Justification and Objectives

What’s the purpose of hosting this connectathon track?

• Demonstrate use of FHIR across the continuum of health care and social services
• Explore alignment opportunities across active FHIR-based initiatives:
  • PACIO: Functional and Cognitive Status Assessments  https://paciowg.github.io/cognitive-status-ig/
    • 2020-05 PACIO-eLTSS Post-Acute Care Transition Summary
  • eLTSS: Person-Centered Social Services Planning  – http://hl7.org/fhir/us/eltss/
    • 2020-05 PACIO-eLTSS Post-Acute Care Transition Summary
    • eLTSS Reference Implementation https://github.com/onc-healthit/eLTSS-Reference-Implementation
  • Gravity Project: Social Determinants of Health   – http://build.fhir.org/ig/HL7/fhir-sdoh-cc/
    • 2020-05 Gravity SDOH-CC Track
  • PC WG Care Planning and Management
    • Prior FHIR Connectathon Activities
    • 2020-05 Care Planning and Management Track 

Other Resources for Reference and for Alignment

• Multiple Chronic Conditions (MCC) eCare Plan: MCC Care Planning  – Multiple Chronic Conditions (MCC) eCare Plan
• Bidirectional Services eReferral (BSeR): Closed Loop Clinical and Non-Clinical Referrals  – http://hl7.org/fhir/us/bser/ 
• Da Vinci Clinical Data Exchange (CDex)  – http://build.fhir.org/ig/HL7/davinci-ecdx/
• Structured Data Capture (SDC) http://hl7.org/fhir/us/sdc/
• NLM Form Builder https://lhcforms.nlm.nih.gov/
• CMS Data Element Library (DEL) https://del.cms.gov/DELWeb/pubHome

What do you hope to achieve?

• Demonstrate patient and person-level information exchange across acute, ambulatory, post-acute care settings, community-based organizations, and patient digital mobile devices. 
• Create an opportunity to explore alignment across multiple care planning IG development projects.
• Show information exchange that addresses some of these challenges:
  • Coordination across multi-disciplinary provider groups
  • Navigating eligibility across Medicare and Medicaid programs
  • How to manage health care and HCBS received
  • Sharing multiple assessments across settings
  • Not able to see big picture ‘care plan’
  • Valuable secondary uses of care planning and management information collected at the point of care
  • The role of the "empowered patient" with a System Actor under the individual's control

Clinical input requested (if any)

• health and social services integration within a clinical care setting
• Hoping for support and participation from EHR actors 
• Need assistance with populating certain scenario information into the EHR sandboxes

Related tracks

• Gravity Project Connectathon
• PACIO-eLTSS Connectathon

Related  Track Actors-Transactions-Payload Review

Track Leads

Lisa Nelson, LNelson@Max.md

Evelyn Gallego Evelyn.Gallego@emiadvisors.net 

Expected participants 

Sign up to be a participant here

• Dave Hill - MITRE
• Greg White (Security Risk Solutions)
• Matt Menning - AMA
• Forrest White - Altarum
• Jim Kamp - Altarum
• Nancy Lush, Patient Centric Solutions - PACIO and eLTSS
• Siama Rizvi - MITRE
• Gay Dolin - Namaste
• ONC
• MaxMD
• The Sequoia Project

Track Orientation & Connectathon Schedule

Planning meetings are scheduled bi-weekly on Fridays from 1 to 2 pm ET. 

Virtual Connectathon Schedule:

System Roles

Care Coordination Track Actors-Transactions-Payload:

https://docs.google.com/spreadsheets/d/1AZrtn3-PFFVirmqxm0EHLptdSpWK0Cy8JPhlqYs5mBE/edit#gid=431312950

Technical Actors

Care Coordination Patient Story download here

Scenario CC1:

Patient receiving HCBS services at home falls and is admitted to the hospital. After a course of care, the patient is assessed by PT/OT and recommended to continue care in a Skilled Nursing Facility (SNF). Cognitive assessments were completed during the hospital encounter. The patient is discharged and transferred to a SNF.  Patient is admitted to SNF for PT/OT services. After 28 days, patient is ready for discharge back to home.  Home Health Agency (HHA) assesses the patient, and completes and submits forms to CMS. HHA provider develops Plan of Care and submits to CMS. HCBS case manager reviews updated patient data and updates eLTss Plan.

Describe the different scenarios participating systems can engage in during the connectathon. Each scenario should provide sufficient description that participants can appropriately construct their software in advance to prepare to interoperate during the connectathon.

The following scenes were identified for this track. ONLY Scene 1 and Scene 9 will be tested at the May Connectathon.

1. Person receives home and community-based services (HCBS) at home
2. Person/Patient falls and is hospitalized
3. Pre-discharge, patient is evaluated for functional and cognitive status
4. Patient is discharged to SNF
5. Patient is admitted to SNF
6. Patient is discharged to Home Health
7. Patient is admitted to HHA Services and continues HCBS
8. Patient is discharged from HHA and follows up with PCP
9. Person receives and reviews her updated assessments and plan information

Scenario CC1 Scene 1: Patient receives HCBS Services at home 

Revised to use PACIO/ eLTSS Track Betsy Johnson-Smith persona data.

Action:

Stella is living with CKD and recently lost her job working at the local library. Over the past month she has become increasingly worried and depressed regarding her progressive CKD and what course of action she needs to take should her kidneys fail, especially with no job and no health benefits. Her employer has offered her COBRA benefits for the next month. Stella makes an appointment to see her Primary Care Physician (PCP).

Stella’s last appointment with her Nephrologist left her feeling more confused about her medications and diet plan. She hopes her PCP, Dr. Carlson, can help clarify what medications she should be taking and what food she should be eating.

During the patient encounter, Dr. Carlson examines Stella and reviews labs completed from Stella’s last visit to the Nephrologist. He finds her CKD has not progressed but she has gained significant weight. Stella states she saves money by buying low-cost foods such as macaroni and cheese and pizza.  She wishes she could buy more fruits and vegetables, but they are expensive.  She also notes that she cannot always afford her CKD medications and spaces out her medication to every other day instead of every day.  

Dr. Carlson asks Stella whether she is willing to complete a quick social risk screening questionnaire that will help inform Dr. Carlson’s understanding of Stella’s social risks. Stella agrees and Dr. Carlson proceeds to invite the care coordinator,  Jessica Smith, to administer the questionnaire. 

Jessica explains to Stella she can complete the questionnaire from her own mobile phone via the PCP’s patient portal. Stella agrees and Jessica proceeds to send the questionnaire from the PCP EHR to the patient mobile app. Jessica walks Stella through how to access the questionnaire, respond to the questions, and submit back to the doctor. Jessica leaves the room while Stella answers the questions (Gravity UC1;  Scene 1)

Dr. Carlson reviews the completed questionnaire in the EHR. Dr. Carlson returns to the exam room and asks Stella if she would like to talk a bit more about her food, housing, and transportation challenges as identified in Stella’s questionnaire responses.  Stella is open to this.  She confirms these are three areas of concern for her as well, and that she would appreciate any assistance Dr. Carlson could provide.  

Dr. Carlson refers Stella to the state’s HCBS Operating Agency because he feels she may be eligible for the state’s HCBS benefits that could cover both her medical and social needs. He does not want to start Stella on a new treatment plan until she completes a state assessment and determines whether she is eligible for services covered by the state. Dr. Carlson sends an electronic referral from his EHR to the St. Louis Operating Agency Intake system.

The HCBS Operating System receives the referral and proceeds to schedule a telephone appointment with Stella. Stella completes the Medicaid and HCBS eligibility requirements. The state designated HCBS Qualified Provider (QP) schedules an in-home visit with Stella where she administers the Cognitive, Behavioral, and Functional Assessment (FASI) in home setting (Gravity UC1; Scene 1). The HCBS QP updates Stella’s record in the HCBS Case Management system with the completed FASI.

Two weeks later the HCBS Case Manager schedules an in-home visit with Stella. Using the person-centered planning approach, the Case Manager and Stella create the eLTSS Plan in the Case Manager’s HCBS mobile app. Once complete, the HCBS Case Manager registers the eLTSS Plan and FASI Assessment with the designated Health Information Exchange (HIE) system (unsolicited communication Gravity Trans #5)

One week later, Stella begins to receive HCBS.

Precondition:

Success Criteria:

Bonus point:

Scenario CC1 Scene 9: Patient receives his/her own health information

Action:

Precondition:

Success Criteria:

Bonus point:

TestScript(s)

Indicate any test scripts that will be used to help verify system behavior

Security and Privacy Considerations

Identify any expectations around security (e.g. will TLS, mutual-TLS, OAuth, etc. be required to participate

2019-05 Care Planning and Management Track

DEMARCATED information below. Will be updated soon. 

To view the 2019-09 Care Planning and Management Track click here