LONGITUDINAL COORDINATION
OF CARE WORK GROUP –
A Community Led Initiative
MEANINGFUL USE REQUIREMENTS FOR:
TRANSITIONS OF CARE
& CARE PLANS FOR
MEDICALLY COMPLEX AND/OR
FUNCTIONALLY IMPAIRED PERSONS
August 2012
i
The S&I Framework Longitudinal Coordination WG –
A Community Led Initiative
The ONC Standards and Interoperability Framework (S&I) Longitudinal Coordination of Care Workgroup (LCC
WG) is a community-led initiative that supports health information exchange (HIE) on behalf of long term and
post-acute care (LTPAC) stakeholders and promotes longitudinal coordination of care on behalf of medicallycomplex and/or functionally impaired persons, including those who receive LTPAC services. The S&I LCC WG is
among the first of the “community-led” S&I activities. The S&I LCC WG employs a collaborative approach that
leverages public and private sector resources including:








ONC staff and contractor resources: Made available through the S&I initiative, they have supported
virtual and in-person meetings and led development of the LCC Use Case, and committed to supporting
the identification and harmonization of data standards, and development of implementation guides for
some of the needed longitudinal coordination of care documents;
ASPE staff and contractor resources: Have provided leadership and materials for the S&I LCC WG, and
supported the production of written deliverables that emerged from this effort;
CMS staff and contractor resources: Have provided materials leveraged by the workgroup;
Massachusetts ONC State Health IT Challenge Grant and Keystone Beacon Community Grant
representatives: Have provided critical leadership and guidance across S&I LCC WG activities and will be
piloting standards that have emerged from this effort;
Volunteer resources: Made available from private sector organizations, these volunteer resources
representing acute care and LTPAC providers, clinicians, health IT vendors, HIE organizations,
professional and provider associations, and consultants, have provided invaluable expertise and insight;
Lantana Consulting Group: Has provided critical leadership in development of several HL7
implementation guides needed to support interoperable HIE for LTPAC;
HL7 Structured Documents Workgroup: Has engaged in collaborative efforts with the S&I LCC WG that
resulted in the balloting of important standards and implementation guides for the exchange of content
needed for longitudinal coordination of care; and
HL7 Patient Care Workgroup members: Have provided invaluable assistance in describing the health IT
exchange standards, and gaps in such standards, needed for the exchange of care plans.
The S&I LCC WG has prepared this paper to report the activities and accomplishments of the WG, present
recommendations for consideration in future Meaningful Use (MU) program development, outline next steps
for the WG, and synthesize the analysis and insights garnered to date on care plan components and
requirements.
S&I Longitudinal Coordination of Care WG
August 2012
ii
Executive Summary
The attached report describes the work undertaken and recommendations made by the Standards and
Interoperability Longitudinal Coordination of Care Workgroup (S&I LCC WG). The S&I LLC WG completed several
activities to inform Stage 2 of the Meaningful Use (MU) Electronic Health Record (EHR) Program.
In addition, based on work completed to date, the S&I LCC WG is advancing the following recommendations to
support requirements for Stage 3 MU. These recommendations are summarized below and consistent with the
preliminary Stage 3 MU recommendations advanced by the Health IT Policy Committee Meaningful Use
Workgroup.
Recommendations
Stage 3 Meaningful Use (MU) Recommendation
The S&I LCC WG recommends that Stage 3 of the Meaningful Use Program incorporate requirements for the use
of interoperable clinical content, standards, and implementation guides to support (i) transitions of care and (ii)
care planning on behalf of medically complex and/or functionally impaired persons.
Recommendations for Advancing Standards, Implementation Guides, and EHR Certification
Criteria to Support the Preceding Stage 3 MU Recommendation
The S&I LCC WG recommends that the Office of the National Coordinator for Health Information Technology
(ONC)/ Office on Standards and Interoperability (OSI) provide support for the following activities for purposes of
advancing requirements for Stage 3 of the Meaningful Use program:
1. Information Exchange Requirements for Transitions in Care and Home Health Plan of Care.
Complete the work begun in the initial phase of the S&I LCC WG regarding the exchange of information
at transitions in care and for home health plans of care by identifying the content standards and
developing implementation guides needed for Stage 3 MU requirements. Specifically:
a. Identify and fill gaps in content standards for the interoperable exchange of clinical content
identified in the initial S&I LCC WG Use Case regarding:
i. Transitions in care on behalf of medically complex and/or functionally impaired persons; and
ii. Home health plan of care.
Timeline: Work should be completed in the fall of 2012.
2. Develop implementation guides to support the interoperable exchange of information identified in
the initial S&I LCC Use Case for transitions of care and the home health plan of care.
Timeline: Work should be undertaken in collaboration with HL7 and balloted by HL7 in the January 2013
ballot cycle.
S&I Longitudinal Coordination of Care WG
August 2012
iii
Executive Summary
Information Exchange Requirements for Collaborative Care Plan.
Extend the initial S&I LCC WG Use Case and health information exchange requirements described in item #1
above and identify requirements for the interoperable exchange of Collaborative Care Plans for Stage 3 of the
Meaningful Use Program. Specifically:
1. Leverage and extend the Care Plan White Paper (attached) and the Home Health Plan of Care
Implementation Guide to develop a use case for the exchange of Collaborative Care Plans on behalf of
medically-complex and/or functionally impaired persons. The use case will describe 2-3 scenarios
involving the exchange of a Collaborative Care Plan.
Timeline: Work should be completed by January 2013.
2. Identify and fill gaps in content standards needed for the interoperable exchange of a Collaborative Care
Plan.
Timeline: Work should be completed in the February 2013.
3. Develop, and ballot through HL7, an implementation guide for the interoperable exchange of
Collaborative Care Plans.
Timeline: Work should be undertaken in collaboration with HL7 and balloted by HL7 in May 2013.
Needed ONC/OSI Support and Resources
The S&I LCC WG, a community led initiative, recommends that the ONC/OSI support and advance the activities
described above by leveraging and collaborating on related activities underway in other venues (e.g., HL7, ONC
Challenge Grants, etc.) and providing the following:
1. S&I personnel to guide and support the S&I LCC WG by:
a. Supporting activities described above
b. Reaching out to leaders in other settings (e.g., long-term services and supports, behavioral health
providers, physicians, etc.) and soliciting their engagement
c. Facilitating the S&I LCC WG engagement with and reporting to the: Health Information Technology
Policy Committee (HIT PC), Health Information Technology Standards Committee (HIT SC), and
others
2. Meeting support (virtual and face-to-face)
3. Wiki support
4. Standards analysis, harmonization, and gap filling
5. Development of three implementation guides in collaboration with and balloted through HL7 :
a. LTPAC Transitions of Care
b. Home Health Plan of Care
c. Collaborative Plan of Care
S&I Longitudinal Coordination of Care WG
August 2012
1
The ability to create, transmit and
incorporate a longitudinal
collaborative care plan is essential
to managing the care of medicallycomplex and/or functionally
impaired individuals. The S&I LCC
WG has undertaken extensive
analysis of the components of care
plans and the care plan
requirements proposed for Stage 2
Meaningful Use rules.
Recommendation:
Extend, for Stage 3 of the MU
Program, transition in care and
care plan requirements and
standards needed on behalf of
medically-complex and/or
functionally impaired persons.
Overview
The following paper:
 Describes the health information exchange (HIE) challenges
that were addressed by the Standards & Interoperability Framework
(S&I) Longitudinal Coordination of Care Workgroup (LCC WG) on
behalf of medically complex and/or functionally impaired persons at
times of transition and referrals in care, and the need to exchange
care plans across multiple providers for these individuals;
 Describes the accomplishments to date of the S&I LCC WG,
 Presents recommendations made by the S&I LCC WG for
Stage 3 of the Meaningful Use (MU) Electronic Health Record (EHR)
Program;
 Presents a white paper that describes a vision for a
longitudinal care plan and examines the relationship between
requirements of the MU Program in terms of this vision; and
 Includes appendices that describe in more detail the work
undertaken by the S&I LCC WG to advance Stage 2 MU requirements
and which can be leveraged and extended to support Stage 3 MU.
The Challenge
Each year approximately 15 million medically-complex and/or functionally impaired Americans need long-term
and post-acute care services in nursing facilities (NFs), home health agencies (HHAs), and other settings such as
Long Term Care Hospitals (LTCHs) and Inpatient Rehabilitation Facilities (IRFs); and may also receive services
across the health delivery spectrum, including hospital, physician, pharmacy, and a wide array of social services
and supports. The numbers of service delivery encounters required by these individuals, as well as the failure
to deliver and coordinate needed services, are significant sources of frustration and errors, and are drivers of
health care expenditures.
Providing person-centered care is particularly important for medically-complex and/or functionally impaired
individuals given the complexity, range, and on-going and evolving nature of their health status and the services
needed. Effective, collaborative partnerships between service providers and individuals are necessary to ensure
that individuals have the ability to participate in planning their care and that their wants, needs, and preferences
are respected in health care decision making.1
The ability to target appropriate services and to coordinate care over time, across multiple clinicians and sites of
service, with the engagement of the individual (i.e. longitudinal coordination of care) is essential to alleviating
fragmented, duplicative and costly care for these medically-complex and/or functionally impaired persons.
Institute on Medicine. “Crossing the Quality Chasm: A New Health System for the 21st Century”.
http://iom.edu/Reports/2001/Crossing-the-Quality-Chasm-A-New-Health-System-for-the-21st-Century.aspx
1
S&I Longitudinal Coordination of Care WG
August 2012
2
Indeed, implementing such coordination of care is foundational to many health care reform initiatives (e.g.,
accountable care organizations, health homes, bundled payment initiatives, etc.).
Timely exchange of needed health information is one factor
necessary for effective coordination of care. Efficient health
information exchange to support coordination of care is
believed to require the electronic exchange of several types of
data including:


Standardized transitions of care data:
o As these individuals transition between long
term and post-acute care (LTPAC), hospital
care, and primary care providers (such as
transfers from nursing home to Emergency
Department or home health to hospital); or
o When care is shared across medical and social
service providers (such as physician and home
care nursing encounters on behalf of home
health recipients); and
A collaborative care plan, among the many providers
typically involved with these medically-complex and/or
functionally impaired persons, which organizes these
providers and aims to achieve goals set by the person
and family.
The exchange of a technology-enabled care plan among all
team members, across all sites of care in concert with the
individual’s goals and wishes, is a critical capability in
supporting medically-complex and/or functionally impaired
persons and in enabling improvement of system function.
Medically-Complex and/or
Functionally Impaired Persons
Are:
Clinically complex:
 Compounded by each additional
level of comorbidity (e.g., acute
urinary tract infection is
superimposed on chronic heart
conditions).
 Further compounded by social,
financial, and environmental
issues.
 Management, treatment and
rehabilitation are further
complicated by functional
impairment, cognitive impairment
and/or behavioral issues.
Organizationally complex:
 Complexity of organizing and
providing care matches the
clinical complexity.
 Individuals require and receive
health care services from multiple
sites of care (including home),
over long periods of time, from
many clinicians and social support
providers.
As described in detail below, work undertaken by the S&I LCC
WG has:
Recommendation:
 Identified, in collaboration with HL7, a foundational
Leverage and extend the S&I LCC
set of health IT standards needed for the exchange of
work to develop a use case for a
key data and documents needed to support
collaborative care plan needed to
coordination of care;
serve the clinical complexity of
medically-complex and/or
 Identified transitions of care data sets needed for
functionally impaired persons and
shared care and care transitions;
meet their service needs across
 Identified the data set needed for the home health
settings and time.
plan of care;
 Developed a white paper describing a preliminary vision
for a care plan to support the longitudinal care needs of medically-complex and/or functionally impaired
S&I Longitudinal Coordination of Care WG
August 2012
3
persons across providers. The white paper identifies many of the components that are believed to be
needed for such a care plan, and initiates an analysis of the standards needed to support the
interoperable exchange of the care plan.
The impetus for the S&I LCC WG undertaking the activities described in this report was to describe how each of
these types of information exchange fit or could fit within the current or future stages of the Meaningful Use
Program.
S&I LCC WG Accomplishments Supporting and Advancing HIE for
Longitudinal Coordination of Care as Part of the Meaningful Use
(MU) Program
Recognizing the influence of the MU Program in advancing health IT and HIE, a goal of the S&I LCC WG has been
to identify standards that support the longitudinal coordination of care of medically-complex and/or functionally
impaired persons that are aligned with, and could be included in, future Meaningful Use requirements. To
support this goal, the S&I LCC WG identified, analyzed, and made recommendations regarding needed
refinements to the MU Program to support longitudinal coordination of care:


The S&I LCC WG collaborated with the HL7 Structured Documents
Workgroup in identifying and reviewing refinements to a key
health information exchange standard (i.e., the Consolidated
Clinical Document Architecture (Consolidated-CDA)) required in
the MU Program for the exchange of “summary care records.”
The MU Program proposes the use of the Consolidated-CDA to
support the exchange of summary care records at times of
transition and referrals in care. As a result of the S&I LCC WG and
HL7 collaboration, refinements to the Consolidated-CDA now
permit the standardized exchange of functional status, cognitive
status, and pressure ulcer content. Refinements to the
Consolidated-CDA were being considered for Stage 2 of the MU
Program.
Recommendation:
Stages 3 of the MU
Program include
standards to support
exchange of important
key clinical content
regarding an individual’s
status that builds on
functional status,
cognitive status and
pressure ulcers.
The S&I LCC WG also collaborated with the HL7 Structured Documents Workgroup to identify additional
refinements to document exchange standards to support coordination of care:
o The September 2012 HL7 ballot updates an earlier HL7 Draft Standard for Trial Use (DSTU) for
Questionnaire Assessments. The September ballot identifies vocabulary standards for a subset
of the CARE patient assessment instrument (previously piloted by CMS) and represents these
CARE items in a CDA format. Members of the S&I LCC WG collaborated with CMS on this
activity, including identifying the need to apply health IT standards to this instrument. The S&I
LCC WG collaborated with HL7 in reviewing the drafts of the implementation guide for the
exchange of this content. An example of the S&I LCC WG contribution to this DSTU is the
inclusion of information on vocabulary standards for the nursing home Minimum Data Set
S&I Longitudinal Coordination of Care WG
August 2012
4
o

(MDS) and the home health Outcomes and Assessment Information Set (OASIS). Spreadsheets
mapping the MDS and OASIS data elements to question patterns, value sets and Logical
Observation Identifiers Names and Codes (LOINC) codes are housed in the S&I Framework
Repository and linked in this DSTU.
The September 2012 HL7 ballot includes a further refinement to the Consolidated-CDA to
support the exchange of a Patient Questionnaire Assessment Summary. The Patient
Questionnaire Assessment Summary leverage s electronic assessments that nursing homes and
home health agencies are required to complete (i.e., respectively, the MDS and OASIS). Through
the S&I LCC WG, clinical and other subject matter experts validated a clinically relevant subset of
data elements from these instruments that would be useful to exchange at times of transition
and for instances of shared care. HL7, in collaboration with S&I LCC WG, identified additional
Consolidated-CDA templates for the interoperable exchange of these Patient Questionnaire
Assessment Summaries.
The S&I LCC WG developed an initial Use Case describing some of the key health information exchange
needs surrounding transition in care and instances of shared care
for medically-complex and/or functionally impaired individuals.
Recommendation:
The Use Case highlights four specific exchange scenarios involving
Standards needed for
transition in care, referrals in care, and the exchange of a plan of
data required to support
care. While the identified scenarios involve different parties for
transitions of care and
these exchanges, generally the Use Case highlights: provider-tocare plans for medicallyprovider data exchanges and provider-to-patient exchange. The
complex and/or
different scenarios described in the use case require health
functionally impaired
information exchange across different acute/primary care and
persons be identified,
LTPAC providers; and the exchange of different clinical content in
and, fills key gaps for
different document types. Scenarios described in the Use Case
Stage 3 of the MU
are:
program.
o Scenario #1 describes needed health information
exchange to support transitions in care between the acute
care hospital and home health agency (HHA) and between a skilled nursing facility (SNF) and the
Emergency Department (ED). The standardized data elements required for these two
transitions also meet the requirements of most other clinical exchanges between acute care and
LTPAC sites.
o Scenario #2 describes the exchange of a plan of care between the physician and the HHA. This
scenario describes the initial, interim and recertification exchange of the Home Health Plan of
Care (HH-POC) between the home health agency and the ordering primary care physician, for
purposes of update and signature, based upon a use case created by the Visiting Nurse Service
of New York (VNSNY).
The S&I Harmonization team committed to analyzing the data elements to be exchanged in each of the
scenarios of this use case and developing implementation guides to enable the exchange of this
information. This analysis will:
S&I Longitudinal Coordination of Care WG
August 2012
5
o
o
o
Identify how the exchange of this content is supported by accepted standards, including the
Consolidated-CDA;
Identify whether there are gaps in standards that need to be filled to support these types of
information exchange; and
Permit the development of implementation guides to support the exchange of this content.
Sites have been identified to pilot the exchange of information described in the LCC Use Case, leveraging the
health IT standards described above and other standards that are expected to be identified through the ONC S&I
standards harmonization activity (see below). The following pilots are anticipated in 2013:
 The Improving Massachusetts Post-Acute Care Transfers (IMPACT) Program, an ONC Challenge Grantee,
will pilot LTPAC transitions of care transactions using HIE; and
 The VNSNY will pilot exchange of the HH-POC between home health agencies and the ordering primary
care physician.
The S&I LCC WG presented information to the HIT PC Meaningful Use Workgroup regarding the need to refine
care plan requirements for Stage 3 MU. The HIT PC is recommending to the ONC that Stage 3 MU transitions of
care and care plan requirements be refined. We note that the recommendations advanced by the S&I LCC WG
are consistent with the preliminary recommendations advanced by the HIT PC Meaningful Use Workgroup (see
slides 27 – 21).
Starting on page eight of this document, we present a white paper on the “care plan” needed to support
longitudinal coordination care for medically-complex and/or functionally impaired individuals. Considerations
regarding this care plan were informed by: (a) consultation with and input by (i) persons with clinical expertise in
the health and long-term services and support needs of medically-complex and/or functionally impaired
persons, and (ii) representatives of the HL7 Patient Care Workgroup; and (b) the development of the home
health plan of care scenario for the initial LCC Use Case. The White Paper presents:
 A preliminary vision of the components needed for such a care plan;
 Initial considerations regarding the health IT functionality and standards needed to support the
interoperable exchange of this care plan; and
 The relationship of the vision for such care plan and the proposed requirements in the MU Program.
Recommendations
Stage 3 Meaningful Use (MU) Recommendation
The S&I LCC WG recommends that Stage 3 of the Meaningful Use Program incorporate requirements for the use
of interoperable clinical content, standards, and implementation guides to support (i) transitions of care and (ii)
care planning on behalf of medically complex and/or functionally impaired persons.
S&I Longitudinal Coordination of Care WG
August 2012
6
Recommendations for Advancing Standards, Implementation Guides, and EHR Certification
Criteria to Support the Preceding Stage 3 MU Recommendation
The S&I LCC WG recommends that the Office of the National Coordinator for Health Information Technology
(ONC)/ Office on Standards and Interoperability (OSI) provide support for the following activities for purposes of
advancing requirements for Stage 3 of the Meaningful Use program:
1. Information Exchange Requirements for Transitions in Care and Home Health Plan of Care.
Complete the work begun in the initial phase of the S&I LCC WG regarding the exchange of information
at transitions in care and for home health plans of care by identifying the content standards and
developing implementation guides needed for Stage 3 MU requirements. Specifically:
a. Identify and fill gaps in content standards for the interoperable exchange of clinical content
identified in the initial S&I LCC WG Use Case regarding:
i.
Transitions in care on behalf of medically complex and/or functionally impaired persons; and
ii. Home health plan of care.
Timeline: Work should be completed in the fall of 2012.
2. Develop implementation guides to support the interoperable exchange of information identified in
the initial S&I LCC Use Case for transitions of care and the home health plan of care.
Timeline: Work should be undertaken in collaboration with HL7 and balloted by HL7 in the January 2013
ballot cycle.
Information Exchange Requirements for Collaborative Care Plan.
Extend the initial S&I LCC WG Use Case and health information exchange requirements described in item #1
above and identify requirements for the interoperable exchange of Collaborative Care Plans for Stage 3 of the
Meaningful Use Program. Specifically:
1. Leverage and extend the Care Plan White Paper (attached) and the Home Health Plan of Care
Implementation Guide to develop a use case for the exchange of Collaborative Care Plans on behalf of
medically-complex and/or functionally impaired persons. The use case will describe 2-3 scenarios
involving the exchange of a Collaborative Care Plan.
Timeline: Work should be completed by January 2013.
2. Identify and fill gaps in content standards needed for the interoperable exchange of a Collaborative Care
Plan.
Timeline: Work should be completed in the February 2013.
3. Develop, and ballot through HL7, an implementation guide for the interoperable exchange of
Collaborative Care Plans.
Timeline: Work should be undertaken in collaboration with HL7 and balloted by HL7 in May 2013.
S&I Longitudinal Coordination of Care WG
August 2012
7
Needed ONC/OSI Support and Resources
The S&I LCC WG, a community led initiative, recommends that the ONC/OSI support and advance the activities
described above by leveraging and collaborating on related activities underway in other venues (e.g., HL7, ONC
Challenge Grants, etc.) and providing the following:
1. S&I personnel to guide and support the S&I LCC WG by:
a. Supporting activities described above
b. Reaching out to leaders in other settings (e.g., long-term services and supports, behavioral health
providers, physicians, etc.) and soliciting their engagement
c. Facilitating the S&I LCC WG engagement with and reporting to the: Health Information Technology
Policy Committee (HIT PC), Health Information Technology Standards Committee (HIT SC), and
others
2. Meeting support (virtual and face-to-face)
3. Wiki support
4. Standards analysis, harmonization, and gap filling
5. Development of three implementation guides in collaboration with and balloted through HL7 :
a. LTPAC Transitions of Care
b. Home Health Plan of Care
c. Collaborative Plan of Care
The S&I LCC WG has identified the need for a Collaborative Care Plan use case as a critically important next step
to advance longitudinal coordination of care for medically complex and/or functionally impaired persons. It is
our request that the ONC supports the extension of the work started by the S&I LCC WG to produce a use case
and align this process with the preliminary HIT PC Meaningful Use Workgroup recommendations. This will
require support to extend and complete the current S&I LCC WG activities. We are committed to developing HIE
standards and tools on behalf of persons who are medically complex and/or functionally impaired and the
clinicians who provide their care.
S&I Longitudinal Coordination of Care WG
August 2012
8
Care Plan White Paper
Care Plan White Paper
I. Overview
The Standards & Interoperability Framework (S&I) Longitudinal Coordination of Care Workgroup (LCC WG) has
developed this Care Plan White Paper to:
 Explore the “care plan” needed to support longitudinal coordination care for medically-complex and/or
functionally impaired individuals, and
 Identify opportunities to strengthen the care plan process through standards and requirements that
support the interoperable exchange of cross-setting care plans.
Recommendations
The S&I LCC WG recommends that the Office of the National Coordinator for Health Information Technology
(ONC) support the development of a care plan use case to identify the functional requirements, standards, and
implementation specifications needed for the interoperable exchange and maintenance of care plans to support
medically-complex and/or functionally impaired persons. Towards that end, the S&I LCC WG suggests the
following next steps to (i) lay the groundwork for developing care plan requirements and (ii) advance standards
for interoperable exchange of such care plans:
 Further assess the role and value of care plans for medically-complex and/or functionally impaired
persons.
 Validate care plan concepts identified in this white paper. Possible methods to consider include:
o Conducting further research on existing care plan standards
o Socializing care plan concepts presented
o Convening an ONC roundtable to validate care plan analysis
o Widely soliciting comments on analysis and concepts presented
 Identify and fill gaps in content standards needed for the interoperable exchange of a collaborative care
plan.
 Develop, and ballot through HL7, an implementation guide for the interoperable exchange of
Collaborative Care Plans.
Collaborative and longitudinal coordination of care is a critical piece of infrastructure for bringing effective and
efficient person-centered care to the most frail, complex and vulnerable individuals who receive health care
services.
Introduction
Considerations regarding this care plan were informed by: (a) consultation with and input by (i) persons with
clinical expertise in the health and long-term services and support needs of medically-complex and/or
functionally impaired persons, and (ii) representatives of the HL7 Patient Care Workgroup; and (b) the
development of the home health plan of care (HH-POC) scenario for the initial LCC Use Case. This White Paper
describes:
 A preliminary vision of the components needed for such a care plan;
S&I Longitudinal Coordination of Care WG
August 2012
9
Care Plan White Paper


Initial considerations regarding the health IT functionality and standards needed to support the
interoperable exchange of this care plan; and
The relationship of the vision for such care plan and the proposed requirements in the Meaningful Use
Program
Findings from the S&I LCC WG analysis of proposed care plan requirements in the Stage 2 Meaningful Use
proposed rules were shared with the Health IT Policy Committee (HIT PC) Meaningful Use sub-Workgroup #3
(Improve Care Coordination) on July 16, 2012. The HIT PC is recommending to the ONC that Stage 3 MU
transitions of care and care plan requirements be refined. We note that the recommendations advanced by the
S&I LCC WG are consistent with the preliminary recommendations advanced by the HITPC Meaningful Use Subworkgroup (see slides 27 – 21).
II. Analysis of MU Proposals Regarding Care Plans
1. Need for Care Plans
People living with serious chronic conditions and disabilities ordinarily have quite complicated situations –
medically, functionally, financially, and indeed, in multiple spheres of their lives. While certain principles and
practices tend to be common, the actual application to any one person’s situation routinely requires creative
work to assess strengths, problems, and likely course and to match with available services and supports. Thus,
most care plans are quite specific to the particulars of an individual’s situation, preferences, and resources. The
documentation of that plan is critical in arranging a practical set of services, in communicating the goals and
plans across time and settings, in enabling feedback as to the worthiness of the plan, and in enabling
management of the service delivery system by monitoring needs and service availability.
Each site of care develops a “care plan” which usually addresses the needs of the organization to use resources
efficiently and to initiate the individual’s transition to another site of care. As is often the case, these “care
plans” do little to inform the activities of the next site of care because the plans are not shared across sites or
because their applicability is limited to the originating site of care. Each new site of care develops its own “plan
of care” which continues this pattern of sequential, but not necessarily coordinated, care plans. A further
limitation of these plans is that they often address the “goals” of the health care provider rather than the goals
of the individual.
2. Care Plans That Support Person-Centered Care
The process of creating a care plan involves the collection of critical data sets from each discipline involved in
care, aggregating that data into four major categories: Personal Goals, Health Concerns (problems that need
management), Interventions and the Roles required to support the care. Through a process of prioritization of
goals and health concerns, identification of appropriate interventions to address those concerns and
identification of specific individuals with responsibility for managing elements of the care, the care plan provides
a blueprint for coordination of care across sites and providers.
Each plan is person-centric and addresses the individual’s specific Health Conditions, personal goals and
identified care team. The following diagram highlights the key inputs to the care planning process that the S&I
LCC WG believes are needed to support transition of care and concurrent shared care for medically-complex
S&I Longitudinal Coordination of Care WG
August 2012
10
Care Plan White Paper
and/or functionally impaired individuals. The “output” is an exchangeable care plan that provides the basis for
longitudinal coordination of care. These constructs require detailed representation in the Consolidated-CDA.
Figure 1: Care Plan Inputs and “Black Box” Process
3. Care Plan and the CMS/ONC NPRM
Based on considerations to date, the S&I LCC WG believes that clearer and more complete specification of the
functional requirements for care plans and their exchange standards is needed to support the interoperable
exchange of care plans and the meaningful use of care plan content in electronic health records (EHRs). The
considerations by and recommendations of the S&I LCC WG are presented below.
3.1 S&I LCC WG Analysis of CMS/ONC Proposed Care Plan Requirements
The S&I LCC WG believes that additional considerations and actions are needed to supplement the Centers for
Medicare and Medicaid Services (CMS) and ONC proposed rules to advance the meaningful use and
interoperable exchange of care plan components at transition of care, including evaluation of:
A. Care plan components needed to support medically-complex and/or functionally impaired individuals
over time and across multiple settings and providers. As summarized below (and more completely
S&I Longitudinal Coordination of Care WG
August 2012
11
Care Plan White Paper
discussed in section 3.3), the S&I LCC WG anticipates that clarification/refinement/expansion of care
plan components will be needed:
1. All care plan components identified for information exchange need to be clearly defined. The rules
identify but do not adequately define the following concepts:
a. Care plan and its components
b. Problems
c. Goals/outcomes
d. Instructions
e. Care team member
2. Some identified care plan components may need to be refined such as:
a. Identification of “instructions” as a subset of “interventions”
b. Expansion of the concept of “team member”. The ONC and CMS rules require that the summary
of care record include the name and contact information for referring and receiving providers,
and any additional known team members. The S&I LCC WG believes that a field in the care plan
should, at a minimum, identify all team members involved in the creation of the care plan, and
the roles of the team members involved in the execution of the care plan.
3. Some key care plan components may not have not been included in the CMS/ONC proposed rules
(e.g. “care plan decision modifiers” and “risk factors”)
B. Adequacy of standards to support the creation, transmission, and incorporation of the care plan and its
components at times of transition of care and concurrent shared care for medically-complex and/or
functionally impaired individuals. Issues requiring further investigation include:
1. Can the summary of care record, as currently required in the CMS and ONC proposed rules,
adequately support the creation, transmission and incorporation of care plans?
2. Is a document exchange standard for a care plan document type (e.g. identify “care plan” as a
document type in the Consolidated-CDA) needed?
3. Can the Consolidated-CDA standard support the:
a. Need to map Goals to Health Conditions (i.e., problems) and Interventions/Actions where there
is a many-to-many-to-many relationship?
b. Complete representation of complex medical conditions (such as CHF or Anticoagulation) for
purposes of care planning?
4. Are the Consolidated-CDA sections for Goals and Advance Directives adequate to support personal
values/expectations/preferences?
5. Are the Consolidated-CDA sections for Goals adequate to support barriers to success and
milestones?
6. Are the Consolidated-CDA Functional Status and other sections adequate to support Care Plan
Decision Modifiers (e.g., access to care, transportation, and Long Term Services and Supports)?
7. Can the Consolidated-CDA, or other appropriate standard, support the iterative document exchange
and management needed for care planning over time and across multiple settings and providers?
S&I Longitudinal Coordination of Care WG
August 2012
12
Care Plan White Paper
3.2 Care Plan Components
Based on (i) preliminary discussions among the S&I LCC WG; and (ii) an informal review of the literature for
terms related to care plan [see Appendix B], the S&I LCC WG members believe the following care plan
components should be further evaluated, reviewed, and defined as appropriate. In addition, work is needed to
evaluate the care plan components needed for additional care settings (e.g. rehab facilities, long term services
and supports, etc.).
Care Plan Term/
Component
Care Plan
Problem
Health Concern
Care Plan Decision Modifiers
Risk Factors
Interventions
Instructions
Goals
Patient Status/Outcome
Team member
Discussion
Referenced by HIT PC and in CMS Rules
Referenced in CMS Rule and defined as “the focus of the care plan”
The S&I LCC WG believe that care plans should capture and address
the broad array of “health concerns” experienced by medically-complex
and/or functionally impaired individuals such as:

Acute and Chronic Active Medical Problems

Concerns for potential problems such as injury, illness, and health
promotion (wellness). These are identified by possible disease
progression, treatment side effects, or as the result of Risk Factors
or Patient Status (defined below)
The S&I LCC WG believe that decisions being made during the care
planning process (e.g. prioritizing health concerns, setting goals, and
identifying interventions)are informed and modified by personal/family
preferences (e.g. values, priorities, wishes, expectations and advance
directives) and the individual’s situation (access to care, support,
resources, setting, and transportation). These are collectively called
“care plan decision modifiers.” Includes factors supported by long term
supports and services (LTSS) such as transportation, etc.
Historical factors that increase an individual’s risk for illness or injury,
including:

Age, gender

Significant Past Medical/Surgical History

Family History, Race/Ethnicity, Genetics

Historical exposures/lifestyle (e.g., alcohol, smoke, radiation, diet,
exercise, workplace, sexual practices)
Not in CMS/ONC rules, but believed to be a necessary component of a
care plan
In CMS/ONC rules. Believed to be a subset of interventions, being those
interventions assigned to specific member or members of the care team,
including the individual.
In CMS/ONC rules. Believe goals/outcomes should be disaggregated.
At any point in time, assessments are performed which identify the
current status of an individual’s health conditions or the results of
interventions or the risk for illness/injury. These are collected in the
following domains:

Functional (e.g. ability to walk)

Cognitive (e.g. mood, behavior, memory, etc…)

Physical (e.g. wound status)

Environmental (e.g. exposures, home safety, etc…)
In CMS/ONC rules, but value sets not defined.
Next Steps
These concepts should be further
reviewed, refined/supplemented,
vetted and, if necessary, defined
Table 1: Key Care Plan Terms and Components
S&I Longitudinal Coordination of Care WG
August 2012
13
Care Plan White Paper
3.3 Care Plan Components – Standards Analysis
Based on (i) preliminary discussions among the S&I LCC WG; and (ii) an informal review of the Consolidated-CDA
Implementation Guide for components related to care plan, the S&I LCC WG members believe that further
analysis is needed of available standards to support care plan components, processes and the interrelationships
of the care plan components As illustrated in Section III – Figure 2, initial thinking by members of the S&I LCC
WG suggests that there is a many-to-many-to-many relationship between health concerns, goals and
interventions. For example, a diabetic with coronary artery disease (2 problems) will have an LDL cholesterol
goal that relates to both of those problems, and a glucose goal that only relates to the diabetic problem, and
interventions of medications, diet, and exercise that relate to one or the other or both problems and goals. The
standards analysis will need to consider whether (i) the care plan and its components are represented in a
standard, (ii) the representation is appropriate and the components are clearly defined, and (iii) the available
standards will support the exchange and iterative expression of these complex and evolving relationships. The
S&I LCC WG will begin this analysis by:
 Leveraging and extending standards harmonization activities from the Home Health Plan of Care
scenario of the LCC Use Case, and
 Collaborating with the S&I Transitions of Care WG, HL7 Structured Documents WG and HL7 Patient Care
WG to evaluate the availability of, and gaps in, standards to support the creation, transmission and
incorporation of the care plan and its components.
4. Additional Actions/Analysis Needed
As stated in the Overview of this White Paper, collaborative and longitudinal coordination of care is a critical
piece of infrastructure for bringing effective and efficient person-centered care to the most frail, complex and
vulnerable individuals who receive health care services.
To address this need, the S&I LCC WG recommends that the ONC support the development of a care plan Use
Case to identify the functional requirements, standards, and implementation specifications needed for the
interoperable exchange and maintenance of care plans to support medically-complex and/or functionally
impaired persons. Towards that end, the S&I LCC WG suggests the following next steps to (i) lay the groundwork
for developing care plan requirements; and (ii) advance standards for interoperable exchange of such care plans:
 Further assess the role and value of care plans for medically-complex and/or functionally impaired
persons.
 Validate care plan concepts identified in this white paper. Possible methods to consider include:
o Conducting further research on existing care plan standards
o Socializing care plan concepts presented
o Convening a ONC roundtable to validate care plan analysis
o Widely soliciting comments on analysis and concepts presented
 Identify and fill gaps in content standards needed for the interoperable exchange of a collaborative care
plan.
 Develop, and ballot through HL7, an implementation guide for the interoperable exchange of
Collaborative Care Plans.
S&I Longitudinal Coordination of Care WG
August 2012
14
Care Plan White Paper
III. Considerations for Technology Enabled Care Plans
The S&I LCC WG undertook the task of documenting gaps to technology enabled sharing of care plans between
health care entities. One major assumption was that there were common elements of a care plan process and
model which could be extended across these entities. An ongoing environmental scan of care planning models
revealed the following common clinical concepts: Problems, Interventions and Goals. Terminology and
hierarchy of the concepts in the care plans was variable, however. It became immediately apparent that gaps
not only impacted the ability to share care plans between organizations, but more importantly, there was
extensive mal-alignment of the care plan with clinical information streams and documentation systems and
therefore the care delivery process itself was not well supported by current technology and standards.
The S&I LCC WG has documented the inputs and outputs of care plan by studying how care plans develop. The
resulting use case produced artifact(s) of a care plan designed to validate CMS payment for services to a home
health agency (i.e., the Home Health Plan of Care). A list of high level functional requirements (data objects and
data elements) for the care plan has been defined. This list extends concepts previously identified in S&I
Transition of Care requirements and the HL7 Patient Care Workgroup.
In addition, care plan concepts contained in Stage 2 MU proposed rules have been evaluated in the context of
these functional requirements and critical components of a care plan not yet represented in the proposed rules
have been identified (see Section II above). These gaps in information streams, semantics and care plan
document architecture, as well as functional requirements, will be used to evaluate the current ConsolidatedCDA document types and data templates for their adequacy to communicate a more complete care plan.
Information Streams Common to Care Plan Models
Planning and coordination of care for complex or frail persons usually involves the creation of a care plan. Since
the introduction of the SOAP note in the 1970’s, the medical provider community has typically created a section
of the medical progress note for the Plan. This content would most typically contain a listing of the individual’s
medical problems or conditions and an articulation of a plan, often an assessment of the status of the condition,
followed by the interventions intended to address that diagnosis.
The evolution of the concepts of the care plan seem to logically progress from the Plan section of a SOAP-based
progress note to the concept of a Treatment Plan, which would typically contain the instructions for the
individual and staff relative to that individual’s care requirements. The S & I LCC WG proposes that every care
discipline can create a treatment plan and that the compiled, reviewed and edited treatment plans for each
condition being proactively managed would be considered a Plan of Care for purposes of the CMS
reimbursement requirement for a Home Health Plan of Care.
As exemplified by this Home Health Plan of Care scenario, the process of creating a care plan involves the
collection of the critical data sets from each discipline involved in care, aggregating that data into categories,
prioritizing health concerns, and then identifying appropriate interventions, if any, to address those concerns.
As a care plan becomes more abstract and potentially applicable to other situations, it might be considered
interdisciplinary when the input from each discipline is processed into a consensus document reflecting the
appropriate decision modifiers represented by the individual, the care team and the external influences to the
plan. It is also a continuously (or repeatedly) evolving plan. The care plan is updated as outcomes are achieved,
assessments are performed, and the individual’s status changes.
S&I Longitudinal Coordination of Care WG
August 2012
15
Care Plan White Paper
Figure 2: S&I LCC WG Vision of Longitudinal Care Planning
There are at least 10 recognized nursing care plan models and vocabularies. Representative examples include
the Clinical Care Classification (CCC) system, North American Nursing Diagnosis (NANDA), Nursing Intervention
Classification (NIC) and Nursing Outcomes Classification (NOC), and The Omaha System. In addition,
Rehabilitative Services such as Physical and Occupational Therapy, Speech and Language Pathology, Respiratory
Therapy as well as Behavioral Health and supportive services such as Nurse Case Managers/Social Work Case
Managers, Pastoral Care and Social Work provide input to the care plan process. Individuals and health care
proxies and other advocates for the individual would be reasonably expected to contribute to the care plan as
well as receive instructions for self-care and expectations for services rendered including expectations of their
participation in care delivery.
The interdisciplinary care plan commonly contains the following information streams.
A. Goals
1. Goals are complex concepts used in a wide variety of contexts. Some goals are short term and
measureable, such as a goal weight or target blood pressure or pain score. Indications may be attached
to a medication message however; in a care plan the indication for a treatment is not sufficient to define
the goal.
S&I Longitudinal Coordination of Care WG
August 2012
16
Care Plan White Paper
a. Other terms are commonly used in care plans. Desired outcomes and expected major and minor
manifestations of success or failure of the intervention is often represented. For example,
”Dyspnea, as evidenced by a respiratory rate of greater than 24 or a patient report of shortness of
breath or the use of nebulized bronchodilators at a rate of greater than every 4 hours, is addressed
by the following …..”. The goals are suggested by the desired outcomes (comfortable breathing, no
symptoms, and infrequent use of as needed medications). These manifestations of success or
failure provide important guidance to the service delivery team as well as information regarding the
success of the intervention and status of the health concern. Other important concepts are
Milestones. These are very common in Rehabilitation care plans. For example: “In two weeks,
patient to be able to ambulate 100 feet with distant supervision only.” This phasing of progress has
been implemented into payment for rehabilitation, where progress to milestones has been evidence
of successful response to treatments and in many cases ongoing extension of an insurance benefit
(i.e. the service has been determined to meet medical necessity criteria).
b. Goals may or may not be health care concepts. Individuals may have a goal of attending a
grandchild’s wedding or walking her down the aisle. Individuals may wish to survive to a religious
holiday, or visit a site of military action where they served. These types of goals are more global and
require the success of not one intervention but most or all interventions.
c. The relationship between milestones, desired outcomes and overarching goals is important for
coordination of care and to gauge the success of the care plan in its entirety. This connection is not
yet defined in any known standard. Additionally, the concepts, vocabularies and value sets are not
standardized.
B. Problems
1. “Problems” is the term most commonly used to define the target condition for the intervention, with
the presumption that optimizing the status of the problem will create a desired outcome.
a. “Problems” is a concept already in common usage for the medical diagnosis list and is part of the
structured data required for EHR Certification and the Meaningful Use Program.
b. Concerns and conditions which are inputs into the care plan will contain some of the data
unchanged from the medical diagnosis list, but will also contain concepts from other sources, such
as CCC, NANDA, NIC, NOC and the International Classification of Functioning, Disability and Health
(ICF). Concerns reported by an individual may not be able to be represented in any known standard
but may require investigation or other interventions.
i. HL7 has defined a concept called Health Concerns which represents a broader set of standards
and definitions to collect impairments and barriers to optimized health status from a wider set
of clinical observers.
ii. Some care plan models focus on what the individual and their situation offer as opposed to their
deficits (i.e., “strength based”). This might include the treatments intended to augment strength
in a limb with preserved motor function or to leverage intellectual capacity to minimize
manifestations of dementing illnesses (e.g. coping strategies). Some interventions are intended
to be habilitative (designed to preserve a functional capacity required for self-care) or
restorative (intended to increase the time spent engaging in self-care or assisted self-care). In
general, however, these strength based interventions are compensatory for a health deficit.
iii. Well people can also have a personal plan of care. The concept of Health and Wellness
Maintenance is not defined as the problem, however, the risk of functional decline and illness
with increasing longevity could be represented as the Health Concern.
S&I Longitudinal Coordination of Care WG
August 2012
17
Care Plan White Paper
C. Interventions
1. “Interventions” is the term most commonly used to define the set of instructions to the care team and
orders for additional services to refine the care plan.
a. Interventions may contain orders or recommendations.
i. Medications as interventions: Medications are among the most common interventions for
health concerns however, the structured message from an e-Prescribing or CPOE system is not
structured for use in the care plan. Additional information such as administration schedules,
precautions, monitoring requirements, potential side effects, strategies for compliance and
administration, may be needed by the care team responsible for ensuring safe medication
practices.
b. Additional interventions come from a variety of sources and might include treatments such as
wound care, assessments by skilled service providers, as well as human services such as grocery
shopping, transportation, compliance support and a wide range of other potentially helpful
strategies to optimize the management of health conditions. Although these elements are
important to a care plan, they are not yet structured to support interoperability.
D. The data inputs into the care plan are collected and the care plan process interacts with that data. This may
be done in discrete episodes, or nearly continuously, depending on the setting, complexity of the individual,
and accessibility of the information. Decision support tools linking assessments and care plans with
associated alerts for suboptimal responses to interventions would be an important outcome of greater
structure and interoperability. Processes that lead to the output of a care plan include:
1. Collection of the data sets for input;
2. Determination of the critical decision modifiers for the individual under review. These decision
modifiers:
a. Include considerations such as prognosis, personal values, family and cultural biases, spiritual
convictions, prior experiences with care, access to care, financial consequences, clinical practice and
disease management guidelines, and other major decision modifiers.
b. Provide the filter through which the health conditions are prioritized and the goals personalized and
optimized to that individual’s condition. For example, a diabetic may express a goal of longevity
however, economic and environmental factors may impede the ability to make healthy diet choices
and maintain the medication regimen that would support that goal. Therefore, it is the realistic
application and negotiation of the decision modifiers which allows for a subset of health concerns to
be care planned effectively. This is a process that involves shared decision making with the
individual, taking into account decision modifiers, evidence based medicine, as well as the risks and
value of the interventions.
3. Creation of the care plan - The component information is compiled. The relationships of Goals,
Interventions and Health Conditions may be many to many. The care plan is represented as Treatment
Plans, Medication Administration Records, Instructions for Patients, or for payment purposes, as a
Provider Plan of Care.
E. Other concepts identified in the care plan via the process of its creation are also important to call out.
1. Team members. The Stage 2 MU proposed rules require the inclusion of team members in the care plan
section of the clinical summary.
a. “Team members” is ambiguous.
i. The team creating the care plan may be different from the providers effectuating the plan.
b. Care plans may be developed through a collaborative process with a variety of inputs. The roles
providing input into sections like Risk Factors and Care Plan Decision Modifiers may not be part of
the collaborative process using the decision modifiers and creating the care plan.
S&I Longitudinal Coordination of Care WG
August 2012
18
Care Plan White Paper
c. The reconciliation of provider treatment plans with the care plan is not a well-defined process and
the semantic and functional interoperability of those two data sets are not well defined.
Figure 3: Care Plan Inputs and Process in the “Black Box”
S&I Longitudinal Coordination of Care WG
August 2012
19
Appendix A – The Work of the S&I Longitudinal
Coordination of Care Workgroup
Introduction & Background
The ONC Standards and Interoperability Framework (S&I) Longitudinal Coordination of Care Workgroup (LCC
WG) is a community-led initiative that supports health information exchange (HIE) on behalf of long term and
post-acute care (LTPAC) stakeholders. This workgroup addresses potential gaps in the S&I Transitions of Care
work products to support HIE and promotes longitudinal coordination of care on behalf of persons who receive
LTPAC services and the providers who serve them. The initial use case developed for the S&I LCC WG includes
scenarios and user stories that delve into the health IT standards needed to support HIE on behalf of persons
receiving LTPAC services. Activities of the S&I LCC WG are directed towards furthering the meaningful use of
EHRs and informing the identification of EHR certification criteria needed by LTPAC providers, and advancing
longitudinal coordination of care.
Background
Each year approximately 15 million medically-complex and/or functionally impaired Americans need long-term
and post-acute care (LTPAC) services in nursing facilities (NFs), home health agencies (HHAs), and other settings
such as Long Term Care Hospitals (LTCHs) and Inpatient Rehabilitation Facilities(IRFs). This mostly elderly
population is highly susceptible to unanticipated hospitalizations and re-hospitalizations and requires a
coordination of treatments, interventions and advance communication technologies to deliver the care that
they require. Managing acute care transitions is key to targeting health care expenses, making it a national
priority. Since many of these individuals are in the 5 percent of high-cost patients that account for 50 percent of
health care spending2 a longitudinal, person-centered approach to their care is required.
There are at least three significant sets of complexities that merge to drive these costs. The first is the clinical
complexity of these individuals which is compounded with each additional level of comorbidity. These
individuals are sicker and have more active problems than average. Routine acute care problems such as
respiratory and urinary tract infection are often superimposed on chronic heart, lung, liver and kidney
conditions. These combinations are often more difficult to treat successfully than the acute problem alone. The
complex medical issues often result in functional impairments that further complicate treatment and
rehabilitation. Cognitive impairments and behavioral issues also confound management and treatment options.
Each level of comorbidity significantly increases the physiological complexity of these individuals with the result
that they are sicker than the average patient and sicker for a longer time.
The clinical complexity of these individuals is only part of the story. The medical complexity is matched by the
organizational complexity of providing care. These individuals receive health care from more sites of care, and
often also requiring long term services and supports (e.g. housing, nutrition services, homemaker), over longer
periods of time, with more clinicians, providers and caregivers contributing to their care. The organizational
Cohen S. The Concentration of Health Care Expenditures and Related Expenses for Costly Medical Conditions, 2009. MEPS Statistical Brief
No.359. February 2012. Agency for Healthcare Research and Quality, Rockville, MD.
http://meps.ahrq.gov/mepsweb/data_files/publications/st359/stat359.shtml
S&I Longitudinal Coordination of Care WG
August 2012
20
Appendix A – The Work of the Longitudinal Coordination of Care WG
complexity increases with the addition of each new site and team member. Complex individuals with multiple
comorbidities face greater challenges for coordination of care and comprise the highest cost patient population.
The third level of complexity results from engaging the individual and family caregiver(s) in their care. Although
specific health concerns drive the organization of care, it is the individual that sets the overall goals of care,
determines whether proposed interventions are consistent with their wishes, and sets the outer boundaries of
what is permitted. This is the heart of person-centered coordination of care. How individuals make these
decisions, how they are communicated and how they are amended creates the final level of complexity.
Without the individual’s engagement from this third level, the interventions lack context, and the vision of
person-centered care will not be realized.
The complexities outlined above make longitudinal coordination of care essential. Without the ability to
coordinate care over time, across multiple clinicians and sites of service, and with the engagement of the
individual (i.e. longitudinal coordination of care) these medically-complex and/or functionally impaired persons
are faced with care that can be fragmented, duplicative and costly. Typically these individuals experience
multiple transitions to and from LTPAC settings to emergency rooms and hospitals. Management of these
transitions is complicated by the lack of standardized transitions of care data and the absence of a platform that
permits the exchange of a care plan among the many providers typically involved with these individuals. Such
deficits create potential information gaps that can result in omissions of essential care, unintended duplication
of tests and treatments, and excessive cost.
Work of the S&I LCC WG
The S&I LCC WG established the following three sub-workgroups:
 Patient Assessment Summary Sub-workgroup
 LTPAC Transitions Sub-workgroup
 Longitudinal Care Plan Sub-workgroup
In addition to supporting the activities of these sub-workgroups as described below, the S&I LCC WG has
completed an initial, baseline use case identifying the functional requirements and data elements necessary for
clinical information exchange to:
 Support longitudinal coordination of care, transitions of care and instances of shared care among
healthcare providers in hospital, primary care, and LTPAC sites; and
 Inform individuals/caregivers/delegates and engage them in the management of the individual’s care.
The S&I Transitions of Care Initiative Use Case V1.1 was the starting point for the development of concepts,
requirements and data relevant to longitudinal support of medically-complex and/or functionally impaired
persons. The following scenarios, which leverage MU incentives to eligible professionals and eligible hospitals
and support information exchange with LTPAC, are found in the baseline LCC use case:
Scenario 1: Provider-to-Provider data exchanges for Transfer of Care and Referral including:
 Transition from acute care hospital to LTPAC site (exemplified by HHA) - exchange Transfer of Care
Summary
 Transition from LTPAC Site (exemplified by NF) to Emergency Department/Consultant – exchange
Consultation Request and Clinical Summary
S&I Longitudinal Coordination of Care WG
August 2012
21
Appendix A – The Work of the Longitudinal Coordination of Care WG

Transition from Emergency Department/Consultant to LTPAC Site (exemplified NF) - exchange Shared
Care Encounter Summary
Scenario 2: Provider-to-Provider data exchanges of the Home Health Agency plan of care (HH-POC)
including:
 Exchange HH-POC (Initial and Recertification) - HHA to Physician, Physician to HHA
 Exchange interim changes to HH-POC - HHA to Physician, Physician to HHA
Scenario 3: Provider-to-Patient data exchanges that provide a copy of the Provider-to-Provider data to the
individual/delegate for the transitions of care data exchanges described in Scenario 1.
Scenario 4: Provider-to-Patient data exchanges that provide a copy of the Provider-to-Provider data to the
individual/delegate for the HH-POC data exchanges described in Scenario 2.
With the LCC Use Case completed, the next needed activities are: harmonizing existing standards, identifying
gaps, developing implementation guides and reference implementations, and coordinating pilots with a goal of
making tested implementation guides for the Use Case transactions and documents available for MU3
consideration by mid-2013.
The functional requirements identified in this initial LCC Use Case are the first steps towards identifying health
IT/HIE standards to support longitudinal coordination of care on behalf of medically-complex and/or functionally
impaired persons. For example, the exchange of the HH-POC for update and signature is a starting point for the
identification, and development, of standards that enable the exchange of care plans. It builds, incrementally,
towards a care plan that could further evolve to support longitudinal coordination of care.
Patient Assessment Summary Sub-workgroup
Purpose
The S&I LCC Patient Assessment Summary Sub-workgroup (PAS SWG) was formed to identify standards needed
for the interoperable exchange of patient assessment content and patient assessment summary documents to
support the care of persons receiving LTPAC services. The PAS SWG worked to support interoperable exchange
and re-use, to the extent possible, of assessment information as a near-term opportunity to engage LTPAC
providers in health information exchange with other members of their communities.
Background
The Centers for Medicare and Medicaid Services (CMS) requires that certain providers complete and
electronically transmit patient assessments. For example, almost all nursing homes and home health agencies
electronically transmit to the agency the following, non-interoperable, patient assessment instruments:
 Minimum Data Set 3.0 (MDS3.0) for nursing homes
 Outcome and Assessment Information Set - C (OASIS-C) for home health agencies
Data from the MDS and OASIS assessment instruments is used for several purposes including care planning,
Medicare/Medicaid payment, survey, and quality measurement.
S&I Longitudinal Coordination of Care WG
August 2012
22
Appendix A – The Work of the Longitudinal Coordination of Care WG
For purposes of a payment demonstration, CMS piloted the CARE (Continuity Assessment Record & Evaluation)
instrument at hospital discharge and upon admission and discharge from post-acute care sites. Some CARE
content overlaps with MDS content. Effective October 2012, CMS will require that Long-Term Care Hospitals use
certain CARE data elements to measure quality in this setting.
While content in these assessment instruments is similar, it is not the same. Currently there are no uniform
definitions, assessment methods or scales across these instruments. The lack of comparability across
assessment instruments creates challenges for re-using assessment content across provider settings.
Challenge
The Keystone Beacon Community (KBC) launched a project to engage nursing homes and home health agencies
in the Keystone Health Information Exchange (KeyHIE) by leveraging the electronic MDS and OASIS files LTPAC
providers are required to create for CMS. Working with their vendor partner (GE), HL7, and the PAS SWG; and
using the health IT content standards identified and linked to the MDS 3.0 and OASIS-C in the ASPE study
Opportunities for Engaging Long Term and Post-Acute Care Providers in Health Information Exchange KBC is
piloting the interoperable exchange of a subset of the most clinically relevant MDS and OASIS items (i.e., a MDS
Patient Assessment Summary or OASIS Patient Assessment Summary).
Work on the development of interoperability standards for the exchange of patient assessment summaries is
being advanced by KBC under the PAS SWG in collaboration with HL7.
Actions and Timeline
A. In collaboration with HL7, identified standards needed to represent and transmit using the ConsolidatedCDA the content in the following domains: functional status, cognitive status, and pressure ulcers. HL7
included these standards in a May 2012 out-of-cycle ballot. Status: Complete.
B. For patient assessment summaries, validated and refined a subset of MDS 3.0 and OASIS-C content
(originally identified through the ASPE study Opportunities for Engaging Long Term and Post-Acute Care
Providers in Health Information Exchange) that could be clinically useful to exchange with hospitals,
physicians, other LTPAC providers, and/or family members. Status: Complete.
C. Patient Questionnaire Assessment Summary IG: In collaboration with KBC and HL7, identify, develop, and
ballot in September 2012 a Consolidated-CDA implementation guide and schema that includes the clinical
domains in the patient assessment summary documents (based on the MDS and OASIS) to support
transitions in care and instances of shared care. Status: On-going (IG included in HL7 September 2012
ballot)
D. Provide input and guidance on the transformation tool being developed by KBC to transform the noninteroperable MDS 3.0 and OASIS-C into interoperable clinical summary documents (i.e., patient assessment
summary documents) that can be made available for HIE. Status: On-going.
E. Beginning in December 2012, KBC will pilot the exchange of patient assessment summary documents using
the standards balloted by HL7 in May and September 2012. Status: Work in progress.
F. Questionnaire Assessment IG: In collaboration with CMS, Lantana Consulting Group, and HL7, update the
closed HL7 Questionnaire Assessment DSTU. The update would represent the CARE assessment instrument
in a CDA format and includes information on vocabulary standards for MDS and OASIS. Spreadsheets
mapping the MDS and OASIS data elements to question patterns, value sets and LOINC codes are housed in
S&I Longitudinal Coordination of Care WG
August 2012
23
Appendix A – The Work of the Longitudinal Coordination of Care WG
the ONC S&I Framework Repository and linked in the DSTU. Status: On-going (IG included in HL7 September
2012 ballot)
LTPAC Transitions Sub-workgroup
Purpose
The LTPAC Transitions Sub-workgroup (LTPAC SWG) was formed to identify standards needed for the exchange
of an interoperable summary document to support transitions in care. Representatives from the ONCsponsored Massachusetts Challenge Grant are leading this SWG.
Background
The Massachusetts Challenge Grant seeks to advance interoperable HIE on behalf of LTPAC providers by
leveraging their state HIE and implementing the Improving Massachusetts Post-Acute Care Transfers (IMPACT)
program. The IMPACT program is developing tools to support decision-making and information sharing at the
point of transfer to improve patient safety, reduce unnecessary hospitalizations and lower overall health care
costs.
Challenge
The Massachusetts IMPACT program is working with the S&I LCC LTPAC SWG to identify standards needed for
the exchange of an interoperable [universal] transfer form. The LTPAC SWG anticipates re-using a subset of
ubiquitous MDS and OASIS assessment content, that will be made interoperable, to partially populate standard
data sets for all transitions from LTPAC providers to acute care hospitals, and transitions between LTPAC
providers. In addition, the LTPAC SWG envisions re-using a subset of standardized MDS 3.0 and OASIS
assessment data to support HIE with individuals and family members. Within these data sets are many, but not
all, of the data elements required for creating a longitudinal care plan.
Actions and Timeline
A. Developed a priority list of acute/post-acute transitions based on volume, clinical instability and acuity of
the required information. Status: Complete.
B. Identified standard clinical content defined by the receiving clinicians for all high-priority transitions. Status:
Complete.
C. Develop standard data sets that apply to all high priority LTPAC transitions of care. Status: Complete.
D. Re-use selected data elements from OASIS and MDS to populate the transitions data sets from home health
agencies and skilled nursing facilities/extended care facilities. Status: Work in progress.
E. Identify available standards and develop an implementation guide to support the interoperable exchange of
the standard transitions data sets. Status: Work in progress. To be completed by December 2012.
F. Beginning in December 2012, pilot the exchange of transfer forms using the standards balloted by HL7 in
June and September 2012. Status: Work in progress.
Longitudinal Care Plan Sub-workgroup: Home Health POC Initiative
Purpose
The S&I LCC Longitudinal Care Plan Sub-workgroup (LCP SWG) was formed to identify standards needed for the
interoperable exchange of care plans. The work being undertaken by this SWG is divided in two tracks:
S&I Longitudinal Coordination of Care WG
August 2012
24
Appendix A – The Work of the Longitudinal Coordination of Care WG
A. The Home Health Plan of Care (HH-POC, see below); and
B. Identification of the components and standards needed for a “collaborative care plan” to support
longitudinal care needed by medically-complex and/or functionally impaired individuals and the relationship
of needed care plan components and standards to proposed requirements in the Meaningful Use program
(see Care Plan White Paper on page 8 of this paper).
Challenge
The LCP SWG is supporting work being undertaken through the New York e-Health Collaborative in collaboration
with Visiting Nurse Services of New York (VNSNY), physician practice groups, and other stakeholders to create an
interoperable plan of care document for home health that would be continuously updated and shared between
the home health agency and a physician. The plan of care document that will be standardized in the NY project
is based on the “485 form” formerly required by CMS which remains in widespread use by home health
agencies. Although originating in New York, this project is gaining state and vendor support around the United
States. The VNSNY anticipates re-using a subset of interoperable OASIS-C assessment content to partially
populate the interoperable home health plan of care (HH-POC).
Representing the constructs and data elements essential to exchange the HH-POC is an essential first step
towards the exchange of longitudinal care plans. However, not all data elements in a longitudinal care plan are
also found in the HH-POC. Further work is required to identify and adequately represent the requirements of a
longitudinal plan of care within the Consolidated-CDA.
Actions and Timeline
A. Validated and refined the content to be included on the HH-POC. Status: Complete.
B. Identify content and format standards needed to represent content of the HH-POC. Status: Complete.
C. Re-use, as feasible, standardized OASIS assessment content provided by the ASPE study Opportunities for
Engaging Long Term and Post-Acute Care Providers in Health Information Exchange. Status: Work in
progress.
D. Develop and ballot a CDA implementation guide and schema leveraging work under way by the VNSNY
home care POC pilot to enable the interoperable exchange of the HH-POC. Status: Work in progress.
S&I Longitudinal Coordination of Care WG
August 2012
25
Appendix B – Care Plan Definitions & References
1. Definitions
Source
Care Plan
Health Information Technology Standards
Panel
Definition
The plan of care (care plan) is the structure used by all stakeholders,
including the patient, to define the management actions for the
various conditions, problems, or issues identified for the target of
the plan. It is the structure through which the goals and care
planning actions and processes can be organized, planned,
communicated, and checked for completion
Specifically, a care plan is composed of the following elements:
“Problem” is another data type
“Intervention” may be a procedure, medication, substance… (any
data type that is an action)
The “goal” is what is expected to happen.
The “outcome” is what happened which can be shown by other
data types
ISO/TC215-ISO 13940- System of
Statement, based on needs assessment, of planned health care
concepts to support continuity of careactivities in a health care process. Care plan will be reviewed
ContSys-Committee Draft- Nov. 2011
repeatedly during a health care process, each review based on a
new needs assessment.
Agency for Healthcare Research and
A sequenced list of treatments, other services, and resources that
Quality, United States Health Information are prescribed to improve a PARTY´s STATE OF HEALTH AND
Knowledgebase (http://ushik.ahrq.gov )
WELLBEING. For example, a rehabilitation program for a back injury.
Registration Authority: Australian
A care plan is a scheme which groups and specifies the role...s of
Institute of Health and Wellness
material or human resources, planned events and parties in
providing health and welfare services to an individual or group. A
CARE PLAN may not always be formally notified or even
documented.
Stedman's Medical Dictionary for Health
A carefully prepared outline of nursing care showing all of the
Professions and Nursing. 7th Edition,
patient's needs and the ways of meeting them; a dynamic
2012 Wolters Kluwer Health, Lippincott
document initiated at admission and subject to continuous
Williams & Wilkins, pp. 1821 plus APP 512 reassessment and change by the nursing staff caring for the patient;
typically includes nursing diagnoses, nursing interventions, and
outcomes; ensures consistency of care; may be standardized or
preprinted. SYN plan of care.
http://medicalCare plan - a document that identifies nursing orders for a patient
dictionary.thefreedictionary.com/provisio and serves as a guide to nursing care. It can either be written for an
nal+treatment+plan
individual patient, be retrieved from a computer and individualized,
or be preprinted for a specific disease, condition, or nursing
diagnosis and individualized to the specific patient. Standardized
care plans are available for a number of patient conditions.
S&I Longitudinal Coordination of Care WG
August 2012
26
Appendix B - Care Plan Definitions & References
Source
http://medicaldictionary.thefreedictionary.com/provisio
nal+treatment+plan
Definition
Plan (Omaha) in the Omaha System - an analytical process of
activity designed to establish a course of client care; this includes
establishing priorities and selecting a course of action from
identified alternatives.
Problem
Instruction
Goal
Health Information Technology Standards
Panel
A goal is a defined target or measure to be achieved in the process
of patient care. A typical goal is expressed as an observation
scheduled for some time in the future with a particular value
Table 2: Definitions of “Care Plan” and Components of Care Plans
S&I Longitudinal Coordination of Care WG
August 2012
27
Appendix B - Care Plan Definitions & References
2. References
Ref.
Section
Content
S&I Framework
Transitions of Care Initiative
Elements in Transitions of Care Use Case (8/1/2011)
Table 15: Data Set for Discharge Instructions
T.CC.21
Plan of Care
Proposed interventions
and procedures for patient
S&I Framework
Transitions of Care Initiative
Elements in Transitions of Care Use Case (8/1/2011)
Table 17: Data Set for Clinical Summary
T.CC.22
Plan of Care
Proposed interventions
Plan of
and procedures for patient
Treatment/Treatment
Plan/Care Plan (R/N) -
S&I Longitudinal Coordination of Care WG
Additional Notes
Subsections include the following (1-7)
1. Goals.
2. Results yet to be received and procedures
to be followed up on.
3. Active and scheduled interventions and
orders (short term direct instructions [e.g.
Vital sign checks, labs, etc.] - in the long run
as validated by the patient and those
contributed by the patient/caregiver).
4. Education Resources/Materials - Patient
education needed. To include classes,
educational sessions, and printed materials
along with steps to a specific need.
5a. Diet and Diet/Fluid Restrictions: All
instructions that describe the expected diet.
b. Restrictions: List of limitations being
placed on the diet
6a. Fluids Management (C/N): All
instructions that describe the expected
fluids and method of administration.
b. Restrictions: List of limitations being
placed on fluids
7. Activity/Exercise
NOTES. Instructions may be more detailed if
sent to another provider.
- Yes/No - has the discharge instruction
been reviewed with the patient?
- Yes/No - has the discharge instruction
been accepted by the patient, if no then
how addressed
Goals.
Results yet to be received and procedures to
be followed up on.
Active interventions and orders (short term
August 2012
28
Appendix B - Care Plan Definitions & References
Ref.
Section
Content
Covers the
considerations that
encompass a range of
scopes and/or
timeframe (could be
a description of a
single encounter or
across multiple
encounters
S&I Framework
Transitions of Care Initiative
Elements in Transitions of Care Use Case (8/1/2011)
Table 18: Data Set for Clinical Summary for Specialist Notes
T.CC.27
Recommended Plan
Proposed interventions
of Care
and procedures
Plan of Treatment/
Treatment Plan/Care
Plan (R/N) - Covers
the considerations
that encompass a
range of scopes
and/or timeframe
(could be a
description of a single
encounter or across
multiple encounters
Additional Notes
direct instructions - in the long run as
validated by the patient and those
contributed by the patient/caregiver).
Goals. Details for follow-up, expectations,
as needed.
Active interventions and orders (short term
direct instructions - in the long run as
validated by the patient and those
contributed by the patient/caregiver).
Yes/No - has the specialist findings,
recommendations and instruction been
reviewed with the patient.
Yes/No - Have these instruction been
accepted by the patient, if no then how
addressed
Yes/No - Has patient been involved in
formulation of plan of care
Table 3: Care Plan References
S&I Longitudinal Coordination of Care WG
August 2012