Longitudinal+CC+WG+Charter

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Background
Improving transitions of patients across acute and post-acute care settings has been a key driver of recent healthcare reform initiatives and regulations. Ineffective care transitions are widely recognized as major contributors to poor quality and waste. Gaps in treatment and poor communication among provider groups and between providers and patients have been shown to diminish patient health and increase costs. The Meaningful Use (MU) Electronic Health Record (EHR) Incentive Program addresses this gap by introducing two new measures to improve care coordination during Transitions of Care (ToC): 1) medication reconciliation during ToC and 2) Summary of Care record for ToC/referrals.

The ONC S&I ToC Initiative emerged to identify and develop the standards that would enable the electronic exchange of core clinical information among providers, patients and other authorized entities so that Stage 1 and Stage 2 MU ToC requirements could be met. The ToC Initiative standards target specific provider groups or disciplines—eligible providers (EPs) and eligible hospitals (EHs)—and the software developers and vendors who would design or upgrade EHR systems to enable the exchange. Absent from these scenarios are the exchange requirements for interdisciplinary interventions and care planning across the continuum of care, regardless of setting or service provider. This limitation highlights a critical gap in both the provider and patient populations targeted by the MU Program. For example, each year an average of fifteen million medically complex and/or functionally impaired individuals receive care services not only from eligible provider groups, but also from nursing facilities (NFs), home health agencies (HHAs), long-term care hospitals (LTCHs), inpatient rehabilitation facilities (IRFs) and a wide array of social services and supports. The quantity of service delivery encounters required by these individuals, as well as the failure to deliver and coordinate needed services, are significant sources of frustration and errors, and thereby drivers of healthcare expenditures.

The S&I Longitudinal Coordination of Care (LCC) Initiative builds on the ToC Initiative standards and aims to address identified gaps in transitions of care and care planning.

Challenge Statement
Efficient health information exchange to support coordination of care across multiple clinicians and sites of service—regardless whether these sites receive MU incentive payments—requires more than medication reconciliation and care summary exchange. The availability and adoption of standards to support and inform care delivery without regard to setting are essential to alleviating fragmented, unsafe, duplicative and costly care for those patient populations that need it most.

Individuals of all ages are living longer with chronic illness and disability. As the number and complexity of their health conditions increase over time and episodes of acute illness are superimposed, the number of care providers contributing to the care of these individuals increases as well. It becomes significantly more difficult to align and coordinate care among diverse provider groups across multiple sites.

Without a process to reconcile potentially conflicting plans created by multiple providers, it is impossible to avoid unnecessary and potentially harmful interventions. Without such a process, it is also difficult to shift the perspective of providers from the management of currently active issues to consideration of future goals and expectations. Similarly, the challenge of establishing a consensus driven process across multiple disciplines and settings is confounded by a fragmented system of policies, technologies and services to support the process and thereby enable longitudinal coordination of care.

Scope Statement
To define the necessary requirements that will drive the identification and harmonization of standards that will support and advance patient-centric interoperable health information exchange, including care plan exchange, for medically complex and/or functionally impaired individuals across multiple settings.

This initiative will identify and validate a standards-based longitudinal care management framework built around the needs and experience of the patient respective to:
 * The **Patient Assessment Summary (PAS) or LTPAC Summary** document leveraging the Minimum Data Set (MDS), Outcome and Assessment Information Set (OASIS) and Care Tool datasets
 * A more robust **Transition of Care (ToC)** dataset required by Care Team ‘receivers’ building off the S&I ToC dataset
 * The **Care Plan/Plan of Care** documents used to coordinate patient care across multiple settings and disciplines

The infrastructure will identify new standards that will enable EHRs to exchange clinical and administrative information across multiple settings and disciplines. The identification, evaluation and harmonization of these standards will be organized in terms of three sub-workgroups (SWG):


 * Patient Assessment Summary SWG.** This sub-workgroup will be led in partnership with the Gesinger Keystone Beacon Project Team (an ONC Beacon Community Grantee) and the Office of the Assistant Secretary for Planning & Evaluation (ASPE) and will focus on:
 * Developing a requirements-driven view and model of the patient assessment summary based on clearly-scoped use case and functional requirements
 * Identifying key assessment areas and exchange scenarios for the assessment, as well as the core data elements needed to represent them
 * Coordinating outreach to existing LTPAC vendors and standards development bodies
 * Providing actionable guidance to pilots and building community outreach for pilot programs


 * Long-term and Post-Acute Care (LTPAC) Care Transition SWG.** This sub-workgroup will be led in partnership with the Improving Massachusetts Post-Acute Care Transfers (IMPACT) Program, an ONC State Health Information Exchange (HIE) Grantee, and will focus on:
 * Developing a requirements-driven view of the needed data elements for LTPAC information exchange based on a clearly scoped set of additional TOC user stories
 * Identifying the key business and technical challenges that inhibit long term care data exchanges through existing ToC standards gap analysis
 * Standardizing LTPAC transfer summaries around a single, unambiguous standard and guide
 * Providing actionable guidance to potential pilots
 * Tracking progress on LTPAC pilots and providing best practice feedback


 * Longitudinal Care Plan SWG.** This sub-workgroup will be led in partnership with the Office of the Assistant Secretary for Planning and Evaluation (ASPE) and will focus on:
 * Identification and development of the key functional requirements and use cases that would be supported by a longitudinal care plan
 * Identifying and standardizing the key data elements and providing recommendations for what the longitudinal care plan would look like
 * Addressing key longitudinal care planning gaps in existing or evolving standards
 * Providing clear, unambiguous implementation guidance and outreach to potential pilots

Value Statement
As information moves across settings in the longitudinal care space, Care Team Members need more information than standard chart summaries typically provide. Care Team Members, including patients, benefit from shared patient assessments as well as from Care Plan/Plan of Care exchanges.

Meaningful Use Stage 3 is poised to identify the requirements for care coordination and sharing of information across multiple provider groups—from long-term care and post-acute care to behavioral health and other allied services. There is growing recognition of the need for and benefits of fully interoperable Health Information Technology (HIT) capabilities across these provider groups. Of importance are the information or data needs of the medically complex and/or functionally impaired individuals these provider groups service. Effective, collaborative partnerships among service providers and these individuals are necessary to ensure that individuals have the ability to participate in planning their care and that their wants, needs, and preferences are respected in health care decision making. The identification and harmonization of standards for the longitudinal coordination of care will improve efficiencies and promote collaboration by:
 * Improving provider’s workflow by enabling secure, single-point data entry for ToC and Care Plan exchange
 * Eliminating the large amount of time wasted in phone communication and the frustrations on the side of the receiving provider in not always obtaining care transition and care planning information in a timely manner
 * Reducing paper and fax, and corresponding manual processes during a ToC or Care Plan exchange
 * Supporting the timely transition of relevant clinical information at the start of homecare and as the patient’s condition changes
 * Enabling sending and receiving provider groups to initiate and/or recommend changes to patient interventions more promptly

Target Outcomes & Expected Deliverables
The LCC Initiative will provide an infrastructure to standardize transitions of care and care plan exchange across the continuum of care. In the short term, standards for enabling the most clinically relevant and common transitions of care, the exchange of the Home Health Plan of Care (HHPoC), and patient assessments will be identified. In the longer term, the initiative will solidify the concept of the Longitudinal Care Plan, define the information model necessary to supports its adoption, and a gap analysis to inform future efforts to implement a patient center longitudinal care plan.

The value of this initiative will be measured through the attainment of the following immediate and long-term outcomes:
 * 1) Identification of functional requirements from a Use Case describing key conditions and business rules to enable transitions of care and care plan exchange, while protecting privacy and confidentiality
 * 2) Development of concise architectural guidance using easy-to-understand documentation, user-friendly tooling and formal models to assist providers, software vendors and others in applying technical requirements for transitions of care and the interoperable exchange of care plans
 * 3) Execution of one or more pilots to evaluate the specific use case for transitions of care and care plan exchange
 * 4) Development or identification of new national standards building upon existing and validated S&I ToC standards, and specific for: patient assessment summaries; priority transitions of care across the continuum of care; and care plan exchange.

Standards
Standardization efforts established by other projects will be leveraged. These include, but are not limited to:
 * Standards identified through the S&I Framework's [|Standards Catalog] to include the Consolidated Clinical Document Architecture (C-CDA) (Transitions of Care (ToC)) [|Implementation Guidance]
 * ONC Direct Project (as a transport standard, in relation to the send form functionality)
 * Centers for Medicare & Medicaid (CMS) Standards and Guidance:
 * [|Outcome and Assessment Information Set (OASIS)]
 * [|Minimum Data Set (MDS)]
 * [|Continuity Assessment Record and Evaluation (CARE) Tool]
 * [|Homecare Plan of Care (Form 485)]
 * Massachusetts Department of Health Universal Transfer Form (UTF)
 * Rhode Island Continuity of Care Form

Stakeholders and Other Interested Parties

 * Other ONC Program Grantees: State HIE; Challenge Grants; and Beacon Community
 * Healthcare Providers and Clinical Informaticists
 * Privacy and Security Experts
 * Patient Advocates
 * Pharmaceutical Firms
 * Government Agencies:
 * Assistant Secretary for Planning and Evaluation (ASPE), NIH (NLM & other Institutes/Centers), AHRQ, Centers for Disease Control (CDC), Centers for Medicare & Medicaid Services (CMS), Indian Health Services, Human Resources and Services Administration (HRSA), Institute of Medicine (IOM), Veterans Administration (VA), Department of Defense (DoD)
 * Vendors: EHR, Health Information Exchange (HIE),
 * Standards-Related Organizations: Standards Development Organizations (SDOs), vocabulary/terminology organizations, standards setting organizations
 * Healthcare payers
 * Professional liability carriers
 * Other Healthcare IT Associations: AHIMA, HIMSS

Role of Community Members
The S&I Framework outlines the role of an Initiative Committed Member on the S&I Initiative Overview, Phases and Outputs wiki page. A meaningful commitment means attending required meetings, contributing to discussion, and development of key outputs, as defined by individual workgroups.

Role of S&I Framework Support Staff
The S&I Framework support staff will provide "coaching" support to the WG leads and participants to ensure they understand the processes and tools provided by the S&I Framework. Support staff will also be made available to provide guidance and support to the WG leads and participants to guide them through the various phases of the S&I Framework process.

**Coordination Points**
The following are coordination points with internal and external partners that the workgroup will need to be mindful of when developing key deliverables.


 * Internal Partners (within S&I Framework)**
 * Extending the Transitions of Care Initiative CEDD to include LTPAC-specific information to facilitate care transitions beyond the acute-care and primary care setting
 * Leveraging Transitions of Care Initiative key information exchange documents as vehicle for LTPAC transitions of care and patient assessments


 * External Partners (outside of S&I Framework)**
 * Leveraging State HIE, Challenge Grantees, and Beacon Community efforts in long-term and post-acute care (e.g. IMPACT patient assessments)
 * Utilizing ASPE/AHIMA LTPAC Health IT Collaborative strategy to engage LTPAC community
 * Ensuring regular coordination with federal partners such as CMS, AHRQ and HHS to determine how related activities impact the workgroup

Reference Materials

 * = **Reference Material** ||= **Date** ||= **Description** ||= **Owners** ||
 * [[file:siframework/Longitudinal Care Work Group FINAL.ppt|Longitudinal Care WG Presentation]] || 10-28-2011 || This presentation provides an overview of the proposed restructuring of the LTPAC WG by the leads into four component subgroups, presented to WG on 10-27-2011. || WG Leads ||
 * LTPAC WG Roadmap || 10-28-2011 || This wiki page contains the latest version of the LTPAC Roadmap and will be used to capture comments and feedback on the document. || Participants ||
 * [[file:siframework/Care Coordination Charter v 0 1 2.docx|Care Coordination Charter]] || 11-03-2011 || This word document contains the charter proposal for the development of a Care Coordination WG. || Eva Powell, Russell Leftwich ||
 * [[file:siframework/LCC WG Leads_Roadmap Slide_12152011_Final.pdf|S&I Framework Roadmap for LCC WG]] || 12-15-2011 || This slide provides an overview of sample milestones and outputs, aligned to S&I Framework phases, that the LCC WG may want to produce. || Meredith Lewis, Russell Ott ||

=Workgroup Members=
 * WG Advisory Committee:** SWG Leads & WG Champions
 * ONC Point of Contact:** Evelyn Gallego

**Support Team**

 * **Name** || **Organization** || **Contact Information** || **Role** || **S&I Support Team** ||
 * Evelyn Gallego-Haag || ONC Contractor || evelyn.gallego@siframework.org || LCC Initiative Coordinator ||  ||
 * Becky Angeles || ESAC || becky.angeles@esacinc.com || LCC Initiative Support || Project Management ||
 * Lynette Elliott || ESAC || lynette.elliott@esacinc.com || LCC Initiative Support || Project Management ||

**LCC Work Group Members**
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|| Organization || Participant Name(s) || Statement of Commitment || Committed Deliverables || Workgroup Commitment ||

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