| Scene # | Setting | Description | Time Period | Key Integration Demonstrations | Scene steps |
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| Betsy receives care and records care preference details | pre-scenario | NA | - Initial data loaded into Betsy's Health Manager, including current medications, problems, and allergies, advance directive details, diabetes care plan, eLTSS care plan, prior cognitive / functional / SPLASH functioning level.
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| 1 | Home - TX | Betsy is able to care for herself in her home with assistance from Long-term Services and Support. Her hearing has been getting worse over the past few months, so she is evaluated for hearing aids. | Late 2020 | - Transfer of hearing data using the SPLASCH IG
- Push of data to a health manager
| - Hearing evaluation performed and data captured by audiologist and hearing aids prescribed.
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| 2 | Hospital - TX | Betsy is taken to the hospital after she experiences right side weakness and slurred speech where she is treated for a stroke. | Mid-February 2021 through late-February 2021 | - Access previously collected data from health manager
- Use of prior functioning information to inform ongoing care
- Transfer of acute care data using the functional status, cognitive status, and SPLASCH IGs
- Push of data collected in an acute setting to a health manager
| - Betsy experiences a stroke and is taken to the hospital. Hospital staff pull Betsy's current information from her Health Manager
- Betsy receives care: she is evaluated and treated and relevant information is captured in the hospital documentation systems
- Betsy has stabilized and is being discharged to a skilled nursing facility.
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| 3 | Skilled Nursing Facility - TX | Betsy receives long-term care in a nursing home care to continue her stroke recovery. | Late-February 2021 through Early-April 2021 | - Access previously collected data from health manager
- Push of cognitive, functional, and SPLASCH data collected in the SNF setting to a health manager
- Access of specific SNF data using the structure of Re-Assessment Timepoints
| - Betsy transferred to a skilled nursing facility, where nursing performs intake including pulling Betsy's current information from her Health Manager.
- SNF staff perform periodic evaluations and required assessments (PPS 5-day MDS, IPA, MDS Discharge Assessment)
- Betsy's payer wants to evaluate Betsy's care and performs an audit of the past month's bill. Their system uses the re-assessment timepoints structure to pull all clinical data associated with the billing period.
- Betsy has regained enough independence and is being discharged to her home where she will continue to receive care from a home health agency.
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| 4 | Home Health Agency - TX | Betsy continues her stroke recovery at home with the help of a home health agency. Her diabetes flares up again, requiring additional visits to her doctor's office for which she needs help with transportation. | Early-April 2021 through Mid-September 2021 | 4A (eCQM - diabetes measure) - eCQM evaluation using aggregated health record
4B (SDOH - transport needs) - SDOH closed loop referral workflow
- Transfer of SDOH data to the health manager using the SDOH Clinical Care IG
4C (MCC Care Plan updates) - Transfer of data using the MCC Care plan IG
4D (eLTSS Care Plan updates) - Transfer of data using the eLTSS IG
| 4A (eCQM - diabetes measure) - HHA staff perform periodic evaluations and required assessments (OASIS admission, 60 and 120 day followups, discharge)
- Following Betsy's MCC care plan, Betsy's nurse periodically checks Betsy's blood pressure and A1c levels. The ACO responsible for Betsy's health care gets these care details and checks for eCQM care gaps in the background. The software flags that Betsy's diabetes is becoming uncontrolled again and notifies Betsy's PCP office who then calls Betsy to schedule a follow-up appointment.
4B (SDOH - transport needs) - After scheduling an appointment to address her diabetes, Betsy tells her nurse that she isn't sure how she will get to the appointment. The nurse administered a survey to assess Betsy's transportation needs and starts a referral process that gets Betsy the help she needs.
4C (MCC Care Plan updates) - Betsy and her PCP review her prior care plan, current A1c values, and new challenges and restrictions following her stroke. Updates are made to her MCC care plan to reflect the new plan.
4D (eLTSS Care Plan updates) - Betsy has completed her stroke treatment and is being discharged from Home Health. She re-engages with her social worker so that she can continue to get the support she needs to stay in her home. She reviews her stroke care and new diabetes plan with the social worker who updates her eLTSS care plan.
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| 5 | Home - MI | Betsy travels to Michigan to visit Charles and his family for an extended holiday now that she has completed her stroke recovery. While there, she decides to update her advance directives. | Mid-November 2021 | - Access of care data by family members
- Transfer of data using the Advance Directives IG
- Advance directives updates and access by family members.
| - In preparation for her visit, Betsy gives Charles access to her health data. He reviews that information to make sure he has. everything she will need to be safe and comfortable in his home.
Betsy decides to change her First Alternate HCA after reflecting on recent family events and interactions. The new paper document is signed, witnessed, scanned, and uploaded to the ADI custodian. - Betsy also updates her Personal Advance Care Plan (PACP) in her ADI custodian, reflecting the changes to her HCAs and expressing her preference for her grandchildren to be allowed to visit her either in person or virtually when she is not feeling well.
- Betsy's Health Manager discovers that new information is available from Betsy's ADI custodian and pulls the current information to include in her record.
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| 6 | PCP - MI | Because she plans to start spending more time with Charles and his family in Michigan, Betsy decides to establish care with a PCP in Michigan | Early-December 2021 | - Information sharing and accessibility not restricted by location and data can cross state lines
- Access of care data by family members
| - Betsy has a first visit with her new Michigan-based PCP. Betsy is able to grant the PCP access to her data in Health Manager and they review Betsy's complete history, including her recent stroke care and her MCC Care Plan.
- Betsy shares details on her care with her daughter Debra back in Texas. Debra is able to view details on Betsy's care.
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