User Story - The NIC Collaboration Hub2024-03-29T15:43:25Zhttps://hub.nic-us.org/groups/project-unify/resources/feed/category/User+StoryUpdated User Story Cataloguehttps://hub.nic-us.org/groups/project-unify/resources/updated-user-story-catalogue2023-02-02T15:52:17.000Z2023-02-02T15:52:17.000ZDaniel Steinhttps://hub.nic-us.org/members/DanielStein<div><p><a href="https://docs.google.com/document/d/13oZfyZr8ceLWiHjq2SHe5ne5j8k5rFlh0cSQjsAFY-E/edit#heading=h.6hl1nqp2w3ix" target="_blank">User Story Catalogue</a></p></div>2019 MITATAC Adult Opioid Detailed User Storyhttps://hub.nic-us.org/groups/project-unify/resources/2019-mitatac-adult-opioid-detailed-user-story2020-06-29T22:13:36.000Z2020-06-29T22:13:36.000ZBrian D. Handspickerhttps://hub.nic-us.org/members/BrianDHandspicker<div><p> </p><p>Sarah Thomson is 27 years old, divorced mother of Billy Thomson, age seven, who live together in a tiny apartment in a run-down, non-rent controlled building in Temperance, MI. Sarah has asthma and an opioid addiction, for which she is currently in Medication Assisted Therapy (MAT), and which also caused her to develop Chronic Kidney Disease (CKD). She is 6 months pregnant, and has several nonmedical issues with food, housing, and transportation. </p><p>Billy was born with Neonatal Abstinence Syndrome (NAS), and as a preschooler watched far too frequently as Emergency Medical Services came to the house to resuscitate his mother. In spite of all these Adverse Childhood Events, he has never been screened or diagnosed for any developmental disabilities, even though he has been held back to repeat first grade.</p><p>When Sarah was married and had health insurance through her husband’s employer, Dr. Carla Sanchez, Sarah’s Primary Care Physician, worked with Sarah to establish an integrated care team for her and Billy. Sarah’s Care team consists of</p><p>Dr. Sanchez and her office’s clinical staff</p><p>Dr. Jordan Emmett, an Ohio-based MAT Treatment provider</p><p>Billy’s care team consists of</p><p>Dr. Amy Taylor, a Pediatrician in Dr. Sanchez’s practice </p><p>Florence Whitaker RN, the School nurse at Billy’s school in the Monroe County Independent School District (added when Billy entered first grade)</p><p>Sarah schedules an appointment for her annual well visit with her primary care physician, At the appointed time, Sarah arrives at the office of Dr. Sanchez. While waiting to see Dr. Sanchez in the exam room, Samir Anand LPN, one of the practice’s clinical staff, collects Sarah’s vital signs and asks Sarah to answer a few questions from a social risk screening tool the practice is using. Samir explains Dr. Sanchez’ practice is screening all patients as part of their annual well visit exam. Samir provides Sarah with a mobile tablet with the electronic questionnaire. Sarah answers the questions and returns the tablet to Samir. Samir uploads the completed questionnaire into the EHR.</p><p>Dr. Sanchez enters the exam room and begins the consult inquiring how Sarah has been since their last visit. Sarah shares that over the past year the family has experienced significant life changes including Sarah separating from her husband, who is not paying child support, and on top of it she’s lost her health insurance. She is struggling living off one salary to pay for rent, childcare, and food. She feels overwhelmed and guilty that she comes home too tired to do anything but get Billy fed and ready for the next day.</p><p>Dr. Sanchez uses her EHR to review the results of the social risk screening and history for Sarah. She examines Sarah and notes Sarah is gaining weight and her asthma is worse. Sarah acknowledges she saves money by buying low-cost foods such as macaroni and cheese and pizza. She rarely buys fruits or vegetables because they are more expensive and the neighborhood in which she lives is considered a food desert, i.e. Sarah has to travel a long way to find a grocery store that sells fresh vegetables and healthy food options.</p><p>She also notes that she cannot always afford medications so she spaces out her asthma controller medication to every other day instead of every day. Dr. Sanchez inquires whether Sarah has talked to her landlord about mold or another allergen remediation. Sarah confirms she has not. Dr. Sanchez tells Sarah the screening responses indicate distinct risk around food insecurity, housing instability and quality, and transportation access. Sarah confirms she needs help with these are three areas. To address the asthma concern, Dr. Sanchez and Sarah identify goals to reduce asthma triggers in the home and minimize the cost of medications. Dr. Sanchez reviews the cost of Sarah’s asthma controller medication and determines an equally effective, lower cost medication is available. She also confirms Sarah is eligible to receive an asthma home visit. Dr. Sanchez places an order for a new asthma medication and submits an electronic request for an asthma home visit to assess for asthma triggers.</p><p>To address the three social risk factors, Dr. Sanchez and Sarah identify goals to 1) find more affordable housing solutions and healthier food options; and 2) find more efficient transportation options. They discuss an action plan to address the goals that involves Sarah working with a care coordinator to identify and secure available services and supports. Dr. Sanchez refers Sarah to Reeza Shah RN, a care coordinator in Dr. Sanchez’s practice who can help connect Sarah to available resources, either those available in-house or those available in the community. Dr. Sanchez adds Reeza to Sarah’s integrated Care team. </p><p>Samir returns to the exam room and works with Sarah to find another date/time to schedule a telephone consultation with Reeza. Samir schedules the appointment with Reeza for the following week and a follow-up appointment with Dr. Sanchez within three months of the appointment with Reeza.</p><p>The following week, Sarah meets with Reeza. Reeza has reviewed Sarah’s care plan and identified several resources available to support the care plan goals. Reeza and Sarah use the Michigan Assistance and Referral Service (MARS), and confer with Ellen Davis, an Eligibility Specialist in Michigan Department of Health and Human Services, to determine Sarah’s eligibility for Michigan Medicaid’s Healthy Michigan, Healthy Kids, Maternity Outpatient Medical Services, SNAP benefits and WIC services. Reeza also contacts Michael Frank, an asthma home-visit provider, to arrange for an asthma site visit.</p><p>Michael contacts Sarah by phone to schedule the asthma site visit. Michael conducts the assessment and discovers there is slight mold in the apartment that is aggravating Sarah’s asthma. Michael emails Sarah, Dr. Sanchez, and Reeza a copy of the home-visit report and recommends Sarah be referred to a housing coordinator. Reeza reviews Michael’s report and uploads into the EHR. Within 1 week, Reeza emails Sarah with the names of two housing coordinators. </p><p>When Sarah has her follow-up visit with Dr. Sanchez, she documents the agreed upon health concerns, patient goals, action plan, and referral (planned intervention) in the care plan within the EHR.</p><p>One day Billy’s First Grade teacher, notices that Billy has come to school in a very drowsy condition, falling asleep several times at breakfast and in early morning classes, and sends Billy to see Florence Whitaker, the School Nurse. </p><p>Florence begins to take Billy’s vital signs and record them in the School’s EMR system. While she is talking to Billy she happens to notice what looks like an empty prescription bottle in his book bag – when she examines it, she finds it is from his mother’s buprenorphine prescription. She immediately suspects that this is the cause for the drowsiness and now opens a triage instrument to ask Billy some questions and record her observations of her behavioral concerns. The Triage tool guidance suggests an intervention of notifying the School Assistance Team, which includes besides Florence, the Principal, and Gerald Brown LSW, a social worker in the Michigan Department of Health and Human Services (MDHHS) Monroe County office, who in turn calls in the MDHHS Child Protective services unit.</p><p>Billy gets placed in a Foster home and Gerald works to get Billy enrolled in a Home and Community Based Services (HCBS) Medicaid Waiver program for Children with Substance Use Disorder. Gerald also works with Lisa Jones JD, Billy’s court appointed Lawyer-Guardian Ad Litem (LGAL), and Dr. Amy Taylor, Billy’s pediatrician, to add Dr. Peter Gutierrez of the Monroe County Mental Health Authority to Billy’s Care Team, and use Consent2Share to Consent to share medical information between Dr. Taylor, Dr. Gutierrez and Nurse Whitaker.</p><p>Dr. Gutierrez performs an assessment and finds Billy has several developmental, behavioral and health care needs, which are recorded in the plan of care which are recorded as an observation and documented using the Subjective, Objective Assessment and Plan (SOAP) note. The Plan of care includes various interventions, including counseling, an Individualized Education Plan (IEP), and screenings for other developmental factors such as Audiology, Vision, etc. In addition, a Machine Learning predictive model used by Dr. Sanchez’s practice has picked out Billy’s situation as high risk for developing asthma, high risk for developing Severe Emotional Disorder and Sarah’s expected child as high risk of being born with NAS.</p><p>Dr. Sanchez makes a note to discuss the NAS issue with Sarah at her next appointment. </p><p>Dr. Taylor sends a note to Gerald about Billy’s risk, who in turn communicates that with LGAL Jones.</p><p>Florence, Gerald, Dr. Taylor and Dr. Guitierrez all collaborate to deliver on this plan of care, and share the results via their respective devices. Mrs. Jones can also be informed of Billy’s progress. Ultimately Lisa and Gerald will work on getting Billy reunified with Sarah, at which point she can follow along on this progress as well.</p><p> </p></div>Project Unify 2020 User Story - Integrated Care for Kids (InCK)https://hub.nic-us.org/groups/project-unify/resources/project-unify-2020-user-story-integrated-care-for-kids-inck2020-06-22T18:59:48.000Z2020-06-22T18:59:48.000ZBrian D. Handspickerhttps://hub.nic-us.org/members/BrianDHandspicker<div><p><strong>Behavioral Health for Children and Youth (InCK NIC/MITATAC 2020 Story - Index Person: Jameson Thomson)</strong> </p><p>Sarah Thomson, now age 30, is a medically complex patient with multiple chronic conditions (asthma and heroin-induced nephropathy, which has not yet progressed to End-Stage Renal Disease). She is still under court-ordered Medication Assisted Therapy (MAT) for Opioid Use Disorder. She has been divorced from Air Force Technical Sergeant John Thomson for three years and has been raising her two children as a single parent. They live in a run-down area of Temperance, MI, near a furniture manufacturer and a large farm, with associated air and water quality issues. </p><p>Since we last checked in on our scenario family, Sarah gave birth to a daughter, Madison, who is now 3 years old. Like her son, Jameson, Madison was born with Neonatal Abstinence Syndrome (NAS). Jameson, who is now 10 years old, also has asthma. He has no medical home, gets minimal well-child care, and receives most of his healthcare at the ER or urgent care facilities He has watched far too frequently as Emergency Medical Services personnel came to his house to resuscitate his mother. He has been in and out of foster care and has been receiving behavioral health therapy ever since Child Protective Services intervened as a result of his Adverse Childhood Experiences (ACEs), which were directly and indirectly due to his mother’s addiction. </p><p>Jameson was held back to repeat first grade but has never been screened for nor diagnosed with any developmental disabilities. Jameson has been traumatized in many ways – being separated on-and-off from his mother and from his father for year; moving away from his friends each time he was placed in foster care; living in care with a different, unfamiliar family each time; and being placed repeatedly into new schools in which he knew no one. During the same period, he has been detached from his personal support system, even as he has been challenged by the new experiences of meetings with an overloaded case manager, appearances in family court, and the stress of his mother’s addiction and his father’s ongoing absence. </p><p>Jameson becomes withdrawn at school and testy with his foster parents. When he moved into his most-recent foster placement, he left his medications behind and has neglected to continue his asthma-controller inhaler treatments; it’s no surprise that his physical and mental health have declined. In addition, although he is getting behavioral health therapy, Jameson uses drugs and alcohol to cope with his misery and anxiety. </p><p>One day Jameson’s fourth-grade teacher notices that he has once again come to school appearing to be under the influence. She sends Jameson to see Florence Whitaker, the school nurse, and writes up an incident report in the School Management Information System (SMIS) on her laptop. </p><p>Florence begins taking Jameson’s vital signs and recording them in the School’s Electronic Medical Records (EMR) system. She suspects misuse of opiods to be the cause for Jameson’s drowsiness, so she opens a triage instrument to ask some questions and record her observations. The Triage tool guidance suggests an intervention: Notify the School Assistance Team, which is made up of Florence, the principal, and Gerald Brown LSW, a social worker in the Michigan Department of Health and Human Services (MDHHS) Monroe County office. </p><p>After discussing the case, the team determines there is enough evidence to trigger a SMIS-generated Mandatory Report to Child Protective Services. Jameson’s child welfare case manager receives the Mandatory Report and now needs to work with the boy’s assigned primary care physician, a psychologist, teachers, foster parents, and the family court to revise Jameson’s Service Plan to ensure he gets additional behavioral health support and substance-abuse rehabilitation. In addition, the case manager initiates a Health Care Plan with Jameson’s Primary Care Coordinator via a FHIR Care Plan Resource. </p><p>The Primary Care Coordinator evaluates the requested Care Plan, updates it to reflect medical necessity, and generates a FHIR eLTSS Resource (electronic Long-Term Support Services request with Care Plan and associated Referrals), which is sent to each of the behavioral and physical health specialists needed to help Jameson get well. </p><p><strong>Desired Outcome</strong>: With appropriate cross-domain social services, case management, and health care coordination, Sarah may finally be helped through successful completion of substance-abuse rehabilitation; her daughter, Madison, could be provided with better early-life care; Jameson could receive appropriate healthcare and therapy; and, once Sarah is clean and sober, her son could be re-integrated into the family. </p></div>HSLynk is participating in the Interoperability Land (IOL) Interopathon May 28/29, 2020https://hub.nic-us.org/groups/project-unify/resources/hslynk-is-participating-in-the-interoperability-land-iol-interopa2020-05-18T02:28:39.000Z2020-05-18T02:28:39.000ZEric Jahnhttps://hub.nic-us.org/members/EricJahn<div><p>HSLynk is participating as a Track in the 2020 MiHIN Interopathon. The topic is Scenario 4 of the Project Unify Charter, involving the Housing Instability Social Determinant of Health. HSLynk contains open source Homeless Management Information System APIs, which Track participants will access, along with IOL FHIR server resources, to build apps. The HSLynk portion of the Track instructions are available at the link below.</p><p><a href="https://docs.google.com/document/d/1VFi1lpwzG_nf9V9lPWOgWw0VVl3DPi4DhFIgd9rjHEY/edit?usp=sharing" target="_blank">Interopathon Project Unify Track document</a></p></div>Family Court Responsehttps://hub.nic-us.org/groups/project-unify/resources/family-court-response2020-05-13T21:52:48.000Z2020-05-13T21:52:48.000ZBrian D. Handspickerhttps://hub.nic-us.org/members/BrianDHandspicker<div><p><a href="{{#staticFileLink}}4993281868,RESIZE_584x{{/staticFileLink}}"><img class="align-full" src="{{#staticFileLink}}4993281868,RESIZE_584x{{/staticFileLink}}" width="523" alt="4993281868?profile=RESIZE_584x" /></a></p></div>Healthcare Coordination Responsehttps://hub.nic-us.org/groups/project-unify/resources/healthcare-coordination-response2020-05-13T21:51:30.000Z2020-05-13T21:51:30.000ZBrian D. Handspickerhttps://hub.nic-us.org/members/BrianDHandspicker<div><p><a href="{{#staticFileLink}}4993255858,RESIZE_710x{{/staticFileLink}}"><img class="align-full" src="{{#staticFileLink}}4993255858,RESIZE_710x{{/staticFileLink}}" width="669" alt="4993255858?profile=RESIZE_710x" /></a></p></div>Child Welfare Mandatory Report Responsehttps://hub.nic-us.org/groups/project-unify/resources/child-welfare-mandatory-report-response2020-05-13T21:50:26.000Z2020-05-13T21:50:26.000ZBrian D. Handspickerhttps://hub.nic-us.org/members/BrianDHandspicker<div><p><a href="{{#staticFileLink}}4993166461,RESIZE_930x{{/staticFileLink}}"><img class="align-full" src="{{#staticFileLink}}4993166461,RESIZE_710x{{/staticFileLink}}" width="710" alt="4993166461?profile=RESIZE_710x" /></a></p></div>School Incident and Mandatory Reporthttps://hub.nic-us.org/groups/project-unify/resources/school-incident-and-mandatory-report2020-05-13T21:48:20.000Z2020-05-13T21:48:20.000ZBrian D. Handspickerhttps://hub.nic-us.org/members/BrianDHandspicker<div><p><a href="{{#staticFileLink}}4993189672,RESIZE_930x{{/staticFileLink}}"><img class="align-full" src="{{#staticFileLink}}4993189672,RESIZE_710x{{/staticFileLink}}" width="710" alt="4993189672?profile=RESIZE_710x" /></a></p></div>Project Unify POC - Use Case Scenario - as of 02/10/2020https://hub.nic-us.org/groups/project-unify/resources/project-unify-use-case-scenario2020-02-13T15:02:27.000Z2020-02-13T15:02:27.000ZHub Adminhttps://hub.nic-us.org/members/NIC<div><p class="paragraph" style="vertical-align:baseline;"><span class="normaltextrun"><span style="font-size:11pt;font-family:Calibri, sans-serif;">John Smith-Jones got hooked on opioids a year ago, after being injured at his warehouse job. One day, after falling asleep at the wheel and totaling his car, he is rushed to the hospital by ambulance. John lives just above the poverty line and has no insurance, so he’s familiar with the emergency room; it’s where he and his 10-year-old son, who has severe asthma, get most of their healthcare when they need it. Today, John receives treatment for minor injuries in the ambulance, then again in the hospital. The next day, he’s charged in court with driving while under the influence and reckless endangerment. Because of the charges John’s son is placed in foster care and, as a result, </span></span><span class="advancedproofingissue"><span style="font-size:11pt;font-family:Calibri, sans-serif;">has to</span></span><span class="normaltextrun"><span style="font-size:11pt;font-family:Calibri, sans-serif;"> change schools. </span></span><span class="eop"><span style="font-size:11pt;font-family:Calibri, sans-serif;"> </span></span></p>
<p> </p>
<p class="paragraph" style="vertical-align:baseline;"><a href="{{#staticFileLink}}3860818704,original{{/staticFileLink}}">Read more >></a></p></div>Project Unify POC - Use Case Scenario - as of 10/29/2019https://hub.nic-us.org/groups/project-unify/resources/proof-of-concept-for-the-let-s-get-technical-and-mita-tac-groups2020-01-22T17:34:02.000Z2020-01-22T17:34:02.000ZHub Adminhttps://hub.nic-us.org/members/NIC<div><p><strong>Objective of the Narrative</strong></p>
<p><br /> The objective of this narrative is to show how clinical care teams, behavioral health case workers, community-based organizations, and the courts all collaborate electronically with a combination of SMART on FHIR apps that use FHIR resources supported by MIHIN and NIEM data exchanges to:</p>
<ul>
<li>Keep Sarah on the path to recovery and give her the tools/skills to care for her children properly</li>
<li>Follow through on care considerations and conditions in the home to improve Sarah’s asthma condition and try to mitigate the children’s risk factors for developing asthma</li>
<li>Keep Jameson on track to ward off developmental disabilities and prevent downstream impacts of ACEs such as Severe Emotional Disorders</li>
<li>Work with the courts to establish a pathway to reunify Jameson with his family </li>
</ul>
<p><a href="{{#staticFileLink}}3686279628,original{{/staticFileLink}}" target="_blank">Read more >></a> </p></div>