eltss plan content sub-work group week 3 meeting may 19, 2015 11:00am–12:00pm 1
TRANSCRIPT
eLTSS Plan Content Sub-Work GroupWeek 3 Meeting
May 19, 2015
11:00am–12:00pm
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Meeting Etiquette
• Remember: If you are not speaking, please keep your phone on mute
• Do not put your phone on hold. If you need to take a call, hang up and dial in again when finished with your other call– Hold = Elevator Music = frustrated speakers and
participants• This meeting is being recorded
– Another reason to keep your phone on mute when not speaking
• Use the “Chat” feature for questions, comments,and items you would like the moderator or other participants to know.– Send comments to All Panelists so they can be
addressed publically in the chat, or discussed in the meeting (as appropriate).
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From S&I Framework to Participants:Hi everyone: remember to keep your phone on mute
All Panelists
Agenda
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Topic Time Allotted
Welcome and Announcements 5 minutes
Domain Harmonization Matrix Working Session 40 minutes
Discussion/Reactions 10 minutes
Homework and Next Steps 5 minutes
Meeting Reminders
• eLTSS Plan Content SWG Meetings are held Tuesdays @ 11:00am – 12:00pm Eastern– Next meeting: May 26, 2015 from 11:00am–12:00pm Eastern– Meeting information can be found on the Wiki:
• http://wiki.siframework.org/eLTSS+Plan+Content+SWG– Duration: May 5–July 21 (11 Weeks)
• eLTSS All-Hands Meetings are held Thursdays @ 12:30pm Eastern– Next meeting: May 21, 2015 from 12:30–2:00pm Eastern– Meeting information can be found on the Wiki:
• http://wiki.siframework.org/electronic+Long-Term+Services+and+Supports+%28eLTSS%29
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REMINDER - Please check the Wiki for the latest meeting schedule –meeting link and call in numbers may change.
eLTSS Use Case Context for SWG
• This initiative will identify key domains that will inform the creation of a structured, longitudinal, person-centered electronic LTSS plan for CB-LTSS beneficiaries.
• The eLTSS plan will be designed in such a way that it can be shared electronically across multiple CB-LTSS settings (e.g., adult day services, beneficiary homes, group homes, foster homes, assisted living, supportive housing, home health and hospice), institutional settings (e.g. hospitals, nursing facilities, primary care, post-acute care) and with beneficiaries and payers.
• eLTSS Initiative Project Charter– http://wiki.siframework.org/electronic+Long-Term+Services+and+Su
pports+%28eLTSS%29+Charter
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eLTSS Plan Content SWG Objectives
Identify and harmonize a core set of domains that will inform the creation of a structured, longitudinal, person-centered electronic LTSS plan for CB-LTSS beneficiaries:• clinical and non-clinical domains with terminology consistent
across the seven TEFT states and• example set of discrete data elements for the purpose of
clarifying the type of information that will be collected per domain area.
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Primary Focus Secondary Focus
TEFT State Requirements Non-TEFT State Initiative Requirements
Common Clinical Data Set RequirementsUse Case Requirements
eLTSS SWG Focus
The eLTSS Plan Content SWG will prioritize TEFT state domain requirements; however, we welcome non-TEFT organizations to provide input and participate in the process based on their respective organization requirements and real-world implementation experience. Non-TEFT organization requirements will be considered for future revisions of the eLTSS Implementation Guide.
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eLTSS Plan Content SWG Method & Approach
The eLTSS Plan Content SWG will:• Identify a core set of domains
– Pinpoint concrete definitions and key attributes for the domains
• Define criteria for evaluating each domain– Relate to state, Common Clinical Data Set, and Use Case
requirements– Look for synergies within other initiatives (i.e. IMPACT Act, National
Core Indicators Domains, NQF Domains, etc.)
• Perform domain validation– Internal validation tools (e.g. matrix)– Gap mitigation
• Finalize and present consensus list of domains• Outline example data elements based on approved domains
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eLTSS Initiative Timeline
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Phase 1 Pilots &Testing …
Standards & HarmonizationUse Case &Functional
RequirementsPre-Discovery
DEC 14 JUNJAN FEB MAY JUL AUG SEP OCT NOV
Kick Off11/06/14
Evaluation...
ContentWork Stream
eLTSS All-Hands Work Group
Use Case WG1. eLTSS Use Case
eLTSS Plan Content SWG1. eLTSS Plan Domains &
Data Elements
Standards & Harmonization WG1. Candidate Standards2. Solution Plan3. Implementation Guide (Phase 1)
MAR APR DEC 15 JAN 16
eLTSS Plan Content SWG Timeline
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Week TargetDate eLTSS Plan Content SWG Meeting Tasks Homework
due Fridays 12pm Eastern
1 5/5 Kickoff• Introduction to Domains and Data Elements
• States begin to identify current relevant domains
2 5/12• Introduce/Review Domain Harmonization Matrix• Validate Domain Mappings
• Review domain mappings• Continue to identify relevant
domains
3 5/19• Finalize Validation of Domain Mappings• Validate/Populate Additional State Domains within
Matrix
• Review domain mappings• Continue to identify relevant
domains
4 5/26• Finalize List of Additional State Domains• Identify Baseline for Domain Standards Evaluation• Validate Criteria for Domain Standards Evaluation
• Review criteria for domain standards evaluation
5 6/2 • Identify Baseline for Domain Standards Evaluation• Validate Criteria for Domain Standards Evaluation
• Review criteria for domain standards evaluation
6 6/9• Finalize Validation Criteria for Domain Standards
Evaluation• Begin Evaluation of Domains per Validated Criteria
• Perform domain evaluation per assigned section
7 6/16 • Continue Evaluation of Domains per Validated Criteria
• Perform domain evaluation per assigned section
eLTSS Domains Realigned
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Person-Centered Planning
eLTSS CommunityACL Person-
Centered Counseling NCI Domains
NQF HCBS Domains
Community input has eluded to domain realignment:
eLTSS Domains Realigned
Domain realignment was necessary to satisfy the needs of TEFT States and community members.• Previous domains were heavy on clinical information• SWG Goal = Identify clinical and non-clinical domains
– Allow for true person-centered planning
• Four key initiatives helped to create new eLTSS Domains:– eLTSS Community-Defined Domains (Previous List)– NCI Domains– NQF HCBS Domains– ACL Person Centered
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eLTSS Domains Realigned
National Core Indicators (NCI) provided a unique perspective on service planning while capturing all pertinent information:• Person-centered domains that are valid, reliable, and risk
adjusted– Presented to All-Hands Community by Mary Lee Fay and
Kelsey Walter on March 26
• Data sources include adult, family, and staff stability surveys• New eLTSS Domains:
– Individual Outcomes– Health, Wellness, and Rights– System Performance– Family Indicators
• Very granular sub-domains under each domain
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Domain: Individual Outcomes
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Sub-Domain Definition
Work People have support to find and maintain community integrated employment.
Residence (Aging) NCI Domain for Aging and Disabled (currently being piloted); formal definition forthcoming.
Community Inclusion People have support to participate in everyday community activities.
Choice & Decision Making
People make choices about their lives and are actively engaged in planning their services and supports.
Relationships People have friends and relationships.
Satisfaction People are satisfied with the services and supports they receive.
Self-Determination People have authority and are supported to direct and manage their own services.Person-Centered Profile
Interests, goals, preferences, and priorities of a beneficiary written by the beneficiary in their own words.
Domain: Health, Wellness, and Rights
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Sub-Domain Definition
Health People secure needed health services.
Respect/Rights People receive the same respect and protections as others in the community.
Medications Medications are managed effectively and appropriately.
Safety People are safe from abuse, neglect, and injury.
Wellness People are supported to maintain healthy habits.
Behavioral Needs (Aging)
NCI Domain for Aging and Disabled (currently being piloted); formal definition forthcoming.
Restraints The system makes limited use of restraints or other restrictive practices.
Domain: System Performance
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Sub-Domain Definition
Access Publicly-funded services are readily available to individuals who need and qualify for them.
Service Coordination Services coordinators are accessible, responsive, and support the person’s participation in service planning.
Financial/Payer Information
Financial information typically includes individual or household income (including wages, benefits, and other income) and general assets.
Service Information Includes items that are important for the transfer of information between facilities but were not otherwise captured, such as information on allergies.
Staff Stability Direct contact staff turnover ratios are low enough to maintain continuity of supports and efficient use of resources.
Domain: Family Indicators
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Sub-Domain Definition
Choice & Control Families/family members with disabilities determine the services and supports they receive and the individuals or agencies who provide them.
Family Outcomes Individual and family supports make a positive difference in the lives of families.
Satisfaction Families/family members with disabilities receive adequate and satisfactory supports.
Family Involvement Families maintain connections with family members not living at home.
Community Connections
Families/family members use integrated community services and participate in everyday community activities.
Access & Support Delivery Families/family members with disabilities get the services and supports they need.
Information & Planning
Families/family members with disabilities have the information and support necessary to plan for their services and supports.
Cross-Cutting Sub-Domains
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Sub-Domain Definition
GoalsA defined outcome or condition to be achieved in the process of person-centered care. Includes beneficiary defined Goals (e.g., longevity, function, comfort) and clinician specific Goals to achieve desired and agreed upon outcomes.
Priorities Actions established in order of importance or urgency to the welfare or purposes of the beneficiary at a given time.
IssuesReflect the concerns, current status, risks and barriers to care as well as “likely course” identified by the beneficiary or other Care Team Members that require intervention(s), including education or monitoring, to increase the likelihood of achieving the beneficiary’s or provider’s Goals of care.
InterventionsActions taken to maximize the prospects of achieving the beneficiary’s or providers’ Goals of care, including the removal of barriers to success. Instructions and the performance of monitoring are subsets of Interventions.
The following sub-domains are not exclusive to a single domain, but rather cross-cut multiple domains:
Domain Harmonization Matrix Working Session
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eLTSS Domains Sub-Domains Kentucky Domains Mapping Success
Individual Outcomes
Work
Residence (Aging)
Community Inclusion Social Support
Choice & Decision Making Cognitive Function and Memory/Learning
Relationships
Satisfaction
Self-Determination
Person-Centered Profile Person Profile/Social History, Demographic
Health, Wellness, and Rights
Health Functional Status/Lifestyle, Clinical Information
Respect/Rights Behavior Concerns
Medications Clinical Information
Safety
Wellness Clinical Information
Behavioral Health Needs (Aging)
Restraints
Domain Harmonization Matrix Working Session
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eLTSS Domains Sub-Domains Kentucky Domains Mapping Success
System Performance
Access
Service Coordination
Financial/Payer Information Financial/Payer Information
Service Information Service Information
Staff Stability Care Team
Family Indicators
Choice & Control
Family Outcomes
Satisfaction
Family Involvement
Community Connections
Access & Support Delivery
Information & Planning
Target Population: Intellectual/Developmental Disability, Aging, Brain Injury, Physical Disability, Ventilator Dependent
Domain Harmonization Matrix Working Session
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eLTSS Domains Sub-Domains Maryland Domains Mapping Success
Individual Outcomes
Work Client Common Program Information
InterRAI Assessment Sub-Domains
Residence (Aging) Client Common Program Information
Community Inclusion Client Common Program Information
Choice & Decision Making Client Common Program Information
Relationships Client Common Program Information
Satisfaction Client Common Program Information
Self-Determination Client Common Program Information
Person-Centered Profile Client Common Program Information
Health, Wellness, and Rights
Health Client Common Program Information
Respect/Rights Client Common Program Information
Medications Client Common Program Information
Safety Client Common Program Information
Wellness Client Common Program Information
Behavioral Health Needs (Aging) Client Common Program Information
Restraints Client Common Program Information
Domain Harmonization Matrix Working Session
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eLTSS Domains Sub-Domains Maryland Domains Mapping Success
System Performance
Access Outside of eLTSS (may be in MMIS)
Service Coordination Agency Staff InformationDepends on what is contained within the sub-domain
Financial/Payer InformationISAS,Agency Staff Information,Money Follows the Person,Client Program Information
Service Information ISAS,Client Program Information
Staff StabilityClient Common Program Information, Agency Staff Information,Client Program Information
Family Indicators
Choice & Control Client Common Program Information
Family Outcomes Client Common Program Information
Satisfaction Client Common Program Information
Family Involvement Client Common Program Information
Community Connections Client Common Program Information
Access & Support Delivery Client Common Program Information
Information & Planning Client Common Program Information
Domain Harmonization Matrix Working Session
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eLTSS Domains Sub-Domains Minnesota Domains Mapping Success
Individual Outcomes
Work
Residence (Aging)
Community Inclusion
Choice & Decision MakingSupport Options and Strengths, Summary of Services
Sub-Domains: Cognitive and Behavior Supports, Prevention of Abuse and Neglect
Relationships
Satisfaction
Self-Determination
Person-Centered Profile Person InformationSub-Domains: Name, Demographics, Person Master Index Number
Health, Wellness, and Rights
Health Support Options and Strengths
Also includes items that are mapped to Functional Status. Sub-Domains: Personal Assistance, Home Management and Supportive Services
Respect/Rights
Medications
Safety
Wellness
Behavioral Health Needs (Aging)
RestraintsSupport Options and Strengths, Summary of Services
Sub-Domains: Personal Security and Cognitive and Behavior and Supports, Prevention of Abuse and Neglect
Domain Harmonization Matrix Working Session
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eLTSS Domains Sub-Domains Minnesota Domains Mapping Success
System Performance
Access
Service Coordination
Financial/Payer Information Funding the Plan, Summary of Services
Service Information Summary of Services 1:1
Staff Stability
Emergency and Back-Up Plan for Services and Supports, Person Information, Coordinated Services and Support Plan Signatures
Sub-Domains: Managed Care Provider, Assessor, Case Manager/Care Coordinator, Emergency Contact, Physician/Health Care Provider, Hospital, Signatures
Family Indicators
Choice & Control
Family Outcomes
Satisfaction
Family Involvement
Community Connections Community Support, Support Options and Strengths
Sub-Domains: Training and Skill Building; Supportive Services
Access & Support Delivery
Information & Planning
Domain Harmonization Matrix Working Session
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eLTSS Domains Sub-Domains Connecticut Domains Mapping Success
Individual Outcomes
Work
Residence (Aging)
Community Inclusion
Choice & Decision Making Cognition,Psychosocial Well-being
Relationships
Satisfaction
Self-Determination
Person-Centered Profile Identification Information
Health, Wellness, and Rights
Health
Diagnosis and Health Conditions, Communication/Hearing and Vision Post Assessment Outcomes, Assistive Technology/Durable Medical Equipment/ Specialized Medical Equipment,Environmental and Overall Status, ADLs, IADLs
Respect/Rights
Medications
Safety
Wellness
Behavioral Health Needs (Aging)
Restraints Mood and Behavior
Domain Harmonization Matrix Working Session
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eLTSS Domains Sub-Domains Connecticut Domains Mapping Success
System Performance
Access
Service Coordination
Financial/Payer Information
Service Information History and Resources, Institutional Data
Staff Stability Informant,Additional Contacts
Family Indicators
Choice & Control
Family Outcomes
Satisfaction
Family Involvement
Community Connections Formal and Informal Supports, Living Situation
Access & Support Delivery
Information & Planning
Target Population:
Domain Harmonization Matrix Working Session
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eLTSS Domains Sub-Domains Colorado Domains Mapping Success
Individual Outcomes
Work
Residence (Aging)
Community Inclusion
Choice & Decision MakingBehavior or Memory/Cognition under Supervision
Relationships
Satisfaction
Self-Determination
Person-Centered ProfileCurrent Living SituationApplicant Information; Areas of Concern
Health, Wellness, and Rights
Health
Emergency Room Data, ADLs – ULTC 100.2, ADLs, Long Term Care Assessment for Instrumental Activities of Daily Living
Respect/Rights
Medications
Safety
Wellness
Behavioral Health Needs (Aging)
Restraints Supervision, Behaviors
Domain Harmonization Matrix Working Session
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eLTSS Domains Sub-Domains Colorado Domains Mapping Success
System Performance
Access
Service Coordination
Financial/Payer Information Claims Data
Service Information Authorized Services, Eligibility Span Information
Staff Stability Case Manager or other HCPB Provider
Family Indicators
Choice & Control
Family Outcomes
Satisfaction
Family Involvement
Community ConnectionsSocial Supports, Participation in Activities, External Resources
Access & Support Delivery
Information & Planning
Target Population: Elderly, Blind, Disabled, Intellectually Disabled, Developmental Disability
Domain Harmonization Matrix Working Session
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eLTSS Domains Sub-Domains Georgia Domains Mapping Success
Individual Outcomes
Work
Residence (Aging)
Community Inclusion
Choice & Decision Making
Captured in assessment. Not explicitly included in the plan unless relevant services are being provided.
Relationships
Satisfaction
Self-Determination
Person-Centered ProfileBeneficiary Goals,Beneficiary Identifying Information
Health, Wellness, and Rights
Health ADLs/IADLs
Clinical information is not captured within a plan in Georgia. Other documents/forms are used to capture and hold that information.
Respect/Rights
Medications
Safety
Wellness
Behavioral Health Needs (Aging)
Restraints May be captured in Comments/Notes
Domain Harmonization Matrix Working Session
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eLTSS Domains Sub-Domains Georgia Domains Mapping Success
System Performance
Access
Service Coordination
Financial/Payer InformationFinancial information is included on a per service basis under ‘Service Information’
Service Information Service Information
Staff Stability Care Team Contact Information
Family Indicators
Choice & Control
Family Outcomes
Satisfaction
Family Involvement
Community Connections Beneficiary Background
Beneficiary background includes other items such as living arrangements, community activities, and preferred medical providers
Access & Support Delivery
Information & Planning
Not Mapped to eLTSS Domains
Plan Info and Important Dates
Signatures and Dates
Home Modifications
Equipment and Supplies Required for MonthNotes/Comments
Discussion
Discussion/Reactions
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eLTSS Plan Content SWG Next Steps
• Sign up for the eLTSS Plan Content SWG on the Wiki– http://wiki.siframework.org/eLTSS+Plan+Content+SWG– Joining the eLTSS Plan Content SWG ensures that you are included on
workgroup communications and announcements.
• Homework– Verification of domains provided by TEFT States by SWG team– Due Friday, May 22
• Next eLTSS Plan Content SWG Meeting– Tuesday, May 26 from 11:00am – 12:00pm Eastern
• http://wiki.siframework.org/electronic+Long-Term+Services+and+Supports+%28eLTSS%29
• Thank you! Your commitment and participation are critical to our success.
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eLTSS Plan Content SWG Contact Information
• For questions, please contact your support leads:– eLTSS Plan Content SWG Lead: Grant Kovich, [email protected]– eLTSS Plan Content SWG Co-Lead (Arizona): Lauren Wiggins-Prole,
[email protected]– eLTSS Plan Content SWG Co-Lead (Colorado): Pam Russell,
[email protected]– eLTSS Plan Content SWG Co-Lead (Connecticut): Dr. Minakshi Tikoo,
[email protected]– eLTSS Plan Content SWG Co-Lead (Georgia): Irina Connelly,
[email protected]– eLTSS Plan Content SWG Co-Lead (Kentucky): Sheena Batts,
[email protected]– eLTSS Plan Content SWG Co-Lead (Maryland): David Wertheimer,
[email protected]– eLTSS Plan Content SWG Co-Lead (Minnesota): Tom Gossett,
[email protected]– Initiative Coordinator: Evelyn Gallego, [email protected]– Project Manager: Lynette Elliott, [email protected] 33