Office of the National Coordinator for Health IT Longitudinal Coordination of Care Community-led initiative

January 10, 2013

From: Susan E. Campbell, Committed Member of the (open source) ONC Longitudinal Coordination of Care Community-led initiative

The Office of the National Coordinator for Health IT (ONC) is seeking your participation in the S&I Framework Initiative,  Longitudinal Coordination of Care (LCC) Workgroup (WG). The LCC WG is a community-led initiative charged with supporting and advancing interoperable electronic health record (EHR) systems and patient-centric interoperable health information exchange across the Long-term and Post-Acute Care (LTPAC) spectrum. Over the past year, the LCC WG has been engaged in developing a standardized patient assessment tool and refining standards and implementation guidance for consideration in Meaningful Use Stage 3. More specifically, the LCC WG and its three sub-workgroups are addressing the following challenges:

  1. Absence of an interoperable, longitudinal care plan which aligns, supports and informs care delivery regardless of setting or service provider
  2. Lack of clear and harmonized terminologies and definitions for care plans
  3. Lack of robust, interoperable EHR systems across the LTPAC spectrum with the ability to electronically exchange clinical information
  4. Underserved community with multiple care settings and needs that exceed exchange of clinical information

Key accomplishments (with hyperlinks) of the LCC WG include:

LCC Use Case. Outlines three scenarios for health information exchange between:

  1. an acute care hospital and home health agency (HHA)
  2. a skilled nursing facility (SNF) and the Emergency Department (ED)
  3. a Physician and a HHA. Two of the scenarios center on the Home Health Plan of Care (HH-POC), based on the CMS 485 form.

Transitions of Care and HH-POC Data Set. Builds from the LCC Use Case and identifies over 480 data elements needed by receiving clinicians to safely and appropriately care for patients at times of transitions of care.

Care Plan Glossary. Describes a key list of care plan terms, definitions and components to be considered
for MU stage 3.

The LCC WG is a community-led initiative that is mainly funded and driven by public and private sector partners, each of which is truly committed to overcoming the interoperability challenges in long-term and post-acute care transitions. These dedicated groups include my company, Care Management Professionals.  We hope it could also include the Case Management Society of America (CMSA) and your own firm, Case Management Innovators.

Given the current timeline to respond to the Health IT Policy Committee (HITPC) Stage 3 Meaningful Use Request for Comment (RFC), the LCC WG has hosted a series of webinars to give key stakeholder groups additional information on the current recommendations and questions related to care plans and other key LTPAC priority areas including transitions of care and advance directives. The LCC WG is focused on gathering and consolidating LTPAC community comments and feedback on the existing recommendations in order to develop a unified and targeted response to influence Stage 3 MU recommendations.

We encourage you to review one of the four presentations and recordings of these webinars which are now available on the LCC wiki page here. The LCC WG wants to ensure all LTPAC stakeholder groups have the opportunity to shape Stage 3 MU recommendations and ultimately influence the development of a collaborative model of care that encompasses a longitudinal and comprehensive care plan.

An initial draft of LCC WG comments is now available here for
your review and additional input.

We also invite you to participate in the LCC WG weekly calls. The
schedule and webex information for these calls are available here.



Susan E.
Campbell, PhD, RN-BC(IN), CPHQ, CCM, CIC

Care Management Professionals

Committed LCC Committee Member

Evelyn Gallego, ONC S&I LCC Initiative Coordinator

Dr. Larry Garber, LTPAC SWG Lead

Dr. Terry O’Malley, LTPAC SWG Lead

Dr. Bill Russell, LCP SWG Lead

Sue Mitchell, LCP SWG & PAS SWG Lead