESS database. While most communication is verbal, there is some electronic transfer of knowledge via fax and email.

76. How do you define success As a result of this project we hope: – that our clients will have better wrap-around care resulting in improved health outcomes. – to gain a better sense of the information that needs to be collected in order to benefit the hospitals and healthcare community. – to further relationships with hospitals and healthcare community to provide access to more meals for the homebound, elderly, disabled and those recovering from injury/surgery. – this opens electronic communications between partnering agencies. The number of clients referred by healthcare community increases. Relationships with partnering agencies grows stronger. Able to create a stronger reporting system from volunteers to MOW staff. If we are able to show growth and move into Tiers 2 and 3.

77. Helpful References www.freshmealsonwheels.org Strengths Marketing Video of ProgramProgram Current Intake FormIntake Social Media: Facebook, Twitter, YouTube, PinterestFacebookTwitterYouTubePinterest

78. Next Week’s Presenters DATEORGANIZATIONTEFT/NONPoint of Contact 11/05/2015Kentucky Office of Administrative and Technology Services TEFTSheena Batts Maryland Department of Health and Mental Hygiene TEFTKale Sweeney Connecticut Department of Social Services Division of Health Services TEFTMinakshi Tikoo Colorado Department of Health Care Policy and Financing TEFTKelly Wilson

79. Next Steps Schedule your Pilot Plan Presentation Next available date: Nov 12 th – Please schedule your presentation by emailing jamie.parker@esacinc.com or any member of the support team and we will schedule you jamie.parker@esacinc.com If you are interested in piloting, please express your interest using the Pilot Interest Survey form: – http://wiki.siframework.org/electronic+Long+Term+Ser vices+and+Supports+Pilot+Interest+Survey http://wiki.siframework.org/electronic+Long+Term+Ser vices+and+Supports+Pilot+Interest+Survey 79

80. Useful Links eLTSS Pilot Starter Kit http://wiki.siframework.org/electronic+Long- Term+Services+and+Supports+%28eLTSS%29+ Pilots#Pilot Starter Kit http://wiki.siframework.org/electronic+Long- Term+Services+and+Supports+%28eLTSS%29+ Pilots#Pilot Starter Kit eLTSS Glossary: http://wiki.siframework.org/eLTSS+Glossary eLTSS Reference Materials http://wiki.siframework.org/electronic+Long- Term+Services+and+Supports+%28eLTSS%29+Ref erences http://wiki.siframework.org/electronic+Long- Term+Services+and+Supports+%28eLTSS%29+Ref erences

81. Comments/Discussion 81

82. eLTSS Initiative: Project Team Leads ONC Leadership – Mera Choi (mera.choi@hhs.gov)mera.choi@hhs.gov – Elizabeth Palena-Hall (elizabeth.palenahall@hhs.gov)elizabeth.palenahall@hhs.gov CMS Leadership – Kerry Lida (Kerry.Lida@cms.hhs.gov)Kerry.Lida@cms.hhs.gov Community Leadership – Mary Sowers (msowers@nasddds.org)msowers@nasddds.org – Terry O’Malley (tomalley@mgh.harvard.edu)tomalley@mgh.harvard.edu Initiative Coordinator – Evelyn Gallego-Haag (evelyn.gallego@siframework.org)evelyn.gallego@siframework.org Project Management – 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 Pilot Guide Development – Grant Kovich (grant.kovich@accenture.com)grant.kovich@accenture.com Pilots Management – Jamie Parker (jamie.parker@esacinc.com)jamie.parker@esacinc.com Standards and Technologies Identification – Angelique Cortez (angelique.j.cortez@accenture.com)angelique.j.cortez@accenture.com 82