Longitudinal Coordination of Care (LCC) Workgroup (WG)

1. Longitudinal Coordination of Care (LCC) Workgroup (WG) LCC All Hands Meeting February 7, 2013

2. Agenda • ONC S&I Updates • Key Accomplishments of the WG & SWGs • Use Case Working Session • Next Steps

3. ONC S&I Updates • Developing S&I LCC Support Work plan to support next phase of LCC Initiative • Engaging with S&I Transitions of Care (ToC) Support team to align and build from ToC artifacts and membership • Identifying and engaging with additional LCC Stakeholder groups • Engaged with ONC Office of Policy & Planning (OPP) to review and schedule LCC WG presentation to the HITPC

4. LCC WG Key Accomplishments • Held two webinars regarding the Meaningful Use (MU) Stage 3 Request for Comments • Reviewed relevant Meaningful Use (MU) Stage 3 sections • Proposed concepts and definitions to reframe the recommendations • Gathered community feedback to develop a shared response • Submitted Comments for the Meaningful Use (MU) Stage 3 Request for Comments • Updated the LCC and SWG Wiki pages • Streamlined content • Meeting Information more visible • PAS SWG is “Completed”

5. Wiki Re-Design • http://wiki.siframework.org/Longitudinal+Coordination+of+Care+%28LCC%29

6. LTPAC SWG Key Accomplishments • Developing a roadmap for a public and private collaboration • Create and ballot through HL7 Implementation Guides to support transitions of care and the care plan/home health plan of care. • Proposed a new CDA template section known as the “MAP” (AKA Master All-care Plan) which maps the many-to-many relations that connect the various elements of the care plan (e.g. Health Concerns, Goals, Interventions, Assessments, and Care Team). • Reviewed and provided feedback to Lantana to support their work on defining a high-level Implementation Guide for the Transfer of Care dataset.

7. LCP SWG Key Accomplishments • Led review and consolidation of LCC Community comments on ‘Care Plan Glossary’ and ‘RFC Webinar’ • Supported review and deep dive of ‘care plan components’ of IMPACT dataset

8. PAS SWG Key Accomplishments • New website regarding transform tool:  www.transform.keyhie.org • Will be updated often as project unfolds • Currently able to see info on benefits and pricing • Sign up under “take a test drive” and you will be included in updates on project • Aggressive launch schedule • Started pilots in mid-January with: • Presbyterian Senior Living (SNF) • Sun Home Health (HHA) • Will bring on Geisinger Beacon facilities in Mar/Apr • Anticipate full public launch in April • Jim Younkin’s ONC presentation on project will be posted to wiki

9. Use Case Outline NEXT STEPS: • Look at the Problem list – expand or reduce the list • Take the list and under each heading identify which health concerns are for what team members and which team members are working collaboratively Team members: • Hospitalist • Floor nurse • Psych Consultant • Case manager Delivered to: • PCP • Community-based care coordinator • HHA nurse • CBSO • Behavior Health professional

10. Use Case Outline Patient has the following Problems: • Diabetic Ulcer – • non weight-bearing on the foot with the ulcer • neuropathy • gait impairment • Depression – • self-medicating with alcohol • Substance Abuse Issues • Malnutrition from alcohol abuse • Lives alone in a 3rd Floor Walkup with Kerosene Heater (no elevator) • Infectious Disease • MRSA • PPD is positive • Vaccination Status • Visually Impaired - Unable to Drive • Cognitive Status • Smoking / COPD

11. Use Case Outline Insurer: • Medicaid/Medicare (dual) Achieve following Goals: • Marginal disease management • Quality of life improvement • Figure out what the patient really wants – what is important and how the care team can help (i.e., get housing on the first floor) • Break the cycle of re-admission in ED • Substance Abuse Intervention Assumption: • The Clinical Summary exists and wraps around this Use Case

12. Use Case Map

13. Next Steps • Finalize S&I LCC WG Support Plan • Update LCC Use Case with new Care Plan component definitions • Revise functional specifications • Kick-off IMPACT/ASPE public private partnership for development of ToC and Care Plan/ HHPoC Implementation Guides