electronic Long-Term Services &
Supports (eLTSS) Initiative
All-Hands Workgroup Meeting
February 19, 2015
1
Meeting Etiquette
•
•
•
•
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hang up and dial in again when finished with your other call
o Hold = Elevator Music = frustrated speakers and
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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
From S&I Framework to Participants:
addressed publically in the chat, or discussed in the Hi everyone: remember to keep your phone
on mute 
meeting (as appropriate).
All Panelists
2
Agenda
Topic
Presenter
Timeframe
Welcome
Announcements
eLTSS Roadmap
Lynette Elliot
5 mins
Use Case Framing
Evelyn Gallego
5 mins
Use Case Working Session: Service Provider and
Payer Perspective
Community
45 mins
Homework / Next Steps
Becky Angeles
5 mins
Concert Series Presentation: IMPACT Act
Stella Mandl
30 mins
3
Announcements
• REMINDER - Join the eLTSS Initiative:
http://wiki.siframework.org/eLTSS+Join+the+Initiative. Only
Committed Members can vote on artifacts.
• 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
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:
Upcoming Webinar: Feb 24th at 3pm ET:
https://attendee.gotowebinar.com/register/3398558919765946881
5
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
6
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
Home and Community-Based Services Programs
7
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
8
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?
9
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
10
Upcoming Concert Series Presentations
• Feb 19th: Improving Post-Acute Care Transformation
(IMPACT) Act
• March 5th: Right Care Now Project
11
12
S&I Framework
Deliverables
Phase
1. Pre-Discovery
︎
Typical Activities
 Development of Initiative Synopsis
 Development of Initiative Charter
 Definition of Goals & Initiative Outcomes
2.
Discovery



Creation/Validation of Use Cases, User Stories & Functional Requirements
Identification of interoperability gaps, barriers, obstacles and costs
Review of Vocabulary
3.
Implementation



Evaluation of candidate standards
Development of Standards Solution Plan
Creation of Implementation Guidance
4.
Pilot
4.
Evaluation






Use Case focused on “what” the
Validation of alignedrequirements
specifications, testing tools,
and referencebe
implementation
tools
should
rather
Revision of documentation and tools
Development andthan
presentation
of Pilot Proposals we still need to
“how”…but
Measurement of initiative success against goals and outcomes
the
Identification of best practices work
and lessonson
learned
from“why”.
pilots for wider scale
deployment
Identification of hard and soft policy tools that could be considered for wider scale
deployments
13
Proposed Use Case & Functional
Requirements Development Timeline
Week
Target Date
(2015)
1-5
1/22-2/19
6
All Hands WG Meeting Tasks
Review & Comments from Community via Wiki page
due following Tuesday by 8 P.M. Eastern
Use Case Kick-Off & UC Process Overview
Use Case Value Framing Discussions
Review and Answer Value Framing Questions on wiki
2/26
Review: Consolidated UC Value Framing
Introduce: In/Out of Scope
Review: In/Out of Scope
7
3/5
Review: In/Out of Scope
Introduce: Context Diagram & User Stories
Review: Context Diagram & User Stories
8
3/12
Review: Context Diagram & User Stories
Review: Continue Review of User Stories
9
3/19
Review: Finalize User Stories
Introduce: Assumptions & Pre/Post Conditions
Review: Assumptions & Pre/Post Conditions
10
3/26
Review: Assumptions & Pre/Post Conditions
Introduce: Activity Diagram & Base Flow
Review: Activity Diagram & Base Flow
11
4/2
Review: Activity Diagram & Base Flow
Introduce: Functional Requirements & Sequence Diagram
Review: Functional Requirements & Sequence Diagram
12
4/9
Review: Functional Requirements & Sequence Diagram
Introduce: Data Requirements
Review: Data Requirements
13
4/16
Review: Finalize Data Requirements
Introduce: Risks & Issues
Review: Risks & Issues
14
4/23
Review: Risks and Issues
Begin End-to-End Review
End-to-End Review by community
15
4/30
End-to-End Comments Review & disposition
End-to-End Review ends
16
5/7
Finalize End-to-End Review Comments & Begin Consensus
Begin casting consensus vote
17
5/14
Consensus Vote*
Conclude consensus voting
14
15
What we learned so far / What questions need
answered
• Work from eLTSS Use Case Framing Questions Results.doc located
on the eLTSS wiki:
http://wiki.siframework.org/file/view/eLTSS%20Use%20Case%20Framing%20Questions%20Consolidated%20Resul
ts%202015-0219.docx/541482334/eLTSS%20Use%20Case%20Framing%20Questions%20Consolidated%20Results%202015-0219.docx
16
17
Next Steps
• HOMEWORK – Due by COB Tuesday, February 24th:
– Review and Provide feedback on the Use Case Value Framing Questions
either using the form or word document located here:
http://wiki.siframework.org/electronic+Long+Term+Services+and+Supports+Use+Case+Value+Frami
ng+Questions
• What is missing?
– Provide feedback, comments, etc. to becky.angeles@esacinc.com and
evelyn.gallego@siframework.org
• NEXT WEEK:
– Overview of Common Themes from Value Framing Questions
– Dive into the In Scope and Out of Scope section of the Use Case
• Join the eLTSS Initiative: http://wiki.siframework.org/eLTSS+Join+the+Initiative
– Only Committed Members can vote on artifacts
18
Concert Series Presentation: Stella Mandl, RN – Deputy Director – The
Division of Chronic & Post Acute Care
IMPACT ACT OF 2014
19
Data Element Uniformity, Assessment Domain
Standardization
and the
IMPACT ACT OF 2014
Stella Mandl, RN
Deputy Director
The Division of Chronic & Post Acute Care
Data Standardization: PAC-PRD and
the CARE Tool: Background
• 2000: Benefits Improvement & Protection Act (BIPA)
– mandated standardized assessment items across the
Medicare program, to supersede current items
• 2005: Deficit Reduction Act (DRA)
– Mandated the use of standardized assessments across acute
and post-acute settings
– Established Post-Acute Care Payment Reform Demonstration
(PAC-PRD) which included a component testing the reliability
of the standardized items when used in each Medicare setting
• 2006: Post-Acute Care Payment Reform Demonstration
requirement:
– Data to meet federal HIT interoperability standards
21
PAC PRD & the Care Tool:
Informed Concepts
Guiding Principles and Goals:
Assessment Data that is Uniform :
• Reusable
• Informative
Can help achieve data use that can:
• Communicate in the same language across
settings
• Ensure data transferability of clinically relevant
information forward and backward allowing for
interoperability, ensuring care coordination
Data Uniformity
• Increases reliability and validity
• Allows data to follow the person
• Facilitates patient centered care,
care coordination
Goals that standardization can enable:
• Fostering seamless care transitions
• Measures that can follow the patient
• Evaluation of longitudinal outcomes for
patients that traverse settings
• Assessment of quality across settings
• Improved outcomes, and efficiency
• Reduction in provider burden
22
More About CARE
• Data collection using the CARE Item Set occurred as part of the
Post Acute Care Payment Reform Demonstration and included
206 acute and PAC providers
http://www.cms.gov/Medicare/Quality-Initiatives-PatientAssessment-Instruments/Post-Acute-Care-QualityInitiatives/CARE-Item-Set-and-B-CARE.html
23
Keeping in Mind, the Ideal State
• Facilities are able to transmit electronic and interoperable
Documents and Data Elements
• Provides convergence in language/terminology
• Data Elements used are clinically relevant
• Care is coordinated using meaningful information that is
spoken and understood by all
• Measures can evaluate quality across settings and evaluate
intermittent and long term outcomes
• Measures and data can follow the person
• Incorporates needs beyond healthcare system
24
Data Elements:
Standardization
HCBS
CARE
OASIS-C
IRF-PAI
LTCH
CARE
Data Set
MDS
3.0
Uniformity
Data
Elements
CMS Data Element Library:
HIT Exchange Standards
Please Pass the Legos:
Standardized
Detailed
Reusable
QIC Presentation: O’Malley/Garber May 20, 2014
26
CMS Framework for Measurement
Clinical Quality
of Care
• Care type
(preventive, acute,
post-acute, chronic)
• Conditions
• Subpopulations
Person- and
Caregiver- Centered
Experience and
Outcomes
• Patient experience
• Caregiver experience
• Preference- and goaloriented care
Care Coordination
• Patient and family
activation
• Infrastructure and
processes for care
coordination
• Impact of care
coordination
Population/
Community Health
• Health Behaviors
• Access
• Physical and Social
environment
• Health Status
Function
Efficiency and
Cost Reduction
Safety
•
•
•
•
•
All-cause harm
HACs
HAIs
Unnecessary care
Medication safety
• Cost
• Efficiency
• Appropriateness
• Measures should
be patientcentered and
outcome-oriented
whenever possible
• Measure concepts
in each of the six
domains that are
common across
providers and
settings can form
a core set of
measures
27
Standardization: Future State
EHR
EHR
EHR
EHR
EMR
Long Term Care
Person
Acute Care
Post-Acute
Care
Home Health
Institutional and
Home and CommunityBased Services (HCBS)
PCP
TCP
CMMI
Duals/Medicaid/Medicare/All Other Payers
Data Follows the Person
28
Improving Medicare Post-Acute Care
Transformation (IMPACT) Act of 2014
• Bi-partisan bill introduced in March, U.S. House &
Senate; passed on September 18, 2014 and signed into
law by President Obama October 6, 2014
• Requires Standardized Patient Assessment Data that
will enable:
–
–
–
–
–
–
Assessment and QM uniformity
Quality care and improved outcomes
Comparison of quality across PAC settings
Improve discharge planning
Interoperability
Facilitate care coordination
29
Definitions
• Applicable PAC settings and Prospective Payment Systems
(PPS):
– Home health agencies (HHA) under section 1895
– Skilled nursing facilities (SNF) under section 1888(e)
– Inpatient rehabilitation facilities (IRF) under section 1886(j)
– Long-term care hospitals (LTCH) under section 1886(m)
30
Definitions (continued)
• Applicable PAC assessment instruments
– HHA: Outcome and Assessment Information Set (OASIS) or
any successor regulation
– SNF: assessment specified under section 1819(b)(3)
– IRF: any Medicare beneficiary assessment instrument
established by the Secretary for purposes of section
1886(j)
– LTCH: any Medicare beneficiary assessment instrument
used to collect data elements to calculate quality
measures, including for purposes of section 1886(m)(5)(C)
31
Requirements for Standardized
Assessment Data
• IMPACT Act added new section 1899(B) to Title XVIII of the Social
Security Act (SSA)
• Post-Acute Care (PAC) providers must report:
– Standardized assessment data
– Data on quality measures
– Data on resource use and other measures
• The data must be standardized and interoperable to allow for the:
– Exchange of data using common standards and definitions
– Facilitation of care coordination
– Improvement of Medicare beneficiary outcomes
• PAC assessment instruments must be modified to:
– Enable the submission of standardized data
– Compare data across all applicable providers
32
Standardized Assessment Data
Elements
One Question: Much to Say
33
One Response: Many Uses
Data Element and Response Code
QI
Care Planning/
Decision Support
Quality
Reporting
Care
Transitions
Payment
34
Specified Application Dates by
Quality Measure Domains
• Functional status, cognitive function, and
changes in function and cognitive function
• Skin integrity and changes in skin integrity
• Medication reconciliation
• Incidence of major falls
• Communicating the existence of and
providing for the transfer of health
information and care preferences
35
Standardized Patient Assessment Data
• Requirements for reporting assessment data:
– Providers must submit standardized assessment data through PAC
assessment instruments under applicable reporting provisions
– The data must be submitted with respect to admission and discharge
for each patient, or more frequently as required
• Data categories:
– Functional status
– Cognitive function and mental status
– Special services, treatments, and interventions
– Medical conditions and co-morbidities
– Impairments
– Other categories required by the Secretary
Use of Standardized
Assessment Data:
HHAs: no later than
January 1, 2019
SNFs, IRFs, and LTCHs: no
later than October 1,
36
2018
Resource Use and Other Measures
– Resource use and other measures will be specified for
reporting, which may include standardized assessment
data in addition to claims data.
– Resource use and other measure domains include:
• Total estimated Medicare spending per beneficiary
• Discharge to community
• Measures to reflect all-condition risk-adjusted
potentially preventable hospital readmission rates
37
(e) Measurement Implementation Phases; Selection of
Quality Measures and Resource Use and Other Measures
(1)Measurement Implementation Phases
(A)Initial Implementation Phase
(i) measure specification
(ii)data collection
(B) Second Implementation Phase – feedback reports to
PAC providers
(C) Third Implementation Phase – public reporting of PAC
providers' performance
(2) Consensus-based Entity
(3) Treatment of Application of Pre-Rulemaking Process
38
SNF QRP Established
• SNFs - amends section 1888(e) of the SSA to
add paragraph (6) —
– (A) Reduction in Update for Failure to Report
• A SNF will receive a 2 percentage point reduction in its
APU for failure to report data beginning with FY 2018
– The result may be less than 0.0 for the FY and/or less than the
preceding
– The reduction will only apply to the FY involved
39
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)
40
41
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**
42
LTSS Information Sharing:
As-Is Workflow
Home
Maintenance
& Repair
Patient-Centered
Employment
Long-Term
Care
Behavioral Health
Person-Centered
Primary
Care
Transport
Education
Emergency
Services
Intensive
Care
Acute Care
Criminal
Justice
Personal
Care
Legal
Services
Meals
Housing
Caregiver
Support
Post-Acute
Care
Specialty Care
Emergency
Care
eLTSS Plan
Future Sharing Options
Extract, Transform,
& Load eLTSS Plan
Data
Generates, updates and
displays eLTSS Plan;
stores/transmits data
Updates and displays eLTSS
Plan; stores/transmits data
Updates and
displays eLTSS
Plan;
stores/submits
data
Move from Patient-Centered to
Person-Centered Planning and
Information Exchange