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A webinar will be hosted on TBD to share further participation information about this track.

Use Case

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The use case starts with the patient (Ms. Betsy Smith) receiving home care-based services (HCBS) services.  A social worker documents eLTSS data including care plan and goals.  Ms. Smith experiences a fall at home and is admitted to the hospital for surgery.  After the surgical intervention, the patient is assessed by physical and occupational therapists (PT/OT) and is recommended to continue her therapy in a skilled nursing facility (SNF).  Cognitive assessments were completed during the encounter and pushed to the Data Manager

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RoleDescription
Data Element Library (DEL)Provides CMS standardized assessment data elements via FHIR API
Care Coordinator
  • Long-Term Care Plan App - captures care plan and goals for the patient
  • eLTSS Server - FHIR-based HIT system that contains the eLTSS care plan and goals for the patient and pushes that data to the Data Manager using the eLTSS IG.
Care Setting A
  • PAC Assessment Application - FHIR-based assessment application that retrieves the standardized assessment data elements from the DEL and captures the cognitive and functional status data for the patient.
  • "EHR"/Server/Database - FHIR-based HIT system storing cognitive and functional status data from the assessment application for the patient and pushes that data to the Data Manager using the PACIO Functional Status and PACIO Cognitive Status IGs.
Health Data Manager
  • FHIR-based HIT system that collects data from the Care Coordinator and Healthcare Setting A using the eLTSS and PACIO Functional Status and PACIO Cognitive Status IGs.
  • Authorization/Identity Server - handles authentication and identity management
Care Setting B
  • Care Coordinator System - updates the care plan and goals
  • eLTSS/PACIO Server - Client HIT system to receive patient’s eLTSS, cognitive and functional status data from the Data Manager system, for display to receiving clinician 
Patient/Family Mobile/Web ClientFHIR-based web/mobile application that is able to receive patients’ eLTSS, cognitive and functional status data from the Data Manager for display to a patient or family member.


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Scenarios

Precondition: 

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