Aging Services Dataset and Interoperability Standards

Offered by the Missouri Aging Services Data Collaborative

The Aging Services Client Dataset and Interoperability Standards are currently in draft format and open for comment.

Participant

Participant name

In most HCBS systems, participant name fields are recorded directly on the participant record. Common field names are as follows:

Field Name Required? Example
Prefix No Mrs.
First Name Yes Susan
Last Name Yes Smith
Middle Initial No A
Suffix No Jr.
Alias No Suzie S

FHIR Patient entities have more flexibility in that they support multiple HumanNames with different uses and periods of validity. This enables systems to track multiple any number of official names, nicknames and aliases, as well as changes in name over time.

The example HCBS participant name data above would be translated to two FHIR HumanName entities as follows.

<name>
  <use value="official" />
  <text value="Mrs. Susan A Smith Jr." />
  <prefix value="Mrs." />
  <family value="Smith" />
  <given value="Susan" />
  <given value="A" />
  <suffix value="Jr." />
</name>
<name>
  <use value="anonymous" />
  <text value="Mrs. Susan A Smith Jr." />
</name>

Participant addresses

Many HCBS systems track participant addresses in a separate table which references the participant record. Common address fields are as follows.

Field Name Required? Example
Address Type Yes Mailing
Building Name No Eastern Apartment
Street 1 Yes 1 First Street
Street 2 No Apartment 2B
Room Number No 213
Town Yes Burlington
ZIP/Postal Code Yes 05401
County Yes Chittenden
State Yes Vermont
Country Yes United States
Municipality No Allentown City
Neighborhood No North End
Township No Mill Creek Township
Directions No 3rd building on right

Using FHIR, multiple Address entities can be associated with a Patient entity. The Address use field enables systems to identify the purpose of the address, such as “home” or “billing”.

The example HCBS participant address data above would be translated to a FHIR Address entity as follows.

<address>
 <use value="billing" />
 <type value="postal" />
 <line value="1 First Street" />
 <line value="Apartment 2B" />
 <city value="Burlington" />
 <district value="Chittenden" />
 <state value="Vermont" />
 <postalCode value="05401" />
 <country value="US" />
</address>

FHIR Address entities follow postal conventions and do not specify how to transmit properties which aren’t essential to navigating to a point such as Room Number, Municipality, Neighborhood, Township, or Directions. FHIR’s extensibility model can be used when necessary to exchange these attributes.

Participant contact methods

Participants may have multiple contact methods, such as phone numbers and email addresses.

Field Name Required? Example
Phone Type Yes Mobile
Area Code Yes 802
Phone Number Yes 868-3146
Extension No 23
Field Name Required? Example
Email Type Yes Personal
Email Address Yes [email protected]

This information maps to the FHIR Patient record’s telecom field which is comprised of zero or more ContactPoint entities. ContactPoint’s system and use attributes identity the contact mode (phone/pager/sms/email) and purpose (home/work).

The example HCBS participant phone and email address data above would translate to two FHIR ContactPoint entities as follows. Rank is used to indicate the preferred contact method, 1 is the highest rank, followed by 2, and so on.

<telecom>
  <system value="phone" />
  <use value="mobile" />
  <value value="802-868-3146 x23" />
  <rank value="1">
</telecom>
<telecom>
  <system value="phone" />
  <use value="home" />
  <value value="[email protected]" />
  <rank value="2">
</telecom>

Participant contacts

HCBS systems typically track the people who serve as a participant’s emergency contact, spouse, or relative. Common fields are as follows.

Field Name Required? Example
Contact Relationship Yes Emergency Contact
Contact Name Yes William Evans
Contact Phone Number No 555-444-4444
Contact Email Address No [email protected]
Contact Location No 2 First Street

FHIR Patient entities contain a contact field enabling the association of multiple patient contact entites. Relationship values follow a coding standard defined by FHIR. The example data above would be translated to a patient contact as follows.

<contact>
  <relationship value="C" />
  <name>
    <use value="official">
    <text value="William Evans">
  </name>
  <telecom>
    <system value="phone" />
    <use value="home" />
    <value value="555-444-4444" />
    <rank value="1" />
  </telecom>
  <address>
    <use value="home">
    <text value="2 First Street">
  </address>
</contact>

Participant Identifiers

A participant will often have one or more identifiers, including a Social Security Number, Medicaid ID, other insurance IDs, or even an ID from the case management system in which they are tracked.

Field Name Required? Example
Social Security Number No 111-11-1111
Medicaid ID No 0000000486100
Medicare ID No 1EG4-TE5-MK73
Veteran ID No 010211954-00
Vendor System ID No 641234

FHIR supports an unlimited number of Identifers per Patient. The identiers in the example above would be translated to FHIR as follows.

<identifier>
  <use value="official" />
  <type>
    <coding value="https://www.hl7.org/fhir/v2/0203/index.html" />
    <text value="SS" />
  </type>
  <system value="http://hl7.org/fhir/sid/us-ssn" />
  <value value="111111111" />
</identifier>
<identifier>
  <use value="official" />
  <type>
    <coding value="https://www.hl7.org/fhir/v2/0203/index.html" />
    <text value="MA" />
  </type>
  <value value="0000000486100" />
</identifier>
<identifier>
  <use value="official" />
  <type>
    <coding value="https://www.hl7.org/fhir/v2/0203/index.html" />
    <text value="MC" />
  </type>
  <system value="http://hl7.org/fhir/sid/us-medicare" />
  <value value="1EG4-TE5-MK73" />
</identifier>
<identifier>
  <use value="official" />
  <type>
    <coding value="https://www.hl7.org/fhir/v2/0203/index.html" />
    <text value="MI" />
  </type>
  <value value="010211954-00" />
</identifier>
<identifier>
  <use value="official" />
  <assigner value="Vendor System" />
  <value value="641234" />
</identifier>

Identifier types follow a coding specified by the FHIR standard.

Participant demographics

Participants must contain the appropriate demographics required for HCBS federal reporting. Common fields used in the HCBS Dataset are as follows.

Field Name Required? Example
Date of Birth Yes 5/01/1933
Age Yes 88
Gender Yes Female
Notes No Lives with daughter
Referred By No Relative
Poverty Level Yes Yes
Race Yes White
Ethnicity Yes Not Hispanic or Latino
Nationality Yes Irish
Understands English No Yes
Limited Speaking English Older Adult No No
Spoken Languages No English
Veteran Status Yes Yes
Household Size Yes 2
Occupation Yes Retired
Homebound Yes Yes
Female Head of Household Yes No
Lives Alone Yes No
Marital Status Yes Widowed
Disability Status Yes Disabled

Referrals

Referral Information

Participants are often referred into and out of programs for differing services, depending on their needs. Referrals include information about the source organization that made the referral, and the destination organization that receives the referral.

Field Name Required? Example
Referral Type Yes TBD
Referral Name Yes HDM Referral for new client
Associated Participant Yes Susan Smith
Associated Service Yes Home Delivered Meals
From Agency No East AAA
To Agency Yes South AAA
From Provider Yes Eastern Meals on Wheels
To Provider Yes Southern Meals on Wheels
From SubProvider Yes County A MOW
To SubProvider Yes City A MOW
Comments Yes Client is seeking meal delivery
Status Yes Pending
Reason Yes Referral generated
Status Date Yes 10/21/2021
Actual Date Yes 10/21/2021
Requested Date Yes 10/21/2021

Program

Enrollments

Participants may be enrolled in one or many programs, based on eligibility and funding requirements. Program enrollments will determine the services that they are eligible to receive.

Field Name Required? Example
Program Enrollment Yes NAPIS Title III
Program Enrollment Status Yes Active
Program Enrollment Reason Yes Eligible
Program Enrollment Start Date Yes 01/01/2021
Program Enrollment End Date No 6/30/2021
Program Enrollment Termination Date Yes 5/15/2021
Program Enrollment Comments Yes Client moved out-of-state

Care Plan

Certain services will require Care Plans be in place prior to delivery.Care plans have a start date, end date, and document the goals and planned interventions. Care plans may include specific services that are to be provided, or those services may be tracked in separate but affiliated service plans.

Field Name Required? Example
Care Plan Start Date Yes 01/01/2021
Care Plan End Date Yes 6/30/2021
Care Plan Status Yes Waiting
Care Plan Status Reason Yes Limited availability
Care Plan Description No Initial care plan for Susan Smith
Needs Identified Yes Improved nutrition
Care Plan Goal Name Yes Improved nutrition
Care Plan Goal Type Yes TBD
Care Plan Goal Status Yes Active
Care Plan Goal Reason Yes In Progress
Care Plan Goal Start Date Yes 01/01/2021
Care Plan Goal End Date Yes 6/30/2021
Care Plan Goal Target Date Yes 6/30/2021
Care Plan Goal Actual Date Yes 6/29/2021
Care Plan Goal Interventions Yes Meals; Nutrition counseling
Care Plan Goal Comments Yes Client
Care Plan Care Manager Yes Ethan Jones
Care Plan Care Manager Phone Number Yes 555-555-5555

Service Plan

Certain services will require Service Plans be in place prior to delivery. Service plans often dictate the specific services, chosen providers and frequency of delivery throughout the lifecycle of the client’s care.

Field Name Required? Example
Level of Care Yes Federal Funding
Service Program Yes NAPIS Title III
Service Plan Status Yes Active
Service Plan Status Reason Yes In Progress
Service Plan Start Date No 01/01/2021
Service Plan End Date Yes 12/6/30/2021
Service Plan Selected Services Yes Home Delivered Meals
Service Plan Selected SubServices Yes Weekend Meals
Service Plan Funding Source Yes Title III
Service Plan Agency Yes South AAA
Service Plan Selected Provider Yes Southern Meals on Wheels
Service Plan SubProvider Yes City A MOW
Service Plan Units Planned Yes 100
Service Plan Rate Yes $5.00
Service Plan Total Cost Yes $500.00
Service Plan Comments Yes 123123
Service Plan Schedule Yes Saturday/Sunday
Service Plan Place of Service Yes Home
Service Plan Provider Selection Agreement Yes TBD
Service Plan Provider Relationship Yes TBD

Service Delivery

As part of their plan of care, participants will receive services for which they are eligible. NEED TO DECIDE HOW TO HANDLE UNDERLYING CODES FOR PROPER CLAIM CREATION.

Field Name Required? Example
Level of Care Yes Federal Funding
Service Program Yes NAPIS Title III
Service Yes Home Delivered Meals
SubService Yes Weekend Meals
Service Funding Source No Title III
Agency Yes South AAA
Provider Yes Southern Meals on Wheels
SubProvider Yes City A MOW
Units delivered Yes 1
Comments Yes Saturday’s meal
Service Date Yes 4/13/2021
Place of Service Yes Home
Service Delivery Address Yes 1 First Street, Apartment 2B, Burlington VT 05401

Assessment

Nutritional Risk

A critical data point for Older Americans Act clients is a participant’s Nutritional Risk score. This is an automatically derived value that is used to document a person’s overall nutritional health, based on responses to a series of 10 questions. Many Older Americans Act-compliant solutions track this in order to adhere to OAAPS reporting requirements.

Field Name Required?
Client has illness or condition that has made them change the kind/amount of food they eat Yes
Client eats fewer than 2 meals per day Yes
Client eats few fruits, vegetables, or milk products Yes
Client has 3 or more drinks of beer, liquor or wine almost every day Yes
Client has tooth or mouth problems that make it difficult to eat Yes
Client does not always have enough money to buy the food they need Yes
Client eats alone most of the time Yes
Client takes 3 or more different prescribed or over-the-counter drugs a day Yes
The client (without wanting to) has lost or gained 10 pounds in the last 6 months Yes
The client is not always physically able to shop, cook and/or feed themselves Yes
High Nutritional Risk Score Yes

Activities of Daily Living (ADLs)

Activities of Daily Living are a key demographic for participants served under the Older Americans Act. Participants are scored on a range of 0-6. Many Older Americans Act-compliant solutions track this in order to adhere to OAAPS reporting requirements.

Field Name Required?
Bathing Yes
Dressing Yes
Toilet Use Yes
Transfer Yes
Eating Yes
Walking in Home Yes
ADL Count/Score Yes

Instrumental Activities of Daily Living (IADLs)

Instrumental Activities of Daily Living are a key demographic for participants served under the Older Americans Act. Participants are scored on a range of 0-8. Many Older Americans Act-compliant solutions track this in order to adhere to OAAPS reporting requirements.

Field Name Required?
Meal Preparation Yes
Managing Medications Yes
Managing Money Yes
Perform Heavy Housework Yes
Light Housekeeping Yes
Shopping Yes
Transportation Yes
Telephone Yes
IADL Count/Score Yes

Organizations

Provider/Resource Record

Provider organizations are tied to participant records, via referrals, care plans, service plans, service and service deliveries. Underlying provider demographic details are necessary in order to provide the proper referrals and affiliation.

Field Name Required? Example
Provider Name Yes South AAA
Provider Legal Name Yes South AAA
Provider URL Yes www.southaaaurl.com
Provider Type Yes Nutrition provider
State Provider Number Yes 04251315621
Provider Identifier Yes 69252810664
Provider Email Type Yes Office
Provider Email Yes [email protected]
Provider Phone Type Yes Office
Provider Area Code Yes 555
Provider Phone Number Yes 555-5555
Provider Extension Yes 1
Provider Location Type Yes Office
Provider Street 1 Yes 2 Main Street
Provider Street 2 Yes Office 3
Provider Town Yes Burlington
Provider ZIP Code Yes 05401
Provider County Yes Chittenden
Provider State Yes VT
Provider Country Yes United States
Provider Municipality Yes Allentown City
Provider Neighborhood Yes North End
Provider Township Yes Mill Creek Township
Provider Directions Yes First building on left, 2nd floor
Provider Contact: Person Name Yes Jennifer Sampson
Provider Contact: Email Yes [email protected]
Provider Contact: Phone Yes 555-555-5555
Provider Contact: Location Yes 2 Main Street, Office 3, Burlington VT 05401
Provider Active Status Yes Active