This page is part of the electronic Long-Term Services and Supports Implementation Guide (v2.0.0-ballot: STU2 Ballot 1) based on FHIR (HL7® FHIR® Standard) R4. The current version which supersedes this version is 1.0.0. For a full list of available versions, see the Directory of published versions

eLTSS Examples

*You can find data instance examples for Resources used in eLTSS here: *

• examples where data elements are in profiles in the IG
• examples where the data elements are not in the IG profiles

The data instances work together as a single example. Start with the CarePlan and follow the references.

We plan to continue to refine examples with feedback from an ongoing pilot. The intent is to create examples that are accurate and comprehensive enough to be instructive during development and useful for testing server/client capability.

An example story-line:

1. Henry has an annual ISP meeting with Stacy, his service coordinator. Stacy updates Henry’s care plan in the state’s case management system (ConneXion) to reflect his employment goals and reviews current health information.
2. Once that has been identified, Stacy emails/calls the selected service provider, Job Avenue Specialists to refer Henry for supported employment services and Henry gets assigned to John Gomez, an Employment Consultant.
3. There are a few administrative steps to finalize this referral, but eventually Stacy notifies Henry and John about the approval of services. John Gomez creates a demographic profile of Henry in the supported employment IT system to track client information and meets with Henry.
4. Stacy also coordinates with Henry’s primary care provider to help inform the career planning and pre-vocational services. Dr. Smith’s primary care team looks up Henry’s health information in their Electronic Health Record system which integrates data from the Health Information Exchange System to understand his health record and sees his updated eLTSS care plan.
5. During the primary care visit, Dr. Smith chats with Henry and his caregiver about his potential job offer and conducts a physical. She discusses with Henry given his asthma and seasonal allergies, a position outdoors is not the best fit and suggests that he pursues a position indoors. She also sees that a goal in Henry’s eLTSS plan is to eat healthier and discusses a meal plan that includes healthy snacks, nutritious breakfast and lunch options to have steady energy on the job.
6. When the visit is done, Dr. Smith updates the Electronic Health Record system she uses to reflect Henry’s visit summary and that he is in good physical health. Dr. Smith tells the StationMD care coordinator to call Stacy to share the recommendation that Henry does not pursue a position outdoors given his health history.
7. After the discovery interviews, John schedules and takes Henry to informational interviews and Henry job shadows at Home Depot (Garden Tools Department) and Walmart (Sporting Goods Section).
8. Henry is placed at Home Depot’s Garden Tools Department.
9. At Henry’s next ISP plan monitoring review with Stacy and John, he shares that he really enjoys his job at Home Depot and has been able to buy two new fishing rods.
10. He looks forward to continuing his work and saving up money to buy a TV. Stacy updates Henry’s ISP in the state’s case management system (FEI) to reflect attainment/tracking of his employment goals.