Electronic Long-Term Services and Supports (eLTSS) Release 1 - US Realm

This page is part of the electronic Long-Term Services and Supports Implementation Guide (v1.0.0: STU 1) based on FHIR R4. This is the current published version in it's permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions

eLTSS Care Plan Example

Format(s):

Narrative view

Bundle careplan of type collection

Entry 1 - Full URL = http://example.org/eLTSS/careplan1

Resource CarePlan:

Sally Person's Long Term Services and Supports (LTSS) Service Plan

Plan Effective Date: 2018-05-01 - 2018-12-31

Step or Action: client action - manage diet

Step or Action: client action - exercise / join a fitness club

Entry 2 - Full URL = http://example.org/eLTSS/planner1

Resource Practitioner:

Support Planner / Phone: Mark Planner / (678) 555 1221

Entry 3 - Full URL = http://example.org/eLTSS/caremgr1

Resource Practitioner:

Plan Monitor / Phone: Sam Monitor / (770) 224 1599

Entry 4 - Full URL = http://example.org/eLTSS/patient1

Resource Patient:

Person Name: Sally Person

Person Identifier | Type: 123456ABC | MRN

Person Phone: (404) 555 1212

Person Date of Birth: 1935-05-01

Person Address: 2222 Peachtree Street, Atlanta GA, 30318

Emergency Contact Name: Jane Daughter

Emergency Contact Relationship: daughter

Emergency Contact Phone Number: (770) 224 1544

Entry 5 - Full URL = http://example.org/eLTSS/episode1

Resource EpisodeOfCare:

Entry 6 - Full URL = http://example.org/eLTSS/careplan2

Resource CarePlan:

Entry 7 - Full URL = http://example.org/eLTSS/goal1

Resource Goal:

Person Goal: lose weight

Entry 8 - Full URL = http://example.org/eLTSS/goal2

Resource Goal:

Person Goal: dance at daughter's wedding

Entry 9 - Full URL = http://example.org/eLTSS/need1

Resource Condition:

Assessed Need: lack of transportation

Entry 10 - Full URL = http://example.org/eLTSS/need2

Resource Condition:

Assessed Need: difficulty in bathing

Entry 11 - Full URL = http://example.org/eLTSS/need3

Resource Condition:

Assessed Need: difficulty in dressing

Entry 12 - Full URL = http://example.org/eLTSS/provider1

Resource Practitioner:

Entry 13 - Full URL = http://example.org/eLTSS/provider2

Resource Organization:

Entry 14 - Full URL = http://example.org/eLTSS/provider3

Resource Practitioner:

Entry 15 - Full URL = http://example.org/eLTSS/funding1

Resource Organization:

Service Funding Source: Georgia Department of Community Health

Entry 16 - Full URL = http://example.org/eLTSS/relative1

Resource RelatedPerson:

Entry 17 - Full URL = http://example.org/eLTSS/guardian1

Resource RelatedPerson:

Entry 18 - Full URL = http://example.org/eLTSS/service1

Resource ServiceRequest:

Service Name: Personal care services, per 15 minutes - 5 units per week

Service Start Date / End Date: 2018-05-01 / 2018-12-31

Entry 19 - Full URL = http://example.org/eLTSS/service2

Resource ServiceRequest:

Service Name: Non-emergency transportation; encounter/trip - 10 trips total

Service Start Date / End Date: 2018-07-01 / 2018-12-31

Entry 20 - Full URL = http://example.org/eLTSS/service3

Resource ServiceRequest:

Service Name: House cleaning - one per week

Service Start Date / End Date: 2018-05-01 / 2018-12-31

Entry 21 - Full URL = http://example.org/eLTSS/strength1

Resource Observation:

Person Strength: Able to manage her bills. Has strong family support.

Entry 22 - Full URL = http://example.org/eLTSS/pref1

Resource Observation:

Person Preference: Accessing the ICWP Waiver for her current service needs, and would like to remain on ICWP and continue with her current services.

Entry 23 - Full URL = http://example.org/eLTSS/risk1

Resource RiskAssessment:

Entry 24 - Full URL = http://example.org/eLTSS/questionnaire1

Resource Questionnaire:

Entry 25 - Full URL = http://example.org/eLTSS/qr1

Resource QuestionnaireResponse:

Entry 26 - Full URL = http://example.org/eLTSS/contract1

Resource Contract:

Entry 27 - Full URL = http://example.org/eLTSS/location1

Resource Location:

Entry 28 - Full URL = http://example.org/eLTSS/coverage1

Resource Coverage:

Entry 29 - Full URL = http://example.org/eLTSS/claim2

Resource Claim: