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2020-05 Care Coordination Track

This track will use  FHIR R4

Zulip chat: https://chat.fhir.org/#narrow/stream/220328-Care-Plan.2FCare.20Coordination

Connectathon Report Out: Here

Connectathon Demonstration Video: Here 

Connectathon Lessons Learned: Here


Submitting WG/Project/Implementer Group

This track has been developed by the Gravity Project FHIR Accelerator in collaboration with implementer communities testing several other FHIR IGs focus on and relevant to care coordination, including: 

  • HL7 FHIR Gravity Social Determinants of Health in the Clinical Care Setting (sdoh-cc)
  • PACIO Functional Status Assessment IG and Cognitive Status Assessment IG
  • HL7 FHIR Electronic Long-Term Services and Supports (eLTSS)
  • IHE Dynamic Care Planning
  • Da Vinci CDex, FAST
  • HL7 FHIR Bidirectional Service Request (BSeR) IG
  • Clinical Practice Guidelines (CPG)
  • CDS Hooks, on-patient-view
  • SMART on FHIR
  • C-CDA on FHIR
  • US Core

The track also will consider modeling work being done for the HL7 Multiple Chronic Care Conditions (MCC) electronic Care Plan Project.

Table of Contents

Justification and Objectives

What’s the purpose of hosting this connectathon track?

Other Resources for Reference and for Alignment

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

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:

DateTimeGravityPACIO/eLTSSCare Coordination
May 131:30 to 3pm
Dry-Run (6 scenes)
May 134 to 4:30 pmHL7 kick-offHL7 kick-offHL7 kick-off
May 134:30 to 5 pm
Track kick-offParticipate in PACIO track
May 135 to 5:30pmTrack kick-off
Participate in Gravity track
May 135:30 to 6. pm

Track kick-off
May 149 to 10 amIntro, overview, provide resources
Intro, review other track schedules
May 1410 am to 5:30 pmTrack testingTrack testingParticipate in Gravity and PACIO tracks
May 159 to 10 amRecap and review Thurs. testing problems and solutionsStarts at 9.15am. From 9.15am till 2pm, we will be recording demos.Schedule Overview; confirm actors for testing
May 1510 am to 12:30pmTrack report-outs (break from 11:00 - 11:30)Track report-outsAttend PACIO or Gravity Tracks
May 151:30 to 2:15 pmParticipate in Care Coordination TrackParticipate in Care Coordination TrackCare Coordination overview and Gravity and PACIO tracks debrief
May 152:15 to 4:00 pmParticipate in Care Coordination TrackParticipate in Care Coordination TrackTest Scenes 1 & 9
May 154:30-4:45 pmGravity Report out (on main Go To line)

May 155:00 to 5:15 pm

Care Coord Scene 1 & 9 and 5:00 - 5:15 Report out (on main Go To line)
May 156:00 - 6:30 pm HL7 Wrap up (on main Go To line)HL7 Wrap up (on main Go To line)HL7 Wrap up (on main Go To line)

System Roles

Care Coordination Track Actors-Transactions-Payload:

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

Actor

Role

Participant Name/ OrganizationDescription

1

PMEHR (PCP)

Lisa Nelson/ MaxMDCreate the Patient Screening Task which includes the Questionnaire to be used for the screening, the list of patients to be screened, and the CommunicationRequest.  Allow the Task to be queried by Screening App , or support posting the task to the Screening App in a message.

2

Screening App | Patient App

Lisa Nelson/ MaxMDQuery for or Receive a Task that includes a Communication Request for a Screening Response of the type that references the type of Questionnaire included with the task.  Do this for each patient referenced in the included list of patients

3

HCBS Eligibility System

Forrest White/ AltarumA system that receives the referral for Home and Community Based Services (HCBS) Services and conducts eligibility and enrollment activities.

4

Screening App | Practitioner App

Dave Hill/ MitreCreate the Patient Screening Task which includes the Questionnaire to be used for the screening, the list of patients to be screened, and the CommunicationRequest.  Allow the Task to be queried by Screening App , or support posting the task to the Screening App in a message.

5

HCBS Case Management System

Forrest White/ AltarumA system that queries for and renders an HCBS Assessment and generates the person-centered service plan (Care Plan).

6

HIE/Hub (Document Reg/Rep)

Nancy Lush/ Patient Centric Solutions

A system that acts as a document or data repository and aggregates information then supports other systems to access that information.

7

PMEHR (Home Health Agency)

Dave Hill/ Mitre (questionnaire only)

Query and pull existing patient data in HIE/Hub. Query for a Questionnaire and send Questionnaire response to HIE/ Hub. Generate Care Plan and send Care Plan to HIE/Hub.

8

PMEHR (Hospital)

Dave Hill/ Mitre Query and pull existing patient data in HIE/Hub. Query for a Questionnaire and send Questionnaire response to HIE/ Hub.

9

PMEHR (SNF)

Dave Hill/ Mitre

Query and pull existing patient data in HIE/Hub. Query for a Questionnaire and send Questionnaire response to HIE/ Hub.

10

CMS Del

Dave Hill/ MitreQuestionnaire form repository.

11

Patient App

Nancy Lush/ Patient Centric SolutionsQueries for, aggregates and displays patient data.

Technical Actors

IG Space

Technical Actor Name

Code

IG Space

Technical Actor Name

Code

bser, gravity

Task Initiator

TI

bser, gravity

Referral Requester

RReq

bser, gravity

Task Recipient

TR

bser, gravity

Referral Receiver

RRec

bser, gravity

Message Sender

MS

cdex

Clinical Data|Document Sender

IS(I)

bser, gravity

Message Recipient

MR

cdex

Clinical Data|Document Recipient

IR

cdex

Information Source

IS

rest

Clinical Data|Document Source

IS

cdex

Information Requester

IR(I)

rest

Clincial Data|Document Requester

IR(I)

careplan

Clinical Practice Guideline Provider

CPGP

sofc

smart-on-fhir client

AppC

ccdaf

Clinical Document Creator

CDocCre

sofs

smart-on-fhir server

AppS

ccdaf

Clinical Document Consumer

CDocCon

cdshooksCDS ClientcdsC

gravity,pacio,eltss

Content Creator

CCre

cdshooksCDS ServicecdsS

gravity,pacio,eltss

Content Consumer

CCon




gravity,pacio,eltss,mcc

Content Updater

CUpd




sdc

Form Designer

FD




sdc

Form Manager

FM




sdc

Form Filler

FF




sdc

Form Response Manager

FRM




sdc

Form Archiver

FA




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 1Patient 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:

Day and Time: 

Friday, May 15 1:30 - 6:00 pm ET







NameOrgZulip User nameSystem Role (Choose from above)Technical Role (Chose from above)StepFHIR end point
Hari Kunamneni


Patient/Screening App, EHR, CMS-Secondary User

Nancy Lush
Patient Centric Solutions


Nancy LushHIE/HUBFHIR Server
http://data-mgr.azurewebsites.net/open







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

Action:

Precondition:

Success Criteria:

Bonus point:

Day and Time: 

Friday, May 15 1:30 - 6:00 pm ET





NameOrgZulip User nameSystem Role (Choosefrom above)Technical Role (Chose from above)StepFHIR end point
Hari Kunamneni


Patient/Screening App, EHR, CMS-Secondary User

Nancy Lush
Patient Centric Solutions

Nancy LushHIE/HUBFHIR Server
http://data-mgr.azurewebsites.net/open
Patient Centric Solutions
Nancy LushPatient AppContent Consumer

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

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