Transcript ONC LCC WG Goal - (S&I) Framework

Longitudinal Coordination of Care
(LCC) Workgroup (WG)
LCC All Hands Meeting
February 7, 2013
1
Agenda
•
•
•
•
ONC S&I Updates
Key Accomplishments of the WG & SWGs
Use Case Working Session
Next Steps
2
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
3
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+%28
LCC%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.
6
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
7
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
8
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 manager
Delivered to:
• PCP
• Community-based care coordinator
• HHA nurse
• CBSO
• Behavior Health professional
9
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
10
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
11
Use Case Map
Health Concern
a
Diabetes
b
Poor compliance
c
Diet
d
Medications
e
Follow-up care
f
PCP
g
Opthalmology
h
Glycemic control
i
HgA1c 11
j
Diabetic Foot Ulcer k
non weight-bearing on the foot with the ulcer
l
dressing changes and monitoring
m
Retinopathy
n
Low vision
o
Neuropathy
p
Gait impairment
q
Chronic pain
r
Infectious Disease
s
MRSA colonization of foot ulcer
t
Positive PPD
u
Depression/anxiety v
Cognitive Impairment
w
Alcoholism
x
COPD
y
Substance Abuse
z
Intermittent opiate abuse
aa
Alcoholism
bb
Smoking
cc
Malnutrition
dd
Environment
ee
Lack of supports
ff
Lack of access to appropriate diet
gg
Social isolation
hh
Lives alone in a 3rd Floor Walkup (no elevator)
ii
Unable to drive
jj
Limited mobility
kk
Health Maintenance
ll
Vaccinations
mm
Cardiovascular risk factors
nn
Suicide risk assessment
A=ACTIVE
B=PRESENT
C=INACTIVE
Issue
Patient
Status
Priority
A
L
A
A
A
A
A
A
Clinician
Priority
H
Delta
H
Relationship of health concerns to other health concerns
H/M/L
Health Concern
Inf Dis
(+PPD) MRSA + Depres Cog Impa
…r
s
t
u
v
H
H
H
H
H
H
H
H
H
M
A
M
H
H
M
M
H
H
H
A
A
H
H
L
A
A
M
H
M
H
M
L
B
B
A
A
A
A
A
P
A
A
A
L
L
H
L
L
L
L
L
L
L
L
L
L
H
H
H
M
H
M
H
H
M
L
L
L
H
H
M
H
M
H
H
M
H
H
H
H
M
H
H
H
P
A
P
P
P
A
I
I
A
H
H
H
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
13