Longitudinal+Care+Plan+SWG+Charter

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Introduction
Health information technology has evolved into an essential strategy of our nation’s goal to improve quality, reduce preventable errors, and contain rising costs in the US healthcare system. Yet despite federal investments to advance the adoption of HIT, our nation’s health goals are at risk of being unfulfilled due to the lack of standards facilitating the electronic sharing of clinical data between providers across the care continuum and between providers and their patients.

Care planning and coordination over time and across multiple settings and disciplines has long challenged the health care community. With clinical automation, the gaps in document standards and clinical processes in silos are major barriers to development of care plans which fully engage patients, families and care providers and which set realistic and achievable goals, optimize services, and create accountability for community based and institutional care.

Challenge Statement
[//A statement of how a standards and interoperability challenge currently limits the achievement of a national health goal//].

The electronic exchange and maintenance of the Plan of Care is necessary to support ongoing coordination, collaboration, and continuity of care when and where needed among providers and patients in and across the healthcare continuum. Some challenges that need to be addressed include defining the content of the longitudinal care plan and supporting the iterative exchange of this plan.

In the near term, the SWG will create clarity on the process of care initiation and coordination between community-based service providers and professionals providing certification, medical oversight (e.g physicians) and management by defining the use case and clinical process(es), and by defining document architecture standards to support effective automation of the process. The creation of standards for exchange of the physician plan of care for Home Care will begin a process of iterative exchange of the care plan elements and the contextual information required to authorize or update a care and service plan, introducing an element of care coordination over time to the technical standards.

Long Term Challenge: The Longitudinal Care Plan
The Longitudinal Care Plan (LCP) concept remains nebulous to many clinical observers. The SWG challenge will be to define the LCP with sufficient constraint in scope as to permit the creation of meaningful elements of that entity. A specific and unambiguous definition of the LCP, and a scope statement for those elements which will be addressed in the workgroup, are essential. Care planning and coordination in the community has been historically under the purvey of nurses. The roles and responsibilities of the physicians, as granting authority for covered services, and the nurses, as independently practicing licensed professional as well as agents of the physicians, has not been effectively reconciled in most care communities. The relationship between care and services, both health services and human services, has not been clearly defined. Health benefits and successful care planning contains elements of traditional interventions (medications, treatments, high touch interventions, diagnostic testing, prognostic assessments, advance care planning, counseling, social services, durable medical equipment) as well as interventions not perceived as pure health related items, such as meals on wheels, rent credits, and home safety assessments. In addition, the concept of an episode of care and the triggers for the creation of the plan of care and comprehensive review, as well as iterative updates, need to be defined.

A single aligned plan of care, semantically available to all disciplines involved, containing information from disparate health and non-health sources, and fully available to the care / service recipient and capable of guiding care and interacting with health IT systems to maintain alignment and concurrency will likely be beyond the scope and timeline of this workgroup, however, the definition of the “floor” elements which become actionable, and the “ceiling” or goals for future efforts will be incrementally useful.

Near Term Challenge: The Homecare Plan of Care (CMS 485)
The electronic exchange of the homecare Plan of Care has been shown to support collaboration between home health agencies (HHAs) and physicians by supporting the timely transmission of relevant clinical information at the start of homecare and as the patient's condition changes. It enables both the physician and the homecare provider to initiate changes to the homecare treatment more promptly as the patient's needs change. Because both parties are working within their EMR in this exchange, the communication occurs immediately in the clinical process. It is anticipated that, through the use of HIT standards to support the exchange of the HH plan of care, collaborations and efficiencies will be enhanced. Throughout the episode of homecare, the homecare provider and the physician exchange information about the patient’s evolving condition and needs, and the services that the homecare provider will perform. The Centers for Medicare and Medicaid Services (CMS) has specified the content of this exchange in a template described as a Plan of Care (formerly CMS 485 form). After receiving verbal orders from the physician and performing a thorough assessment of the patient, the homecare provider sends this comprehensive assessment and treatment plan to the physician as the Homecare POC for review, recommendations, and a signature of approval. In almost all cases today, the POC travels between the homecare provider and the physician as a paper or faxed form. This is true even though the homecare provider may generate the Plan of Care from data it holds in electronic form in its EMR, and even though the physician may use an EMR for all of his/her patient records. For homecare providers and physicians who use EMRs, there are two major benefits from an electronic exchange of the homecare Plan of Care: reducing overhead effort through greater efficiency, and improving clinical outcomes through fuller collaboration. In cases where the patient is in a patient-centered medical home (PCMH), not only are the physician and the homecare provider the beneficiaries of this improved collaboration but the whole PCMH team as well.

__Efficiency __: An electronic exchange of the Plan of Care between the EMRs of the homecare provider and the physician can improve efficiency for both parties by:
 * Placing the POC in the physician’s inbox to review and act on as part of their daily workflow
 * Eliminating the large amount of time wasted in phone tags and the frustration on the side of the homecare provider in not obtaining the signed order in a timely manner
 * Reducing paper and fax, and corresponding manual processes
 * Eliminating the need for physicians who use homecare EMR physician portals to go to these portals, which is typically outside of their daily workflow, to approve POCs
 * Integrating the exchange with the EMRs that both parties are already using to automate their patient care activities; it fits their preferred workflow in the most efficient way

__Collaboration__: The electronic exchange of the Plan of Care may also promote collaboration by:
 * Supporting the timely transmission of relevant clinical information at the start of homecare and as the patient's condition changes
 * Enabling both the physician and the homecare provider to initiate changes to the homecare treatment more promptly as the patient's needs change
 * Providing immediate communication in the clinical process because both parties are working within their EMR in this exchange

Goal and Scope
[//A statement of the value the SWG will create, in specific, measurable, attainable, relevant, and time-bound terms//].


 * //Long Term Goal: The Longitudinal Care Plan//**

The goal of the Longitudinal Care Plan SWG is to evaluate the best practices in technology enabled care planning and coordination and to document the associated information streams and processes as well as the current and emerging standards for care planning. The short term goal and deliverable is a standard for the Home Health Certification and Plan of Care (CMS 485). Use Case analysis focused on coordinated interdisciplinary wound care will provide further insight into the collaborative and iterative processes fundamental to coordinated care. Finally, the long term goal is to solidify the concept of the Longitudinal Care Plan, define the information model necessary to support its adoption, and a gap analysis to inform future efforts to implement a patient center longitudinal care plan.

The definition of the longitudinal care plan is a longer-term effort for the Longitudinal Care Plan SWG. This effort will include the definition, content, sections, and documented standards of a care plan that can support a variety of patient populations. Given the breadth and depth of the work required, the scope of the work will need to be further refined to ensure success.


 * Key Questions**
 * Is the care plan a technology-enabled medium (e.g., hub or databank) or merely a point-in-time document?
 * What is the length of time that the longitudinal care plan covers?
 * What are the trigger points for the creation of data (or updates to the care plan)?
 * What are the connection points between the longitudinal care plan and other clinical documents (e.g. medical summary)?
 * What are the process elements that influence how the information is captured and transported discipline to discipline?
 * How is information reconciled when it comes from different sources?
 * What are the processes enabling coordinated planning of patient care?

__In-scope__: Examination of care plan domain map, including the relationships between comprehensive interdisciplinary problems (e.g., medical and behavioral, functional, caregiving and self-care deficits, including medical and/or nursing diagnoses), causative factors; goals; manifestations of illness as well as strengths and opportunities; and human service opportunities. In addition, we will discuss the workflow and technology barriers to a distributed, patient centered care plan informing multiple systems in parallel as part of the gap analysis.

__Out-of-scope__: Life to death care plan.

Develop mutually agreed upon technical standards for the iterative electronic exchange of the homecare Plan of Care (POC) with physician and hospital EMRs.
 * //Near Term Goal: The Homecare Plan of Care (CMS 485)//**

__In-scope__: Provider-to-provider exchange of homecare plan of care

__Out-of-scope__: Provider-to-patient/family exchange of home care plan of care. While there could be tools developed to add-on the patient and family (such as portals), portal work is out-of-scope for the near term phase of this initiative.

Deliverables & Timeline
[//A high-level outline of SWG deliverables/outputs and corresponding timeline. Includes key milestones and deliverable dates//].

This SWG will focus on an approach that leverages the health IT capacity available in almost all NHs and HHAs and the electronic health information that is available for almost all nursing home residents and home health patients. The SWG will support and advance the electronic exchange and re-use of a subset of interoperable MDSv3 and OASIS-C assessment content. In addition, the group will document as is processes for Care Planning as well as existing standards. In particular, we will focus on the elements of the care plan in the CCD, the proposed CCD+, and template CDA, to determine the current level of granularity of care plan information and propose a format and standard for a “to be” care plan information model, as defined above. We will solicit input from consumers and additional experts in care planning and coordination. We will attempt to harmonize our efforts with concurrent efforts around care plan standards development at HL7.

a) Identify functional requirements for specific care plan use case scenarios (e.g. CMS 485). 2) Examine the relationship between the functional requirements of the longitudinal care plan and those of the specific use cases. a) To what extent can data and exchange standards for the specific use cases can be re-used for the longitudinal care plan? b) Where are there gaps? || Revise ToC Use Case to reflect LCP SWG Use Case Scenarios || Jan. 2012 || a) Validate and refine, as needed, the content that is to be included on the home care POC (formerly 485-form) b) Re-use, as feasible, standardized OASIS-C assessment content (available at the following link: (@http://aspe.hhs.gov/daltcp/reports/2011/StratEng.htm) || Crosswalk of Data Elements || Jan-Feb 2012 || 2) Identify the exchange standards for the LCP use case scenarios. a) Identify care planning gaps in CEDD and CDA and map these care plan elements to existing LTPAC tools and guides. b) Maintain awareness of, and provide feedback on, the standards being identified and piloted by the VNSNY, homecare EMR vendors, homecare agencies, and hospitals/physicians exchanging an interoperable home care POC (formerly CMS 485-form) || Develop a CDA implementation guide and schema for CMS 485 _ for LCP (**Bill/Susan** – is the intent to develop an IG?) || Feb-Mar 2012 ||
 * **Phase** || **Key Activities**|| **Deliverable** || **Timeline** ||
 * Pre-Discovery ||  ||   ||   ||
 * Discovery || 1) Identify the key functional requirements needed to support a longitudinal care plan.
 * ^  || 1) Identify data elements for LCP use case scenarios.
 * Implementation || 1) Identify content and format standards needed to represent content of the home care POC (formerly 485-form). The SWG will take into account and re-use previous standards identified through the ToC Initiative for the home care POC (formerly 485-form).
 * Pilot || Provide clear, unambiguous implementation guidance to potential pilots of specific use case and if possible longitudinal care planning and conduct outreach. || Pilot CDA implementation guide for CMS 485 ||  ||
 * Evaluation || Identify success metrics || Report on pilot success ||  ||

Request for Participants
This workgroup is seeking participants who have any of the following interests or skills:

Return to Longitudinal Care Plan SWG page

**Bill/Susan** – I think the following comments from Terry relate to the LCP. Can you review and include as appropriate? [TO] Proposed components -list of active participants in the individual's care, contact information, last contact/update -updates -individual's values, wishes, goals of care with indication of any limitations on life sustaining interventions -"manager of the plan"

Proposed functionality -view by discipline, site, time range -track goals and progress towards them -capability to re-set priority for each goal and re-sort

Proposed specifications -exchange as a CCD

misc comments: the longitudinal care plan is not only a series of discrete transfers of informationan among those involved in an individual's care plan, it is also an ongoing dialog that iteratively leads to the "latest" version of the care plan. In order to revise a care plan there are at least three stages of evaluation that are required of each compenent: "Can", "Should" and "May". "Can" it be done? Is the proposed item feasible? "Should" it be done? Does the proposed item meet an accepted standard of care? Are the risks and benefits aligned? And, finally, "May" it be done? Does the patient/proxy agree. Often input is required from multiple contributors who will comment on one or more of these issues. Furthermore, someone has to manage the process and make sure there is an outcome that can be implemented. The care plan is not only the conclusion but also the dialog that lead up to that conclusion. Like most care plans with complicated patients, the decisions are revisited frequently.

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