electronic Long-Term Services &
Supports (eLTSS) Initiative
All-Hands Workgroup Meeting
March 12, 2015
1
Meeting Etiquette
•
•
•
•
Remember: If you are not speaking, please keep your
phone on mute
Do not put your phone on hold. If you need to take a call,
hang up and dial in again when finished with your other call
o Hold = Elevator Music = frustrated speakers and
participants
This meeting is being recorded
o Another reason to keep your phone on mute when not
speaking
Use the “Chat” feature for questions, comments and
items you would like the moderator or other participants to
know.
o Send comments to All Panelists so they can be
S&I Framework to Participants:
addressed publically in the chat, or discussed in the From
Hi everyone: remember to keep your phone
on mute 
meeting (as appropriate).
o Please DO NOT use the Q&A—only the presenter
All Panelists
sees Q&A, not necessarily the person facilitating the
discussion
2
Agenda
Topic
Presenter
Timeframe
Welcome
Announcements
eLTSS Roadmap
Lynette Elliott
10 mins
Use Case Working Session:
• Review Context Diagram Comments
• Present User Story Submissions
Evelyn /
Community
45 mins
Homework / Next Steps
Evelyn
5 mins
Concert Series Presentation: State of Maryland
Kale Sweeney
30 mins
Rebecca Van
Amburg
David Wertheimer
3
Announcements
• ONC issued the Connecting Health and Care for the Nation: A
Shared Nationwide Interoperability Roadmap Version 1.0
– The draft Roadmap is a proposal to deliver better care and
result in healthier people through the safe and secure exchange
and use of electronic health information.
– Includes Person-Centered Planning and eLTSS initiative
– ONC is accepting public comments until 5pm ET April 3, 2015:
http://www.healthit.gov/policy-researchersimplementers/interoperability-roadmap-public-comments
• HIMSS Interoperability Showcase is being held April 12-15, 2015 in
Chicago, IL
– Live interactive demonstration where health IT solution providers
collaborate to maximize the collective impact of their technologies
– Highlight seamless health information exchange in multiple care settings
4
New Funding Announcement
• Advance Interoperable Health Information Technology Services to Support
Health Information Exchange Funding Opportunity Announcement
– Letters of Intent Due: March 2, 2015; Application Deadline: April 6, 2015
– Leverages investments and lessons learned from HITECH State HIE Program to
accelerate widespread adoption and use of HIE infrastructure
– Grantees MUST select at least one eligible care provider and at least two non-eligible
care providers for their target populations:
5
Concert Series Presentations
• Organizations are invited to present on an existing project or
initiative that is related to the eLTSS scope of work and/or will
help inform the eLTSS target outcomes and deliverables
• These projects do not have to be
technically-focused
• Criteria for consideration:
• Has solution, whether it is
technical or process driven, been
implemented in a one or more of
the eLTSS settings: home and community-based setting or
clinical setting?
• Does solution incorporate existing or emerging standards
and/or other relevant guidance?
6
Concert Series Presentations: Logistics
• Presentations will be scheduled as part of the weekly eLTSS
Community Meetings and will occur the last 30 mins of the call
• Duration: 15-20 mins webinar (or demo); 5-10 mins Q&A
• eLTSS Workgroup activities will always take precedence over
concert series presentations
• If you have an interest in participating, please contact Evelyn
Gallego (evelyn.gallego@siframework.org ) and Lynette Elliott
(lynette.elliott@esacinc.com)
• A pre-planning meeting will be scheduled prior to any public
demonstration
7
Upcoming Concert Series Presentations
• March 19th: Colorado Regional Health Information
Exchange (CORHIO)
• March 26th: NASDDDS National Core Indicators
• April 2nd: Person-Centered Planning Tools
• April 9th: PeerPlace
• April 16th: MyDirectives.com / A|D Vault, Inc.
• April 23rd: Care at Hand
• April 30th: (available)
• May 7th: (available)
• May 14th: State of Minnesota
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eLTSS Initiative Roadmap
Q3 ‘14
Q4 ‘14
Q1 ‘15
Q2 ‘15
Q3 ‘15
Q4 ‘15
Q4 ‘17
Initiative Kick Off: 11/06/14
Pre-Planning
• Call for
Participation
• Conduct
Environmental
Scan
• Success Criteria
• Stakeholder
Engagement
Phase 2: Use Case Development
& Functional Requirements
Phase 1: Pre-Discovery
• Launch initiative
• Review and Finalize Charter
• Review initial Candidate
Standards
Phase 4: Pilots &
Testing
• Pilot site readiness
• Implementation of
• Develop, review, and finalize
solution
the Use Case and Functional
• Test User Stories and
Requirements
Scenarios
• Monitor Progress &
Phase 3: Standards & Harmonization Outcomes Phase 5:
Evaluation
• Finalize Candidate Standards
• Utilize Requirements
Traceability Matrix
• Standards Gap Analysis
• Evaluate outcomes
• Technical & Standards Design
against Success
• Develop Requirements Traceability
Metrics and
Matrix
Criteria
• Develop Implementation Guide
• Update
Implementation
Guidance
Timelines for Consideration: Two Pilot Phases, SDO Ballot Cycles
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Goals for the eLTSS Initiative
• Identify key assessment domains and associated data elements to
include in an electronic Long-term Services & Supports (eLTSS)
plan
• Create a structured, longitudinal, person-centered eLTSS plan that
can be exchanged electronically across and between communitybased information systems, clinical care systems and personal
health record systems.
We will use Health IT to establish a person-centered electronic
LTSS record, one that supports the person, makes him or her
central to the process, and recognizes the person as the expert
on goals and needs.*
* Source: Guidance to HHS Agencies for Implementing Principles of Section 2402(a) of the Affordable Care Act: Standards for Person-Centered Planning and Self-Direction in
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Home and Community-Based Services Programs
Project Charter and eLTSS Glossary
• FINAL Published Project Charter located here:
http://wiki.siframework.org/electronic+LongTerm+Services+and+Supports+%28eLTSS%29+Charter
• eLTSS Glossary posted here:
http://wiki.siframework.org/eLTSS+Glossary
– The eLTSS Glossary is a working document containing eLTSS-relevant
terms, abbreviations and definitions as defined by stakeholders
– We are looking for your feedback and comments
• Discussion Thread available
• Submit any change requests via the Change Request Form located
on the wiki
– Reminder: the Glossary is a living document and content may change
as the initiative progresses
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Proposed Use Case & Functional
Requirements Development Timeline
Week
Target Date
(2015)
1-5
1/22-2/19
Use Case Kick-Off & UC Process Overview
Use Case Value Framing Discussions
Review and Answer Value Framing Questions on wiki
6
2/26
Review: Consolidated UC Value Framing
Introduce: Context Diagram & User Stories
Review: Context Diagram & User Stories
7
3/12
Finalize: Context Diagram & User Stories
Review: User Stories
8
3/19
Finalize: User Stories
Introduce: In/Out of Scope
Review: In/Out of Scope
9
3/26
Finalize: Assumptions & Pre/Post Conditions
Introduce: Activity Diagram & Base Flow
Review: Assumptions & Pre/Post Conditions, Activity
Diagram & Base Flow
10
4/2
Finalize: Activity Diagram & Base Flow
Introduce: Functional Requirements & Sequence Diagram
Review: Functional Requirements & Sequence Diagram
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4/9
Finalize: Functional Requirements & Sequence Diagram
Introduce: Data Requirements
Review: Data Requirements
12
4/16
Review: Data Requirements
Review: Data Requirements
13
4/23
Finalize: Finalize Data Requirements
Introduce: Risks & Issues
Review: Risks & Issues
14
4/30
Finalize: Risks and Issues
Begin End-to-End Review
End-to-End Review by community
15
5/7
End-to-End Comments Review & disposition
End-to-End Review ends
16
5/14
Finalize End-to-End Review Comments & Begin Consensus
Begin casting consensus vote
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5/21
Consensus Vote*
Conclude consensus voting
All Hands WG Meeting Tasks
Review & Comments from Community via Wiki page
due following Tuesday by 8 P.M. Eastern
12
We Need YOU!
• In order to stick to our timeline and to ensure that the artifacts we
develop fit the need of our stakeholders (you), we need your
feedback, comments and participation
• Each week, please review the use case content and provide
comments via the wiki at: http://wiki.siframework.org/electronic+LongTerm+Services+and+Supports+%28eLTSS%29+Use+Case
• Thank you for providing input for our eLTSS Use Case Framing
Questions (via the wiki, live discussions or email).
– We have consolidated the responses and posted the document on the eLTSS
wiki at: http://wiki.siframework.org/electronic+Long+Term+Services+and+Supports+Use+Case+Value+Framing+Questions
– This document and YOUR responses will be used as input for various
sections of the eLTSS Use Case Artifact
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eLTSS Plan Future
Creation and Sharing
Generates, updates and
displays eLTSS Plan;
stores/transmits servicerelated data
Collects assessment data
for eligibility
determination and to
inform plan of service
Component 1
Component 2
Component n
Owner of plan;
contributes personal
story, demographic
data
Extract, Transform,
& Load financial data
Move from Patient-Centered to PersonCentered Planning and Information Sharing
Updates and displays eLTSS
Plan; stores/submits
medical, clinical, advance
directive data
Context Diagram Feedback
• Comment (from Mark Pavlovich): I think we have disharmony
between the Out Of Scope bullet points and the Use Case
Context Diagram
– Generally, I don’t see how we can achieve our stated goal, “To fully
realize the benefit of health IT” if integration of eLTSS plan into an EHR
or other Clinical System is Out of Scope.
– Specifically, the Use Case Diagram shows direct links between the
eTLSS plan and:
• Clinical IT System integration. The lower right quadrant of the diagram
• Standards Assessment(s). The upper left quadrant.
• Response: The diagram shows that there needs to be an
interaction/exchange of data between the eLTSS plan and the
IT System - to store/submit relevant data, but that doesn't
mean that the eLTSS plan will be integrated into the IT System.
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User Story
• Description:
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–
–
–
User Stories summarize the interaction between the actors of the Use Case
Specify what information is exchanged from a contextual perspective
Describe the real world application as an example of the Scenario
Provide clinical context
• User Stories will be displayed on screen as working draft Word
documents to capture updates and comments during the working
session.
– These will be posted on the wiki Use Case page:
http://wiki.siframework.org/electronic+LongTerm+Services+and+Supports+%28eLTSS%29+Use+Case
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Next Steps
• HOMEWORK – Due by COB Tuesday, March 17th:
– Review Use Case Scope section
– Utilize Comment Form at http://wiki.siframework.org/electronic+LongTerm+Services+and+Supports+%28eLTSS%29+Use+Case
– Email feedback / comments to becky.angeles@esacinc.com or
evelyn.gallego@siframework.org
• NEXT WEEK:
–
–
–
–
Assumptions
Pre Conditions
Post Conditions
Concert Series Presentation: CORHIO
• Join the eLTSS Initiative: http://wiki.siframework.org/eLTSS+Join+the+Initiative
– Only Committed Members can vote on artifacts
19
Maryland’s LTSS System
March 12, 2015
Medicaid’s Rebalancing Vision
• Improving access to home and community-based
services (HCBS)
– Eliminate barriers to receiving HCBS
– Improve collaboration between agencies
– Enhance person-centered focus
• Shift focus from institutional settings to HCBS
– Shift spending
– Increase self-direction options
– Take advantage of opportunities presented by the Affordable
Care Act
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Balancing Incentive Program (BIP)
• Offers an enhanced federal medical assistance percentage (FMAP) for all
HCBS covered during the “balancing incentive period” through September
30, 2015
– Maryland awarded a projected $106 million
– All enhanced federal payments must be used to fund new and expanded
Medicaid community-based LTSS
• States must initiate the following “structural changes” to their LTSS
systems:
– No Wrong Door / Single Entry Point system for LTSS
– Implement a Core Standardized Assessment Instrument
– Ensure Conflict-Free Case Management
• By the end of the BIP period states must:
– Increase HCBS to 50% of total Medicaid LTSS spending
– Implement required structural changes
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No Wrong Door / Single Entry Point
• Maryland Access Point (MAP) Sites
– MAP initiative led by Maryland Department of Aging (MDoA)
– Formalized partnerships between Area Agencies on Aging (AAA),
Centers for Independent Living (CILs), Local Health Departments
(LHDs), Core Service Agencies and Departments of Social Services
– MAP sites will conduct the interRAI-MDScreen and use LTSSMaryland,
a statewide, person-centered tracking system for HCBS
• BIP/MFP Expansion of MAP sites
– 1-800 number and website expansion
• Collaboration with other resource websites (substance abuse and
mental health)
• Working with 211 to ensure coordination of calls and shared
resources
– Increased funding and partnerships
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BIP
• BIP Assessment Requirements
– Data captured Statewide for all populations seeking community
LTSS
– Includes a Level I screen/Level II assessment process across
populations
• Level I screen is available for completion in person or over
the phone
• Level II assessment is completed in person by a qualified
professional
– Used to determine eligibility, identify support needs, and inform
service planning
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Core Standard Assessment: interRAI
• Non-profit organization
• Full membership meets every 10-12 months
• Key interests:
– Science (e.g., cross-national comparisons)
– Instrument development
– Support implementation in other nations
• Holds copyright to assessment instruments
• Grants royalty-free licenses to governments and care providers
• License software vendors around the world
• www.interrai.org
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Why are interRAI assessments different?
• Developed by international panel of experts on geriatrics, gerontology,
assessment, and health services research
• Carefully tested psychometric properties
• Compatible systems across health care sectors
• Cover all relevant domains
– Individuals’ strengths and weaknesses
– Include items on caregivers, environment
– Tradeoff of breadth and length
• Not only self-report
– Use all possible sources of information
• Include full definitions, time delimiters, examples, exclusions
• Training manuals
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interRAI
interRAI-MDScreen – Screening tool during initial contact
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interRAI-Home Care (HC) – Assessment tool for services
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•
•
Completed in person or over the phone by Maryland Access Point staff
Used to identify risk of institutionalization and need for services
Participants will be prioritized by risk/need and date to ensure
services get to the person as soon as possible
Completed in person by a qualified professional
Used to determine eligibility, identify support needs, and inform
service planning
Consistent data captured statewide allows for tracking service
provision, quality and outcomes
27
interRAI (continued)
• The interRAI-Home Care (HC) assessment
• Clinical Assessment Protocols (CAPs)
– Pre-populated on the Plan of Service (from most recent
assessment)
– Each CAP can be used to help interpret information collected
through interRAI
• Flexible Budget
– Equitable allocation of services based on Activities of Daily
Living (ADL) & Instrumental Activities of Daily Living (IADL)
needs
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interRAI-HC Sections
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•
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•
•
•
•
•
•
Section A: Identification Information
Section B: Intake and Initial History
Section C: Cognition
Section D: Communication and Vision
Section E: Mood and Behavior
Section F: Psychosocial Well-Being
Section G: Functional Status
Section H: Continence
Section I: Disease Diagnosis
Section J: Health Conditions
Section K: Oral and Nutritional Status
Section L: Skin Conditions
Section M: Medications
•
•
•
•
•
•
•
Section N: Treatment and Procedures
Section O: Responsibility
Section P: Social Supports
Section Q: Environmental Assessment
Section R: Discharge Potential and
Overall Status
Section S: Discharge
Section T: Assessment Information
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LTSS Populations
•
•
•
•
•
•
Community Options (CO) Waiver
Increased Community Service (ICS)
Community First Choice (CFC)
Medical Assistance Personal Care (MAPC)
Brain Injury (BI) Waiver
Coming soon: Medical Day Care & DDA
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Plans of Service (POS)
• Target participants in need of support of activities of
daily living
• Certain requirements apply to each program, however,
each use the same Plan of Service (POS) to outline
services
• The POS should capture all services that will be
provided to the participant (under these programs or
through other Medicaid or non-Medicaid programs)
31
Resource Utilization Group (RUG)
•
•
•
•
Prior to Plan of Service
Generates RUG score
Score used to assign a recommended flexible budget
interRAI-HC uses statistically validated algorithms to
assign clients to 1 of 23 RUGs
• DHMH has assigned each RUG to 1 of 7 groups (and has
developed budget for each group based on a scale of
needs)
32
Personal Assistance Services
• Offered under the CFC and MAPC programs
• CO waiver and ICS participants are eligible for CFC
personal assistance services if they are not residing in an
assisted living facility
33
In-Home Supports Assurance System
(ISAS)
• Both independent and agency personal assistance
providers must be enrolled
• An automated time-keeping system that tracks clock-in
and clock-out time of providers
34
Substitutes for Human Assistance
•
•
•
•
Home-delivered meals
Environmental assessments
Environmental adaptations
Technology
35
Client Eligibility
• Enrollments in waiver programs are indicated in the
client profile in the ‘Eligibility’ section of the
LTSSMaryland system
• Data under the Special Program Code section indicates
current or prior enrollment in a waiver program,
hospice, or REM
• Supports planners should review the eligibility to
determine if other programs are available and work with
the participant and any other case manager/service
coordinator assigned
36
Activities of Daily Living (ADLs)
•
•
•
•
Bathing/completing personal hygiene routines
Dressing/changing clothes
Eating
Mobility, including:
– Transferring from a bed, chair, or other structure
– Moving, turning, and positioning the body while in bed or in a wheelchair
– Moving about indoors or outdoors
• Toileting, including:
– Bladder /bowel requirements
– Routines associated with the achievement of maintenance of continence
– Incontinence care
37
Instrumental Activities of Daily Living
(IADLs)
• Preparing meals
• Performing light chores that are incidental to the personal assistance
services provided to the participant
• Shopping for groceries
• Nutritional planning
• Traveling as needed
• Managing finances/handling money
• Using the telephone of other appropriate means of communication
• Reading
• Planning and making decisions
38
The Nine Sections in LTSS
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•
•
•
1. Overview Information
2. Strengths
3. Goals
4. Risks
5. Self-Direction
6. Emergency Backup Plans
7. Services
8. Signatures
9. Review
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Lessons Learned
• Many changes at once (merger of waiver programs and a
new system)
• Individuals buying into the assessment tool and tracking
system
• Appropriate individuals for requirements gathering
• Nurse monitoring frequency (modifying)
– LHDs (functions)
• ISAS
– Soft-lives and Hard-lives
– Compliance
– Exceptions processing
41
Maryland Current State (TEFT)
• Live, working LTSS/ISAS system
• Environmental scan, analysis, and selection of PHR
solution
• Continued stakeholder engagement
• Continued participation in e-LTSS all-hands initiative to
develop a charter and standard that aligns with ONC’s
S&I Framework
– Goal: identify, evaluate, and harmonize standards without
taking away from our current system
42
Maryland Future State (TEFT)
• Environmental scan of PHR capabilities and solutions
includes:
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–
–
–
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PHR and Patient Engagement Technology assessment
Ongoing stakeholder engagement
Assessing the current and future state of MD’s LTSS system
Assessing MD’s ecosystem
Discussion of feasibility/capability with statewide and regional
HIEs
• Goal: PHR solution integrated with our LTSS/ISAS
system and the HIE
– Utilize and potentially enhance current system
43
Questions?
Kale Sweeney (kale.sweeney@maryland.gov)
44
eLTSS Initiative: Project Team Leads
•
ONC Leads
– Elizabeth Palena-Hall (elizabeth.palenahall@hhs.gov)
– Patricia Greim (Patricia.Greim@hhs.gov)
•
CMS Lead
– Kerry Lida (Kerry.Lida@cms.hhs.gov)
•
Federal Lead
– Jennie Harvell (jennie.harvell@hhs.gov)
•
Initiative Coordinator
– Evelyn Gallego-Haag (evelyn.gallego@siframework.org)
•
Project Management & Pilots Lead
– Lynette Elliott (lynette.elliott@esacinc.com)
•
Use Case & Functional Requirements Development
– Becky Angeles (becky.angeles@esacinc.com)
•
Standards Development Support
– Angelique Cortez (angelique.j.cortez@accenture.com)
•
Harmonization
– Atanu Sen (atanu.sen@accenture.com)
45
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Use Case Outline
Tailored for each Initiative
• 10.0 Scenario: Generic Provider Workflow
– 10.1 User Story 1, 2, x, …
• 2.0 Initiative Overview
– 10.2 Activity Diagram
– 2.1 Initiative Challenge Statement**
o 10.2.1 Base Flow
• 3.0 Use Case Scope
o 10.2.2 Alternate Flow
– 3.1 Background**
– 10.3 Functional Requirements
– 3.2 In Scope
o 10.3.1 Information Interchange
– 3.3 Out of Scope
Requirements
– 3.4 Communities of Interest**
o 10.3.2 System Requirements
• 4.0 Value Statement**
– 10.4 Sequence Diagram
• 5.0 Use Case Assumptions
• 11.0 Risks, Issues and Obstacles
• 6.0 Pre-Conditions
• 12.0 Dataset Requirements
• 7.0 Post Conditions
• Appendices
• 8.0 Actors and Roles
– Related Use Cases
• 9.0 Use Case Diagram
– Previous Work Efforts
– References
** Leverage content from Project Charter
• 1.0 Preface and Introduction**
47
eLTSS Plan User Story Need
• We need your help:
– Draft 3 – 4 User Stories based on the list of most used services
•
•
•
•
•
•
•
•
Assisted Living
Personal Care
Adult Day Services
Case Management
Transportation
Medication Management
Meal/Food Delivery
Care / Support for Family / Friends
– Volunteers:
•
•
•
•
•
•
Nancy/Mary: Payer perspective - habilitation
Caroline: Beneficiary perspective with sharing to payer/provider
David: Focus on elderly and support for the family (include healthcare provider)
Kelly: Provider perspective on Medication Management
Andrey: sharing of data between waiver system, IT systems, health technology
Rachel: Beneficiary perspective
48