Indiana Institute of Technology eLTSS Use Case Discussion Review the attached final Use Case with the DataSet Suggestions section developed by the Standard
Indiana Institute of Technology eLTSS Use Case Discussion Review the attached final Use Case with the DataSet Suggestions section developed by the Standards and Interoperability (S&I) Framework initiative. It is 90 pages long, so you wont read the whole paper. By skimming through it, you will capture a sense of the work involved in a project to utilize Use Cases to identify data elements and build a data set that supports it. The electronic Long-Term Services & Supports (eLTSS) Initiative is a ONC-CMS partnership that will focus on identifying and harmonizing electronic standards that can enable the creation, exchange and re-use of interoperable service plans for use by health care and community-based long-term services and supports providers, payers and the individuals they serve. These plans can help to improve the coordination of health and social services that support an individuals mental and physical health. M5D5 electronic Long-Term Services & Supports Use_Case_20151105.docx This initiative is driven by the requirements of the CMS Testing Experience and Functional Tools (TEFT) in community-based long-term services and supports (CB-LTSS) Planning and Demonstration Grant Program created in the Affordable Care Act (ACA). In the discussion, answer the following questions What are your observations about the Use Case process? Make some comments about the Coded Element Recommendations. How will implementation of the eLTSS plan benefit the Communities of Interest? Use Case Development and Functional Requirements for Interoperability
electronic Long-Term Services and Supports (eLTSS) Plan
electronic Long-Term
Services and Supports
(eLTSS) Plan
Creation and Sharing of an eLTSS Plan
11/5/2015
DISCLAIMER: This Use Case document was developed solely for informational and decisional purposes in
the identification of standards for the creation and sharing of an eLTSS Plan within the S&I Framework.
This document is not policy binding, does not recommend policy directions nor provide policy guidance.
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Use Case Development and Functional Requirements for Interoperability
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Table of Contents
1.0 Preface and Introduction ………………………………………………………………………………………………………… 1
2.0 Initiative Overview …………………………………………………………………………………………………………………. 1
2.1 Initiative Challenge Statement……………………………………………………………………………………………… 2
3.0 Use Case Scope ……………………………………………………………………………………………………………………… 3
3.2 In Scope …………………………………………………………………………………………………………………………….. 3
3.3 Out of Scope………………………………………………………………………………………………………………………. 3
3.4 Communities of Interest ……………………………………………………………………………………………………… 4
4.0 Value Statement ……………………………………………………………………………………………………………………. 6
5.0 Use Case Assumptions ……………………………………………………………………………………………………………. 8
6.0 Pre-Conditions……………………………………………………………………………………………………………………….. 9
7.0 Post Conditions ……………………………………………………………………………………………………………………. 10
8.0 Use Case Diagram ………………………………………………………………………………………………………………… 10
9.0 User Stories …………………………………………………………………………………………………………………………. 11
9.1 User Story 1: LTSS Eligibility Determination, eLTSS Plan Creation and Approval ……………………….. 11
9.1.1 Actors and Activities – User Story 1……………………………………………………………………………….. 13
9.1.2 Base Flow – User Story 1 ……………………………………………………………………………………………… 14
9.1.3 Activity Diagram – User Story 1 …………………………………………………………………………………….. 15
9.1.4 Information Interchange Requirements – User Story 1 ……………………………………………………. 16
9.1.5 System Requirements – User Story 1 …………………………………………………………………………….. 17
9.1.6 Sequence Diagram – User Story 1 …………………………………………………………………………………. 17
9.2 User Story 2: Sharing a Person-Centered eLTSS Plan …………………………………………………………….. 18
9.2.1 Actors and Activities – User Story 2……………………………………………………………………………….. 20
9.2.2 Base Flow – User Story 2 ……………………………………………………………………………………………… 21
9.2.3 Activity Diagram – User Story 2 …………………………………………………………………………………….. 22
9.2.4 Information Interchange Requirements – User Story 2 ……………………………………………………. 23
9.2.5 System Requirements – User Story 2 …………………………………………………………………………….. 24
9.2.6 Sequence Diagram – User Story 2 …………………………………………………………………………………. 24
10.0 Risks, Issues and Obstacles ………………………………………………………………………………………………….. 25
11.0 Dataset Suggestions ……………………………………………………………………………………………………………. 27
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Use Case Development and Functional Requirements for Interoperability
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11.1 eLTSS Domains and Sub-domains Overview ……………………………………………………………………….. 27
11.2 Sub-domain Coded Element Recommendations …………………………………………………………………. 30
11.2.1 Person Information Domain ………………………………………………………………………………………. 30
11.2.2 Health, Wellness and Rights Domain …………………………………………………………………………… 46
11.2.3 Service Planning and Coordination Domain …………………………………………………………………. 62
11.2.4 Family and Caregiver Information Domain …………………………………………………………………… 69
11.2.5 Cross-Cutting Sub-domains Coded Elements………………………………………………………………… 73
Appendices……………………………………………………………………………………………………………………………….. 75
Appendix A: Related Use Cases……………………………………………………………………………………………….. 75
Appendix B: Previous Work Efforts ………………………………………………………………………………………….. 75
Appendix C: Actors and Activities for establishing eLTSS Information Sharing Resource …………………. 77
Appendix D: References ………………………………………………………………………………………………………….. 86
List of Figures:
Figure 1. eLTSS Plan Sharing Context Diagram ………………………………………………………………………………. 11
Figure 2. Activity Diagram – User Story 1 ………………………………………………………………………………………. 16
Figure 3. Sequence Diagram – User Story 1 …………………………………………………………………………………… 18
Figure 4. Activity Diagram – User Story 2 ………………………………………………………………………………………. 23
Figure 5. Sequence Diagram – User Story 2 …………………………………………………………………………………… 25
List of Tables:
Table 1. Communities of Interest ………………………………………………………………………………………………….. 6
Table 2. Actors and Activities – User Story 1 ………………………………………………………………………………….. 14
Table 3. Base Flow – User Story 1 …………………………………………………………………………………………………. 15
Table 4. Information Interchange Requirements – User Story 1……………………………………………………….. 17
Table 5. System Requirements – User Story 1………………………………………………………………………………… 17
Table 6. Actors and Activities – User Story 2 ………………………………………………………………………………….. 21
Table 7. Base Flow – User Story 2 …………………………………………………………………………………………………. 22
Table 8. Information Interchange Requirements – User Story 2……………………………………………………….. 24
Table 9. System Requirements – User Story 2………………………………………………………………………………… 24
Table 10. eLTSS Plan Content Domains, Sub-domains and Definitions ……………………………………………… 30
Table 11. Work Sub-domain Coded Elements ……………………………………………………………………………….. 31
Table 12. Residence Sub-domain Coded Elements…………………………………………………………………………. 34
Table 13. Community Inclusion Sub-domain Coded Elements …………………………………………………………. 37
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Use Case Development and Functional Requirements for Interoperability
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Table 14. Choice & Decision Making Sub-domain Coded Elements ………………………………………………….. 37
Table 15. Relationships Sub-domain Coded Elements ……………………………………………………………………. 38
Table 7. Self-Direction Sub-domain Coded Elements ……………………………………………………………………… 41
Table 17. Demographics Sub-domain Coded Elements …………………………………………………………………… 46
Table 18. Person-Centered Profile Sub-domain Coded Elements …………………………………………………….. 46
Table 19. Health Sub-domain Coded Elements ……………………………………………………………………………… 50
Table 20. Medications Sub-domain Coded Elements ……………………………………………………………………… 53
Table 21. ADLs/IADLs Sub-domain Coded Elements……………………………………………………………………….. 54
Table 22. Safety Sub-domain Coded Elements ………………………………………………………………………………. 56
Table 23. Wellness Sub-domain Coded Elements…………………………………………………………………………… 60
Table 24. Psychological Well-Being Sub-domain Coded Elements ……………………………………………………. 61
Table 25. Restrictions Sub-domain Coded Elements ………………………………………………………………………. 62
Table 26. Service Coordination Sub-domain Coded Elements …………………………………………………………. 63
Table 27. Personal Finance Information Sub-domain Coded Elements …………………………………………….. 67
Table 28. Service Information Sub-domain Coded Elements …………………………………………………………… 69
Table 29. Family Information Sub-domain Coded Elements ……………………………………………………………. 70
Table 30. Community Connections Sub-domain Coded Elements ……………………………………………………. 71
Table 31. Access & Support Delivery Sub-domain Coded Elements ………………………………………………….. 72
Table 32. Information & Planning Sub-domain Coded Elements ……………………………………………………… 73
Table 33. Cross-Cutting Sub-domains Coded Elements …………………………………………………………………… 74
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1.0 Preface and Introduction
To fully realize the benefits of Health Information Technology (Health IT) for community-based longterm services and supports (CB-LTSS), the Office of the National Coordinator for Health Information
Technology (ONC) and the Centers for Medicare and Medicaid Services (CMS) have partnered to
facilitate the development of a Use Case for person-centered service planning. This Use Case defines the
interoperability requirements for high priority LTSS data exchange that maximizes efficiency, encourages
rapid learning, and protects beneficiaries1 privacy in an interoperable environment. The electronic
Long-term Services and Supports (eLTSS) Use Case addresses the requirements of a broad range of
Communities of Interests including but not limited to: beneficiaries, beneficiary advocates/legal
representatives, CB-LTSS providers, clinical and institutional-based providers, healthcare payers,
accountable entities, vendors, standards organizations, public health organizations, and government
agencies.
The eLTSS Use Case describes the following:
The operational context for the sharing and exchange of LTSS data
The stakeholders with an interest in the Use Case
The information flows that must be supported by the data exchange
The types of data and their specifications required in the data exchange
The eLTSS Use Case serves as the foundation for identifying and specifying the standards required to
support the data exchange and developing reference implementations and tools to ensure consistent
and reliable adoption of the data exchange standards.
2.0 Initiative Overview
This initiative will identify key domains that will inform the creation of a structured, longitudinal, personcentered, electronic long-term services and supports (eLTSS) plan for community-based (CB-LTSS)
beneficiaries2. The eLTSS plan will be designed in such a way that it can be shared electronically, with
beneficiary approval, across multiple CB-LTSS settings (e.g., the homes of beneficiaries receiving
services, adult day services, schools, group homes, foster homes, assisted living, employment sites,
supportive housing, home health, and hospice), institutional settings (e.g. hospitals, nursing facilities,
primary care, post-acute care) and with individuals receiving services and payers. The person-centered
eLTSS plan is led by the beneficiary and includes individuals chosen by the beneficiary to participate in
his or her care.3 The standards identified for the eLTSS plan will support consistent data collection and
interoperable sharing with various information systems to include clinical information systems, State
Medicaid and other Accountable Entity systems, Health Information Exchange (HIE) systems, Personal
Health Record (PHR) systems, and other information systems (e.g. case management, legal, justice,
1
For the purpose of the eLTSS Initiative, beneficiary will refer to all individuals who are eligible for and receive LTSS benefits to
include those paid by Medicaid. These beneficiaries are also referred to as recipients, consumers, persons, participants, clients
and individuals. The beneficiary may also include other individuals like a legal representative or advocate to participate in his or
her care.
2 CB-LTSS (as with home and community-based services (HCBS)) is defined by CMS for this project as assistance with activities
of daily living and instrumental activities of daily living provided to beneficiaries that cannot perform these activities on their
own due to a physical, cognitive, or chronic health condition.
3 The eLTSS plan can be directed by the person or facilitated by a coordinator or other person chosen by the person. The
process of developing the plan is responsive to the priorities and preferences of the person.
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Use Case Development and Functional Requirements for Interoperability
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education, protective services, etc.). Information will be shared and accessed in compliance with policy,
regulation, and Patient Consent Directives (e.g., 42 C.F.R Part 2 Confidentiality of alcohol and drug abuse
patient records; and 38 USC § 7332-Confidentiality of certain medical records, Section 508 of the
Rehabilitation Act). These standards will also support timely revisions to the eLTSS plan as the
beneficiary receives services consistent with CMS final regulations §441.301(c) (1) and (2) regarding
Person-Centered Planning Process/Person-Centered Service Plan.
The Affordable Care Act and other legislative statutes introduce approaches to health care delivery that
encourage the formation of more coordinated systems and person-centered planning, many of which
can be supported by Health IT. Relevant Affordable Care Act programs and policies include the Money
Follows the Person demonstration program (included in the Deficit Reduction Act (DRA) and Extended
through ACA, Section 2403), the Community First Choice (ACA, Section 2401) State Plan option, the
Balancing Incentives Program (ACA, Section 10202) Aging and Disability Resource Center (ACA, Section
2405) and directives to develop additional oversight and assessment of the administration of HCBS.
(ACA, Section 2402(a)). These programs and policies target diverse beneficiary populations4, some of
which are eligible for Medicaid-funded CB-LTSS provided by the states. In addition, recent changes to
the regulations governing Medicaid-funded LTSS provide increased clarity related to the characteristics
and requirements of LTSS, the administration of home and community-based services, and personcentered planning. In 2014 The Secretary HHS issued guidance to HHS operating division regarding selfdirection, and person-centered planning5. In addition, the IMPACT Act of 2014 requires the use of
standardized data to: 1) enable interoperable, longitudinal person-centered goals, preferences and
outcomes and 2) promote quality measurement regardless of the persons transition of care placement
(institutional or HCBS).6
2.1 Initiative Challenge Statement
The Initiative Challenge Statement describes how a standards and interoperability challenge currently
limits the achievement of a national health goal. The eLTSS Project Charter7 defines the challenge
statement as:
The adoption and use of Health IT and quality measurement for community-based long-term services
and supports is limited. Limitations include: insufficient business and/or financial incentives for service
providers to acquire and use Health IT to support coordination of services; minimal national standards
for quality measurement in LTSS outcomes; lack of uniformity in the terminology and definitions of data
elements, including those important to the beneficiary, needed for assessments and service plans used
across and between community-based information systems, clinical care systems and personal health
record systems; and lack of consensus on the inter-relationships between a beneficiarys plan across
care, services and supports settings; and lack of evidence and understanding of how Health IT may
benefit the beneficiary and encourage their adoption and use of Health IT.
4
Sample populations identified by the TEFT Program include: Aged, Disabled, Developmentally disabled, Brain Injury, Serious
Mental Illness.
5 http://www.acl.gov/Programs/CDAP/OIP/docs/2402-a-Guidance.pdf
6 http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Post-Acute-Care-QualityInitiatives/IMPACT-Act-of-2014-and-Cross-Setting-Measures.html
7 The Consensus-Approved eLTSS Project Charter is available at: http://wiki.siframework.org/electronic+LongTerm+Services+and+Supports+%28eLTSS%29+Charter
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electronic Long-Term Services and Supports (eLTSS) Plan
3.0 Use Case Scope
The scope of this Use Case is to define the necessary requirements that will drive the identification…
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