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Longitudinal Coordination of Care (LCC) Pilots Template. Insert the Name of Your Pilot / Organization Here MM/DD/YYYY. Pilot Team. Identify the members of your organization who will be supporting this pilot. If possible include the role he/she will play in the pilot and contact information. - PowerPoint PPT Presentation
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Longitudinal Coordination of Care (LCC)
Pilots Template
Insert the Name of Your Pilot / Organization HereMM/DD/YYYY
Pilot Team
• Identify the members of your organization who will be supporting this pilot. If possible include the role he/she will play in the pilot and contact information
2
Name Role Email
Full Disclosure?
Goal of the Pilot
• Please include a write up or create a Visio diagram of what you intend to show/prove/support during the pilot process.
• Make this an actionable statement with specifics. • Also include in this description what you hope to gain from this pilot.
4
Which of the 5 C-CDA Revisionsare you Piloting?• Please use this section to document which of the 5 LCC
Standards (Transfer Summary, Consultation Request, Consult Note, Care Plan, and/or Home Health Plan of Care ) you are intending to pilot. Please be as specific as possible.
5
SDC Standard / Guidance Specifics to Pilot Notes
What Relevant Scenario (from the Use Cases) does your Pilot support?• Exchange of Clinical Information from Provider to Provider• Exchange of Clinical Information from Provider to Patient• Other: ____(Please specify)
• Link to download Consensus Approved Use Case 1: http://wiki.siframework.org/LCC+WG+Use+Case+%26+Functional+Requirements
• Link to download Consensus Approved Use Case 2: http://wiki.siframework.org/LCC+WG+Use+Case+2.0
Identify the Use Case Actors/Systems Involved:• A pilot may involve the following participants from the longitudinal
coordination of care ecosystem:– Sending Entity Care Team– Receiving Entity Care Team– Sending Entity Information System (EHR)– Receiving Entity Information System (EHR)– Patient and/or Caregiver– Home Health Agency (HHA) Care Team– Home Health Agency (HHA) Information System (EHR)– PHR Application
Minimum Configuration
• What is your current technical / infrastructure set up?• What systems / applications will you be using to conduct the pilot?• Examples:
– Electronic Health Record (EHR) system– Health Information Exchange (HIE)– External database (which one/type)– Existing interfaces– New interfaces (to be developed as part of the pilot)
Timeline
• What is your proposed timeline given we want to wrap-up Pilots by Q4 2014• Guidance: ~6 months minimum / ~1 year maximum• Evaluation: starts @ 6-9 months / final evaluation when pilot is complete• Example Timeline
– September – Kickoff and Logistics– October – Start Pilots– November – Continue with Pilots– March – Conclude Pilots
Milestone Target Date Responsible Party
Success Criteria
• What will you/your organization use to determine the success of this pilot? This needs to be quantitative and not subjective in as much as possible.
• Examples:– X% Reduction in readmission rate– X% Increase in number of unique patient transfers between sites
with complete set of Care Plan data elements
Example: IMPACT Performance MetricsTarget Outcome
Target Value Target Population Data Source
Numerator Denominator
Reduce hospital readmission rate
5% decrease in 30 day hospital readmission rates from baseline
Unique FCHP patient discharges from St. Vincent Hospital and UMass Memorial Hospital that are readmitted to any hospital from IMPACT Pilot Sites
Fallon Community Health Plan’s claims data via Reliant Medical Group
Number of unique patient discharges from St. Vincent Hospital and UMass Memorial Hospital that are readmitted to any hospital from IMPACT Pilot Sites within 30 days during measurement period
Number of unique patient discharges from St. Vincent Hospital and UMass Memorial Hospital during measurement period
Reduce Hospital Admission Rate
5% decrease in Hospital Admission Rate from baseline
Unique FCHP members seen in St. Vincent Hospital and UMass Memorial Hospital ER that had been under the care of an IMPACT Pilot Site during the measurement period, that are subsequently admitted to the hospital from the ER
Fallon Community Health Plan’s claims data via Reliant Medical Group
Number of unique FCHP members in an IMPACT Pilot Site’s care during measurement period that are transferred to the St. Vincent Hospital or UMass Memorial Hospital ER that are subsequently admitted to the hospital
Number of unique FCHP members in an IMPACT Pilot Site’s care during measurement period that are transferred to the St. Vincent Hospital or UMass Memorial Hospital ER
Increase overall completeness of data included in transition process
70% of patients transferred with complete set of required data elements included in electronic Universal Transfer Form (UTF)
Unique patient transfers between IMPACT pilot sites
LAND and SEE data
Number of unique patient transfers between IMPACT Pilot Sites during measurement period with complete set of required data elements in electronic UTF
Number of unique patient transfers between IMPACT Pilot Sites during measurement period
In Scope / Out of Scope
• If you already know what will be in and out of scope for your pilot (beyond the Implementation Guidance (IG) or the Use Case) please document it here.
• Example:
Risks & Challenges
• Identify any risks or challenges
Questions / Needs
• Please include those items you wish to consider any questions you have or hope the pilot addresses.
• Additionally, please include those items you need in order to succeed.
• We will try to accommodate as many of these needs as possible within the scope of ONC, S&I and LCC (and resource availability).
Useful Links
• LCC Wiki Main Page: http://wiki.siframework.org/Longitudinal+Coordination+of+Care+%28LCC%29
• Use Case 1.0 ‘Transfer of Care’: http://wiki.siframework.org/LCC+WG+Use+Case+%26+Functional+Requirements
• Use Case 2.0 ‘Care Plan Exchange’: http://wiki.siframework.org/LCC+WG+Use+Case+2.0
• Transfer of Care Harmonization: http://wiki.siframework.org/LCC+Long-Term+Post-Acute+Care+%28LTPAC%29+Transition+SWG#Lantana%20Working%20Documents
• Care Plan Exchange Harmonization: TBD• Pilots Wiki Page: http://wiki.siframework.org/LCC+Pilot+Plan
LCC WG Timeline: Mar 2013 – Dec 2013
Mar 13 Apr 13 May 13 Jun 13 Jul 13 Aug 13 Sep 13 Oct 13 Dec 13
Mile
ston
es
Pilot Site Identification & Engagement
Care Plan C-CDA Revisions Complete
HL7 Project Scope Statement Due HL7 Intent to Ballot Due
HL7 Fall Ballot Open
NY Pilots Monitoring
LCC Care Plan Use Case 2.0 Development & Consensus
IMPACT ToC Pilot Monitoring
HL7 Ballot Publication
ToC IGs Development (Transfer Summary, Referral Note, Consult Note)
ToC C-CDA Revisions Complete
HL7 Final Ballot Due
LCC Stakeholder Engagement: Lantana, IMPACT, ASPE, NY, CMS
Care Plan/ Home Health Plan of Care IG Development
HL7 Ballot Package Development
HL7 Ballot & Reconciliation
FACA LCC WG Briefings
LCC & HL7 Care Plan Coordination
IMPACT Go-Live NY Care Coordination Go-Live
Appendix A: LCC Timeline