Coordinating Care Through Electronic Messaging

We created an application that renders patient care plans from a consolidated-clinical document architecture, facilitating care coordination among dual-eligibles.

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As part of a CMS demonstration project to improve coordination of care among people enrolled in both Medicare and Medicaid, Altarum created for the Michigan Department of Health and Human Services an application that renders individual patient care plans from a consolidated-clinical document architecture (C-CDA).

Our Approach

Output from C-CDAs can be difficult for laypersons to use; our application solved this problem by putting the C-CDA information in a user-friendly format. As FHIR capabilities advanced, we worked in parallel with CMS and ONC to create a standardized electronic Long-term Services and Support (eLTSS)  reference implementation for the care plan. The eLTSS care plan compliments the C-CDA care plan and aligns with the CMS Interoperability and Patient Access final rule requiring Medicaid organizations and payers to implement and maintain application programming interfaces (APIs) to improve care coordination.

The care plan is easily navigated and shared among members of the care team across physical and behavioral health providers and plans.  Patients also can access their individual plan, and work with a care coordinator to determine their health goals and track their progress. Users access the plan through secure plan-member portals or through electronic health record systems. 


Since implementation of the application, members of the care team are able to more efficiently share updates to patient care plans with each other. More than 350 referrals are exchanged weekly among members of the care team in real time. Eleven health plans are participating, including Aetna, Amerihealth, and Molina, representing 37,000 beneficiaries.Our FHIR reference implementation is being used by other IT developers, accelerating the implementation of eLTSS care plans.