Longitudinal Coordination of
Care (LCC)
Pilots Template
Insert the Name of Your Pilot / Organization Here
MM/DD/YYYY
Pilot Team
• Identify the members of your organization who will be supporting this
pilot. If possible include the role he/she will play in the pilot and
contact information
Name
Role
Email
2
Full Disclosure?
Goal of the Pilot
• Please include a write up or create a Visio diagram of what you intend
to show/prove/support during the pilot process.
• Make this an actionable statement with specifics.
• Also include in this description what you hope to gain from this pilot.
4
Which of the 5 C-CDA Revisions
are you Piloting?
• Please use this section to document which of the 5 LCC
Standards (Transfer Summary, Consultation Request, Consult
Note, Care Plan, and/or Home Health Plan of Care ) you are
intending to pilot. Please be as specific as possible.
SDC Standard / Guidance
Specifics to Pilot
Notes
5
What Relevant Scenario (from the
Use Cases) does your Pilot support?
• Exchange of Clinical Information from Provider to Provider
• Exchange of Clinical Information from Provider to Patient
• Other: ____(Please specify)
• Link to download Consensus Approved Use Case 1:
http://wiki.siframework.org/LCC+WG+Use+Case+%26+Functional+
Requirements
• Link to download Consensus Approved Use Case 2:
http://wiki.siframework.org/LCC+WG+Use+Case+2.0
Identify the Use Case
Actors/Systems Involved:
• A pilot may involve the following participants from the longitudinal
coordination of care ecosystem:
– Sending Entity Care Team
– Receiving Entity Care Team
– Sending Entity Information System (EHR)
– Receiving Entity Information System (EHR)
– Patient and/or Caregiver
– Home Health Agency (HHA) Care Team
– Home Health Agency (HHA) Information System (EHR)
– PHR Application
Minimum Configuration
• What is your current technical / infrastructure set up?
• What systems / applications will you be using to conduct the pilot?
• Examples:
– Electronic Health Record (EHR) system
– Health Information Exchange (HIE)
– External database (which one/type)
– Existing interfaces
– New interfaces (to be developed as part of the pilot)
Timeline
•
•
•
•
What is your proposed timeline given we want to wrap-up Pilots by Q4 2014
Guidance: ~6 months minimum / ~1 year maximum
Evaluation: starts @ 6-9 months / final evaluation when pilot is complete
Example Timeline
– September – Kickoff and Logistics
– October – Start Pilots
– November – Continue with Pilots
– March – Conclude Pilots
Milestone
Target Date
Responsible Party
Success Criteria
• What will you/your organization use to determine the success of this
pilot? This needs to be quantitative and not subjective in as much as
possible.
• Examples:
– X% Reduction in readmission rate
– X% Increase in number of unique patient transfers between sites
with complete set of Care Plan data elements
Example: IMPACT Performance Metrics
Target
Outcom
e
Target Value
Target Population
Reduce
hospital
readmissi
on rate
5% decrease in 30 day Unique FCHP patient
hospital readmission
discharges from St. Vincent
rates from baseline
Hospital and UMass
Memorial Hospital that are
readmitted to any hospital
from IMPACT Pilot Sites
Reduce
Hospital
Admissio
n Rate
5% decrease in
Hospital Admission
Rate from baseline
Unique FCHP members
seen in St. Vincent Hospital
and UMass Memorial
Hospital ER that had been
under the care of an
IMPACT Pilot Site during the
measurement period, that
are subsequently admitted
to the hospital from the ER
Increase
overall
complete
ness of
data
included
in
transition
process
70% of patients
transferred with
complete set of
required data
elements included in
electronic Universal
Transfer Form (UTF)
Unique patient transfers
between IMPACT pilot sites
Data
Source
Numerator
Denominator
Fallon
Community
Health
Plan’s
claims data
via Reliant
Medical
Group
Fallon
Community
Health
Plan’s
claims data
via Reliant
Medical
Group
Number of unique patient
discharges from St.
Vincent Hospital and
UMass Memorial Hospital
that are readmitted to any
hospital from IMPACT Pilot
Sites within 30 days during
measurement period
Number of unique FCHP
members in an IMPACT
Pilot Site’s care during
measurement period that
are transferred to the St.
Vincent Hospital or UMass
Memorial Hospital ER that
are subsequently admitted
to the hospital
Number of unique
patient discharges from
St. Vincent Hospital and
UMass Memorial
Hospital during
measurement period
LAND and
SEE data
Number of unique patient
transfers between IMPACT
Pilot Sites during
measurement period with
complete set of required
data elements in electronic
UTF
Number of unique
patient transfers
between IMPACT Pilot
Sites during
measurement period
Number of unique
FCHP members in an
IMPACT Pilot Site’s care
during measurement
period that are
transferred to the St.
Vincent Hospital or
UMass Memorial
Hospital ER
In Scope / Out of Scope
• If you already know what will be in and out of scope for your pilot
(beyond the Implementation Guidance (IG) or the Use Case) please
document it here.
• Example:
Risks & Challenges
• Identify any risks or challenges
Questions / Needs
• Please include those items you wish to consider any questions you
have or hope the pilot addresses.
• Additionally, please include those items you need in order to
succeed.
• We will try to accommodate as many of these needs as possible
within the scope of ONC, S&I and LCC (and resource availability).
Useful Links
•
•
•
•
•
•
LCC Wiki Main Page:
http://wiki.siframework.org/Longitudinal+Coordination+of+Care+%28LCC%29
Use Case 1.0 ‘Transfer of Care’:
http://wiki.siframework.org/LCC+WG+Use+Case+%26+Functional+Requirements
Use Case 2.0 ‘Care Plan Exchange’:
http://wiki.siframework.org/LCC+WG+Use+Case+2.0
Transfer of Care Harmonization: http://wiki.siframework.org/LCC+Long-Term+PostAcute+Care+%28LTPAC%29+Transition+SWG#Lantana%20Working%20Documents
Care Plan Exchange Harmonization: TBD
Pilots Wiki Page: http://wiki.siframework.org/LCC+Pilot+Plan
Appendix A: LCC Timeline
Mar 13
Apr 13
May 13
Jun 13
Jul 13
Aug 13
Sep 13
Oct 13
Dec 13
LCC WG Timeline: Mar 2013 – Dec 2013
LCC Stakeholder Engagement: Lantana, IMPACT, ASPE, NY, CMS
LCC & HL7 Care Plan Coordination
LCC Care Plan Use Case 2.0 Development & Consensus
ToC IGs Development (Transfer Summary, Referral Note, Consult Note)
HL7 Ballot & Reconciliation
Care Plan/ Home Health Plan of Care IG Development
HL7 Ballot Package Development
Pilot Site Identification & Engagement
IMPACT ToC Pilot Monitoring
NY Pilots Monitoring
Milestones
FACA LCC WG
Briefings
ToC C-CDA
Revisions
Complete
HL7 Project Scope
Statement Due
Care Plan C-CDA
Revisions
Complete
HL7 Fall Ballot Open
HL7 Intent to Ballot Due
IMPACT Go-Live
NY Care Coordination Go-Live
HL7 Final Ballot Due
HL7 Ballot
Publication