electronic+Long-Term+Services+and+Supports+(eLTSS)+References

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This wiki page will be used to capture reference materials for the eLTSS Initiative. The tables below are placeholders to improve the organization of the materials. If you have a suggestion for a new table, or an edit to an existing table, feel free to make the change directly. Documents that will be reviewed and edited by stakeholders will be posted to the main eLTSS wiki page for ease of access.======
 * How to Upload a Reference Material**
 * 1) Click "edit" in the upper right hand corner of the page.
 * 2) Add a row to the table where you want to contribute a reference material by clicking the table icon (add row, add row below).
 * 3) Click "file" in the navigation bar at the top of the page to upload your reference material. Once the file is uploaded, click "link to file," instead of "embed file.
 * 4) Once the file is uploaded, you can change the name of the file by clicking on the file and selecting "change." Please be sure to add the upload date, your name, and a brief description of the reference material.

=eLTSS Plan Use Case Resources=
 * **Link or Download** || **Description** ||
 * [[file:Appendix C Actors and Activities for establishing eLTSS Information Sharing Resource 2015-06-03.xlsx|Appendix C: Actors and Activities for establishing eLTSS Information Sharing Resource Matrix]]|| The eLTSS information sharing resource contains a set of Actors and request and response Activities that must be established for the beneficiary/advocate and providers to share eLTSS information. The steps and process on establishing the eLTSS information sharing resource will vary between states and other payers. Some states can and may have multiple information sharing resources. An example set of activities performed to establish the information sharing resource can be found in this matrix.||

 =S&I Framework Process Resources=
 * S&I Initiative Overview, Phases and Outputs || An insider look at how the S&I Framework process works and the resulting deliverables ||
 * [[file:S&I Framework Grantee Education Session 02SEP14.pptx|TEFT Grantee S&I Framework Education Presentation]] || Provides a detailed look at each phase of the S&I process ||
 * Guidelines for Community Participation || Guidelines on how to get involved as an S&I Framework Community member ||

=Conference and Annual Meeting Presentations=
 * **Link or Download** || **Description** ||
 * [[file:Combined_ ONC_AnnualMtg_LTPAC_LTSS_Session.ppt|Combined ONC Annual Meeting]] || 2015 ONC Annual Meeting LTPAC and LTSS Presentation Materials ||

=Affordable Care Act (ACA) Program Reference Materials=
 * **Link or Download** || **Description** ||
 * Money Follows the Person || The Money Follows the Person (MFP) Rebalancing Demonstration Grant helps states rebalance their Medicaid long-term care systems by increasing the use of home and community-based services (HCBS) and reduce the use of institutionally-based services. This is an ACA Program included in the Deficit Reduction Act (DRA) and Extended through ACA, Section 2403. ||
 * Community First Choice || The "Community First Choice Option" lets States provide home and community-based attendant services to Medicaid enrollees with disabilities under their State Plan (ACA, Section 2401). ||
 * Person-Centered Planning and Self-Direction in Home and Community-Based Services || ACA, Section 2402(a) requires the Secretary to ensure all states receiving federal funds develop service systems that are responsive to the needs and choices of beneficiaries receiving home and community-based long-term services (HCBS), maximize independence and self-direction, provide support coordination to assist with a community-supported life, and achieve a more consistent and coordinated approach to the administration of policies and procedures across public programs providing HCBS. ||
 * No Wrong Door/Single Entry Point (NWD/SEP) Information System || ACA BIP requirement that establishes a Statewide system to enable consumers to access all long-term services and supports through an agency, organization, coordinated network, or portal, in accordance with such standards as the State shall establish and that shall provide information regarding the availability of such services, how to apply for such services, referral services for services and supports otherwise available in the community, and determinations of financial and functional eligibility for such services and supports, or assistance with assessment processes for financial and functional eligibility. ||
 * Balancing Incentive Program (BIP) || The Balancing Incentive Program authorizes grants to States to increase access to non-institutional long-term services and supports (LTSS) as of October 1, 2011. (ACA, Section 10202) ||

=Home and Community Based Services and Supports (HCBS) / Long-Term Services and Supports (LTSS) Reference Materials=
 * **Link or Download** || **Description** ||
 * [[file:healthpolicybrief_144.pdf|Health Policy Brief: Rebalancing Medicaid Long-Term Services and Supports, //Health Affairs//, September 17, 2015]] || Expenditures for Medicaid long-term services and supports (LTSS) expenditures are shifting away from primary dependence on institutional care and focusing more on long-term home and community based services. This brief explores the balance between expenditures in home and community versus institutional settings and whether those system expectations should vary by state, by age, or by other population characteristics.  It also addresses the discussion of how federal policies influence the use of LTSS by different populations. Health Policy Briefs are produced under a partnership of Health Affairs and the Robert Wood Johnson Foundation. ||
 * Serving Low-Income Seniors Where They Live: Medicaid's Role in Providing Community-Based Long-Term Services and Supports || To better understand the low-income population with LTSS needs, including those covered by Medicaid and those who are not, this issue brief examines the need for LTSS among seniors who live in the community and need LTSS. ||

=Centers for Medicare & Medicaid (CMS) Standards and Guidance=
 * **Link or Download** || **Description** ||
 * The HCBS Taxonomy: A New Language for Classifying Home- and Community-Based Services || A description of the HCBS taxonomy, explanation of the construction of a crosswalk to map procedure codes to taxonomy categories, and descriptive statistics on state-, service-, and person-level HCBS expenditures based on 28 states whose 2010 MAX data files had been approved by June 1, 2013. ||
 * Outcome and Assessment Information Set (OASIS) dataset for use in Home Health Agencies (HHAs) || Policy and technical information related to OASIS (the Outcome and Assessment Information Set) data set for use in home health agencies (HHAs), State agencies, software vendors, professional associations and other Federal agencies in implementing and maintaining OASIS ||
 * Minimum Data Set (MDS) dataset for use in Nursing Homes || The Minimum Data Set (MDS) is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. ||
 * Continuity Assessment Record and Evaluation (CARE) Item Set || Provided standardized information on patient health and functional status, independent of site of care, and examined resources and outcomes associated with treatment in each type of setting ||
 * Program for All-Inclusive Care for the Elderly (PACE) Assessment and Care Planning Tools || Regulatory requirements for the Interdisciplinary Team (IDT) as defined by the PACE regulations ||
 * Balancing Incentives Program Tools || BIP Work Plan and Deliverables guidance ||
 * Home and Community-Based Services (HCBS) Taxonomy || Describes the HCBS taxonomy and presents findings on HCBS waiver expenditures and users ||

=Other Standards and Guidance=
 * **Link or Download** || **Description** ||
 * S&I Framework's Standards Catalog || Includes the HL7 Consolidated Clinical Document Architecture (C-CDA) Release 2.0 Implementation Guide, BlueButton Plus, and the emerging HL7 FHIR Profile ||
 * Structured Data Capture || HL7 FHIR Profile Implementation Guide for Structured Data Capture (SDC) ||
 * Data Access Framework || HL7 FHIR Profile Implementation Guide for Data Access Framework (DAF) ||
 * ONC Direct Project || Transport Standard ||
 * Recommended Social and Behavioral Domains and Measures for Electronic Health Records || Institute of Medicine's work to identify domains and measures that capture the social determinants of health to inform the development of recommendations for Stage 3 meaningful use of electronic health records (EHRs) ||
 * National Core Indicators || National Association of State Directors of Developmental Disabilities Services (NASDDDS) and Human Services Research Institute (HSRI) program ||
 * Standards for Social Work Practice || National Association of Social Workers (NASW) Standards ||
 * Standards of Practice for Case Management || Case Management Society of America (CMSA) Standards ||
 * Guidelines for Uniform Assessment || American Medical Association (AMA) and American Academy of Home Care Physicians (AAHCP) guidance ||
 * Standardized Data Collection Tools || Administration of Aging (AoA) guidance ||
 * One Care Early Indicators Projects (EIP) || MassHealth, One Care Implementation Council, and UMass Medical School collaboration reports ||
 * National Information Exchange Model (NIEM) || NIEM domains contain mission-specific data components that build upon NIEM core concepts and add additional content specific to the community supporting that mission. A NIEM domain represents both the governance and model content oriented around a community’s business needs. A NIEM domain manages their portion of the NIEM data model and works with other NIEM domains to collaboratively to identify areas of overlapping interest. ||
 * National Association of State Directors of Developmental Disabilities Services (NASDDDS) || NASDDDS represents the nation's agencies in 50 states and the District of Columbia providing services to children and adults with intellectual and developmental disabilities and their families. NASDDDS promotes systems innovation and the development of national policies that support home and community-based services for individuals with disabilities and their families. NASDDS, in collaboration with the Human Services Research Institute (HSRI) has developed National Core Indicators (NCI), a program to support state member agencies to gather a standard set of performance and outcome measures that can be used to track their own performance over time, to compare results across states, and to establish national benchmarks. ||
 * [[file:///Users/Evelyn/Downloads/map_duals_final_report_2014.pdf|National Quality Forum 2014 Input on Dual Eligible Beneficiaries]] || Report developed by the Measure Applications Partnership (MAP) for the Department of Health & Human Services (HHS) on the use of performance measures to evaluate and improve care provided to dual eligible beneficiaries. The report includes an updated Family of Measures for Dual Eligible Beneficiaries and outlines a basic rational for engaging stakeholders using measures in learning more about their experience to inform MAP's future decision making. ||

=Other Care Assessment Tool Projects=
 * **Link or Download** || **Description** ||
 * Guided Care || Johns Hopkins University program (Comprehensive Primary Care for Complex Patients) ||
 * Case Management Information System || Community Care of North Carolina program (Case Management Information System) ||
 * o Community Health Needs Assessment || Eastern Maine Healthcare Systems program ||

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