Care Coordination Capabilities

Capabilities

Capabilities express "abilit[ies] that an organization, person or system possesses" [1]. Capabilities are independent of business process and they express the "what" rather than the "how".

Capabilities may outlive specific technical specifications or implementations that realize business processes. They may be represented in HL7 V2, V3 or V10 but they will endure and continue to represent what the business does and what services in technology X will need to perform.

Capabilities may be aggregated into logical groupings which may map to interfaces but they will simply be represented here as logical capability sets.

The Care Coordination capabilities comprise the core of the normative content specified in by the CCS HSSP Service Functional Model 2.

As a general rule the capabilities are separate from organizational policies and business rules. This decoupling will allow capabilities to be combined to support various business processes and organizational policies.

Care Collaboration - Build "Social" Network Capability Set

Invite to Collaborate Capability

An invitation is a request to participate in a care coordination or community of collaborators. Invitations may be sent from an authorized participant to new care team member participant.

The ultimate authority resides with the patient and they may directly invite care givers.

The patient's delegated steward, licenced independent practitioner (LIP) (e.g. PCP or other professional care plan facilitators such as a nurse case manager) of their care plan will typically serve as the "seed" of the collaboration tree.

Members who have accepted may invite other care team members based on pre-existing organizational agreements and policies as covered by HIPAA.

Participants join the the Care Team via an invitation based process which helps to organically grow the patient's care network just as it does in the "real world".

Capability Status

2-26-2012

Proposed

Reviewers Here

Precondition	The participant must either be: The patient who holds ultimate authority in selecting his or her care team. The patient's PCP A participant who has received invitations from either the patient or PCP via a chain of trust reflected by pre-existing organizational policies
Inputs	Patient New Collaborator
Outputs	edit here
Postconditions	edit here
Exception Conditions	New collaborator not vetted by external policy checks
Included in Profiles	edit here
Outstanding Issues	edit here

Care Collaboration - Team Conversation Capability Set

Care Team Chat Communications

Care team chat communications with optional multimedia support.

Capability Status

2-26-2012

Proposed

Reviewers Here

Preconditions	edit here
Inputs	Free form text with linked semantic content Communication Semantic context (e.g. Plan, HealthGoal, HealthConcern, Outcomes, Team Member)
Outputs	edit here
Postconditions	edit here
Exception Conditions	edit here
Included in Profiles	edit here
Notes	edit here
Outstanding Issues	edit here

Care Observations and Assessment Capability Set

Capture Subjective and Objective Patient Observations

Capability Status

2-26-2012

Proposed

Reviewers Here

Preconditions	edit here
Inputs	edit here
Outputs	edit here
Postconditions	edit here
Exception Conditions	edit here
Included in Profiles	edit here
Outstanding Issues	edit here

Clinical Evaluation of Plan Items

Check Clinical Appropriateness Capability

Given a health concerns, goals and risks and existing plan actions are the interventions appropriate

Recommend Plan Template Capability

Given a health concerns, goals and risks and barriers recommend a Plan template

Care Plan Implementation Capability Set

Request Resource Allocation Capability

• Human Resources, Rooms, and Materials

Assign Resource Capability

• Human Resources, Rooms, and Materials

Documentation Template for Capability Details

The following template captures the level of detail required for the HL7 SOA HSSP Service Functional Model specification. The details make up section 5 of of the SFM boiler plate template which captures the "Detailed Functional Model for each Interface".

Please include at a minimum the mandatory fields when describing new capabilities.

Capability Status

2-26-2012

Proposed

Link of reviewers doodle poll when approved

Name	[Mandatory] A business-friendly name describing the context of the motivating scenario, and is unique within this Functional Model (e.g., “Find a Person” vs. FindPerson) Please specify as a subsection of a logical capability set grouping
Description	[Mandatory] High-level [functional] description of the expected behavior Please document as free form paragraph after capability title header
Preconditions	[Mandatory] Business Pre-conditions [may be null], i.e. what conditions must have been satisfied before the action can be requested or carried out
Inputs	[Mandatory] Inputs [include both mandatory and optional]
Outputs	[Mandatory] Outputs [include both mandatory and optional]
Postconditions	[Optional] Business Post-conditions, i.e. what conditions will result from the action being carried out.
Exception Conditions	[Mandatory] Business Exception Conditions [may be null]
Part of Profiles	[Optional] Specify service functional profiles which include the capability. Please specify if it is required or optional for profile conformance.
Aspects Left to OMG to Specify	[Optional] Enumeration of aspects left to the technical specification [may be null]
Outstanding Issues	[Optional]If no issues but expect some while the capability is being worked out by the team