Care Team Management

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Dynamic Care Team Management (DCTM) Profile

  • Meeting every other Monday 4:00 – 5:00 pm EST (first meeting Dec 5th, 2017)

Updated DCTM profile materials are located at IHE PCC FTP Site

Volume 1 Call #1 - Dec 5th, 2016

  • Addendees*
    • Emma Jones
    • George Cole
    • Lisa Nelson
    • Chris Melo
  • Changed the colors on the CareTeamFlow_chronicCOndition vsd diagram to match the chronic condition story board care team summarization analysis - see [1]here for these documents
  • Ideally there should be Sub care teams with an overall team. Need to support - see submitted FHIR Change request with supporting documentation - 11342 [2]
    • Condition-focused team may span multiple episodes
    • Need to have care team referencing other care teams - gforge item submitted to support this.
    • Need to have the same structure as care plan
    • Need Care team relationship
    • Share care team is a view that would make up a representative of the overarching care team for the patient and will be able to get at a shared care team structure.
    • Will be able to get to the sub teams from the care plan.
  • Should we pick one from the green set and one from the yellow set? - see slide 3 of [here]
  • Need some use cases - encode the rules by picking one from the green list and one from the yellow list.
  • Lisa: main use case is to be able to take people off a team when the provider is no longer providing care- if need to ask the machine who was on the care team for the purpose of coordinating care and in the context of value-based care - who's getting paid to take care of you, need to be consistent - payor need
  • If condition changes need to have a current care team that provides effective care - clinical need - care coordination
  • Will share "Care team" references with Stephen Chu - [3]
  • Action Items
    • Payer - need brief examples of when Payer will need types of care teams
    • Clinical - need brief examples of when clinical will need types of care teams
    • IT - - need brief examples of when systems will need types of care teams
    • Care coordination - - need brief examples of when care coordination will need types of care teams


Volume 1 Call #2 - Dec 19th, 2016

  • Addendees*
    • Emma Jones
    • Jeremiah Myers
    • Chris Melo
    • George Cole
    • Stephen Chu
    • Denise Downing
    • Lisa Nelson

Use Case discussion

  • How are care team members removed from the care team? Reason for the question is to determine boundary [added to open issue list]
    • If episode-focused, When the episode is over
    • If encounter-focused, When the encounter is over
    • If condition focused, when the condition is resolved
    • If care coordination focused - when the provider takes himself off the care team
    • people can get off the care team either manually or in an automated way. If automated, need to build in exceptions, need to consider business rules with decision logic.
  • what's the scope of an episode?
    • Concept of episode is used in chronic care - where the episode is a continuum
    • In acute care, the episode is like encounters
    • this is a definitional issue, RIM specific topic.
  • Is there multiple care team resources tied to the patient or is there multiple versions of care team resource?
    • Functionally, even in a single episode, there can be multiple care teams. If the teams operate concurrently, is determined by the patient condition. These types of clinical work flow should be determine.
    • Single instances can nest the care team and have multiple instances
    • Care plan has a referenced to the multiple care teams


Volume 1 Call #3 - Jan 30th, 2016

  • Addendees*
    • Emma Jones
    • Russ Leftwich
    • Chris Melo
    • Stephen Chu
    • Denise Downing
  • CCS care coordination functional model - need to add to discussion area how CCS plays into this profile.
  • added to open issues - need discussion in volume 2 of how notification of updates occur.

Calls before F2F in Feb

  • Jan 2 - New Year Holiday - Cancelled.
  • Jan 16 - Cancelled due to conflicts with HL7 WGM
  • Jan 30

Volume 2+

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