Care Coordination

Objective: Shape the issue of care coordination and its relationship to workflow by involvement in national efforts on standardization, interoperability, and certification efforts for LTPAC HIT systems.


1)     Facilitate Care Coordination and Workflow

  1. Workflow issues needing consideration as use of technology emerges into LTPAC settings
    1. Task completion,
    2. Overlap of documentation
    3. Role responsibility and role shift
    4. Time and cost of getting work done
    5. Additional training requirements and time required for adjusting to implementations and upgrades of software.
    6. Cost of getting work done in facilities with tight budgets.
  2. Use cases specific to the LTPAC setting should be developed to allow early adopters to share how increased effectiveness, efficiency, and satisfaction were achieved with LTPAC HIT.
    1. How workflow efficiencies can be enhanced with the use of electronic reminders, alerts, or reports
    2. Descriptions of positive and negative workflows arising from administrative decisions and work/job design
    3. Consequences of patient provider interactions that affected workflow
    4. Interface design and content within LTPAC IT systems
    5. Effect of system integration on workflow
    6. How interdisciplinary care planning activities are supported by LTPAC HIT
  3. Seamlessness of LTPAC HIT care coordination processes
    1. System integration of IT systems to promote data exchange among all care team members
    2. Structure of inter-professional care summaries and maintenance of interdisciplinary longitudinal care plans

2)     Benchmarks are needed to measure care coordination when LTPAC HIT is being used

                                                      I.        Benchmarks should incorporate distal workflow measures, such as,

  • Distal measures for LTPAC settings might include how telemedicine is used to support consultation services
  • How consultation services impact patient and facility cost or number of tests ordered.
  • Adherence to evidenced based guidelines and procedures

                                                     II.        Benchmarks should include proximal workflow measures, such as,

  • Microlevel analysis of workflow efficiencies among clinical settings
  • Assessment of use patterns for LTPAC HIT
  • Calculating processing times

3)     Research to support the development of theoretical links and relationship between these distal and proximal measures and LTPAC outcomes.

Objective:  Facilitate Standards, Interoperability and Certification Efforts of LTPAC EHRs                  


  • Established the use of LTPAC IT as a key tool to support improvements in continuity and coordination of care
    • Achieve timely and complete health information exchange for persons using LTPAC services
    • Eliminate fragmentation of LTPAC services by integrating certified LTPAC IT Systems using recognized standards to provide high quality, safe and efficient healthcare.
    • Incorporate important outcome assessments with LTPAC HIT initiatives, such as how  information technology (health IT) and health information exchange have the potential to address continuity and care coordination of LTPAC patients to reduce rehospitalizations, and control healthcare cost 
  • Showcase health information exchange activities being implemented in federal, state and private-sector programs that engage LTPAC providers in HIT, EHR, and HIE activities
    • ‍ONC Challenge Grants
    • ONC Beacon Communities
    • Other noteworthy State and private sector HIE activities that include LTPAC providers

Objective: Educate the LTPAC Community about Care Coordination, Workflow, and Best Practices for HIE


  • (NGA recommended that) States conduct an environmental scan of LTC facilities, providers, care centers and others to understand their landscape and key challenges. States could bring LTPAC stakeholders into workgroups and planning efforts to identify specific actions for change; and
  • Incorporate LTC into Ongoing State Strategic HIT Plans: States could look for opportunities to establish goals and bring LTPAC into their state strategic and operational plans as well as their HIE outreach plans.
  • Involvement in the ‍ONC Standards & Interoperability Framework (S&I Framework), Longitudinal Coordination of Care Workgroup (LCC WG) which was created as a community-led initiative to support HIE on behalf of LTPAC stakeholders and to address potential gaps in the prior S&I Transitions of Care work products in order to support engagement of LTPAC providers in HIE activities.

Objective: Address ‍HIT Standards Issues Requiring Further Consideration, Functional Status


  • Provide uniform definition, assessment method, or scale for functional status to be communicated consistently across care settings.
    • Standardize vocabulary to support continuity of care, information exchange and re-use..
    • Support work at the HL7 Structured Documents Workgroup (SDWG) to address critical gaps in representing functional status using health IT standards.
    • Support the HL7 SDWG collaboration with the S&I Initiative in the identification of standards needed to support interoperable exchange of functional status and other information needed at times of transition in care.

Objective: Provide Mechanisms for ‍Certification of LTPAC EHR Products


  • Support EHR product certification criteria to create provider confidence when making HIT/EHR investment decisions.
    • Ensure EHR certification criteria supports efficient and cost-effective interoperable health information exchange and re-use across providers.


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