Longitudinal Coordination of Care (LCC) Workgroup (WG)

LCC All Hands Meeting

February 7, 2013

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Agenda

• ONC S&I Updates• Key Accomplishments of the WG & SWGs• Use Case Working Session• Next Steps

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ONC S&I Updates

• Developing S&I LCC Support Work plan to support next phase of LCC Initiative

• Engaging with S&I Transitions of Care (ToC) Support team to align and build from ToC artifacts and membership

• Identifying and engaging with additional LCC Stakeholder groups

• Engaged with ONC Office of Policy & Planning (OPP) to review and schedule LCC WG presentation to the HITPC

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LCC WG Key Accomplishments

• Held two webinars regarding the Meaningful Use (MU) Stage 3 Request for Comments– Reviewed relevant Meaningful Use (MU) Stage 3 sections– Proposed concepts and definitions to reframe the

recommendations– Gathered community feedback to develop a shared response

• Submitted Comments for the Meaningful Use (MU) Stage 3 Request for Comments

• Updated the LCC and SWG Wiki pages– Streamlined content – Meeting Information more visible– PAS SWG is “Completed”

Wiki Re-Design

• http://wiki.siframework.org/Longitudinal+Coordination+of+Care+%28LCC%29

LTPAC SWG Key Accomplishments

• Developing a roadmap for a public and private collaboration– Create and ballot through HL7 Implementation Guides to

support transitions of care and the care plan/home health plan of care.

• Proposed a new CDA template section known as the “MAP” (AKA Master All-care Plan) which maps the many-to-many relations that connect the various elements of the care plan (e.g. Health Concerns, Goals, Interventions, Assessments, and Care Team).

• Reviewed and provided feedback to Lantana to support their work on defining a high-level Implementation Guide for the Transfer of Care dataset.

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LCP SWG Key Accomplishments

• Led review and consolidation of LCC Community comments on ‘Care Plan Glossary’ and ‘RFC Webinar’

• Supported review and deep dive of ‘care plan components’ of IMPACT dataset

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PAS SWG Key Accomplishments

• New website regarding transform tool:  www.transform.keyhie.org– Will be updated often as project unfolds

– Currently able to see info on benefits and pricing

– Sign up under “take a test drive” and you will be included in updates on project

• Aggressive launch schedule– Started pilots in mid-January with:

– Presbyterian Senior Living (SNF)

– Sun Home Health (HHA)

– Will bring on Geisinger Beacon facilities in Mar/Apr

– Anticipate full public launch in April

• Jim Younkin’s ONC presentation on project will be posted to wiki

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Use Case Outline

NEXT STEPS:

• Look at the Problem list – expand or reduce the list

• Take the list and under each heading identify which health concerns are for what team members and which team members are working collaboratively

Team members:

• Hospitalist• Floor nurse• Psych Consultant• Case managerDelivered to:

• PCP

• Community-based care coordinator

• HHA nurse

• CBSO

• Behavior Health professional

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Use Case Outline

Patient has the following Problems:•Diabetic Ulcer – – non weight-bearing on the foot with the ulcer

– neuropathy

– gait impairment

•Depression – – self-medicating with alcohol

•Substance Abuse Issues– Malnutrition from alcohol abuse

•Lives alone in a 3rd Floor Walkup with Kerosene Heater (no elevator)•Infectious Disease– MRSA

•PPD is positive•Vaccination Status•Visually Impaired - Unable to Drive•Cognitive Status•Smoking / COPD

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Use Case Outline

Insurer:

•Medicaid/Medicare (dual)

Achieve following Goals:

•Marginal disease management

•Quality of life improvement

•Figure out what the patient really wants – what is important and how the care team can help (i.e., get housing on the first floor)

•Break the cycle of re-admission in ED

•Substance Abuse Intervention

Assumption:

•The Clinical Summary exists and wraps around this Use Case

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A=ACTIVE Relationship of health concerns to other health concernsB=PRESENT H/M/LC=INACTIVE Health Concern

Health Concern Issue Patient Clinician Delta Inf Dis (+PPD) MRSA + Depres Cog Impaa Diabetes Status Priority Priority …r s t u vb Poor compliance A L H H H Hc Diet A H Hd Medications A H He Follow-up care A H Hf PCP Ag Opthalmology Ah Glycemic control A H Hi HgA1c 11 M Mj Diabetic Foot Ulcer - A M H M Hk non weight-bearing on the foot with the ulcer Hl dressing changes and monitoring H

m Retinopathy A H H Ln Low vision Ao Neuropathyp Gait impairment A M M Mq Chronic pain A H H L Hr Infectious Diseases MRSA colonization of foot ulcer B L L Lt Positive PPD B L L Lu Depression/anxiety - A H H Lv Cognitive Impairment A L H Hw Alcoholism A L H H H Hx COPD A L M My Substance Abuse A L H H Hz Intermittent opiate abuse P L M M

aa Alcoholism A L H Hbb Smoking A L H Hcc Malnutrition A L M M M H Hdd Environment Hee Lack of supports Pff Lack of access to appropriate diet A Hgg Social isolation Phh Lives alone in a 3rd Floor Walkup (no elevator) Pii Unable to drive Pjj Limited mobility A

kk Health Maintenancell Vaccinations I H

mm Cardiovascular risk factors Inn Suicide risk assessment A H

Use Case Map

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Next Steps

• Finalize S&I LCC WG Support Plan• Update LCC Use Case with new Care Plan component

definitions– Revise functional specifications

• Kick-off IMPACT/ASPE public private partnership for development of ToC and Care Plan/ HHPoC Implementation Guides