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Scenario 01: MedAssist Home Health

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Practice Information

Difficulty: Intermediate Domain weights: D1 System Arch: MEDIUM | D2 Security: HEAVY | D3 Data: HEAVY | D4 Solution: MEDIUM | D5 Integration: LIGHT | D6 Dev Lifecycle: LIGHT Designed for 90-120 minute prep window

Before You Start

Print this scenario. Read it twice using the Two-Pass Reading Method — once for understanding, once to extract implicit requirements. Then build your solution artifacts within the 120-minute window.

Project Overview

MedAssist Home Health is a mid-size home health agency providing skilled nursing, physical therapy, occupational therapy, and medical social work services across New York, New Jersey, and Connecticut. The agency has operated for 12 years and is experiencing significant growth.

AttributeDetail
Employees450 total (200 nurses, 30 PTs, 20 OTs, 50 care coordinators, 100 office staff, 50 admin/leadership)
Active patients~25,000
Annual visits~1.25 million
Growth rate15% YoY (patient census)
RegulatoryHIPAA, state health departments, Medicare/Medicaid conditions of participation

The CEO has authorized an 18-month transformation to replace aging systems with a cloud-based platform. Budget: $2.8M for Phase 1, with additional phases planned.

The Chief Compliance Officer: “Patient privacy is non-negotiable. Any new system must meet or exceed our current privacy controls, and we need to be audit-ready at all times.”

Current Systems and Pain Points

Legacy Care Management (CareTrack v4.2)

On-premise system on Windows Server 2012 in a co-located data center, installed 8 years ago. Manages patient demographics, care plans, visit documentation, and physician orders.

  • Vendor end-of-life in 14 months
  • No mobile interface; clinicians VPN from personal laptops to enter visit notes
  • Visit documentation averages 45 minutes due to clunky interface
  • Database: 8 years of records, ~6.2 million historical visits
  • Data quality: 12% duplicate patients, 8% missing required fields, inconsistent free-text notes
  • Proprietary database; CSV export only (no referential integrity across exports)
  • Only 4 AD permission groups (Admin, Clinical, Office, Read-Only)

Billing System (MediBill Pro)

Cloud SaaS handling claims to Medicare, Medicaid, and commercial payers. REST API (v2.3) with OAuth 2.0. Billing team manually re-enters visit data daily from CareTrack. Processes ~$45M in annual claims. 11% claims denial rate, partly from re-entry errors. Must maintain audit trail linking charges to clinical documentation.

Paper-Based Scheduling

Managed via spreadsheets, whiteboards, and phone calls. No visibility into clinician availability or proximity. Double-bookings occur weekly. Coordinators spend ~3 hours/day on scheduling.

No Patient Portal

No electronic access for patients or families. Competitors offer portals for visit schedules, care plans, and messaging — MedAssist is losing referral sources due to this gap.

Business Process Requirements

Patient Intake and Referral Management

  1. Capture referrals from hospitals, physicians, and self-referrals via multiple channels (fax, phone, electronic) and route to the appropriate regional intake coordinator based on patient address and service needs.
  2. Track each referral from receipt through acceptance/declination with timestamps and responsible party; target: intake within 48 hours.
  3. Verify insurance eligibility and pre-authorization requirements during intake before accepting a patient.
  4. Create comprehensive patient records (demographics, emergency contacts, insurance, PCP, diagnoses, allergies, medications, advance directives).
  5. Referral sources need limited visibility into referral status without seeing clinical information.

Care Plan and Clinical Documentation

  1. Clinicians must create, review, and update individualized care plans from mobile devices at point of care, including goals, interventions, visit frequency, and expected duration.
  2. Visit documentation must support structured data (vitals, wound measurements, pain scales, functional assessments) and narrative notes, completable within 15 minutes at point of care.
  3. Multi-discipline care plans: nursing, PT, OT, and social work contribute to the same patient plan; each discipline sees the full plan but edits only their sections.
  4. Track physician orders with signature status; flag orders expiring within 14 days for renewal.
  5. Finalized documentation is locked; amendments preserve the original record alongside corrections.
  6. When clinical thresholds are crossed (e.g., blood pressure out of range, wound deterioration), notify the care coordinator and attending physician within one hour.

Scheduling and Visit Management

  1. Coordinators view all clinician schedules for their region and assign visits based on qualifications, geographic proximity, and patient preferences with real-time adjustments.
  2. Clinicians receive daily schedules on mobile devices with patient address, contact info, visit type, and special instructions; confirm completion and record mileage from the same device.
  3. Missed/cancelled visits are automatically flagged and escalated with required reason codes and tracked follow-up actions.
  4. Patients and families can view upcoming visits, receive 24-hour appointment reminders, and request changes through a digital channel.

Data Model and Migration Requirements

  1. Store 8 years of historical visit records (~6.2M records) with full traceability linking each visit to patient, clinician, care plan, and billing claim.
  2. Preserve historical free-text clinical notes in original form with search by patient and date range.
  3. Deduplicate ~31,000 patient records (12% estimated duplicates) with a survivorship strategy retaining the most complete demographics and all clinical history.
  4. Handle ~5,000 new visit records per business day with Monday morning peaks (~1,200 records in a 2-hour window).
  5. Maintain complete audit trail of all changes (who, when, previous value) retained 7 years after last date of service.
  6. Support “episodes of care” — multiple episodes per patient, each with its own care plans, orders, and visits, with episode-level reporting.
  7. Active records immediately accessible. Records for patients inactive >3 years accessible with longer retrieval. Records >7 years old retained in read-only archive meeting regulatory requirements.

Accessibility and Visibility Requirements

  1. Clinicians see only their active caseload patients — no access to other clinicians’ patients.
  2. Care coordinators see all patients in their assigned region (9 territories across 3 states) but not patients in other regions.
  3. When multiple disciplines serve a patient, all assigned clinicians see the full care plan and history for the duration of their assignment.
  4. Billing team accesses visit records and diagnosis codes for claims but cannot view clinical notes, wound photographs, or psychosocial assessments.
  5. Leadership and compliance officers have read-only access to all records across all regions, with logged and auditable access.
  6. External referral sources see only referral status (pending/accepted/declined) and assigned coordinator name — no clinical or demographic data.
  7. Patients and authorized family members view care plan summaries, visits, and selected results through a secure portal but cannot see internal notes or billing information.
  8. VIP patient records (employee families, high-profile individuals) have additional access restrictions limiting visibility to the assigned care team and designated compliance officers.
  9. All patient record access is logged; compliance can report who accessed which record, when, and what action was performed.

Multi-State Regulatory Considerations

  1. Enforce state-specific documentation requirements (NY, NJ, CT each have different regulations for visit documentation content and retention periods).
  2. Prevent scheduling clinicians in states where they are not licensed; track licensure by state.

Reporting Requirements

  1. Chief Clinical Officer dashboard: patient outcomes by diagnosis, 30-day readmission rates, average visits per episode, clinician productivity — refreshed daily by 6:00 AM.
  2. Regional coordinators: real-time daily visit completion rates, missed visits, and open scheduling slots.
  3. Compliance team: on-demand audit reports showing all access to a specific patient’s record over a configurable time period.
  4. Billing team: weekly report of unbilled visits, denial rates by payer/reason, and average days from visit to claim submission.
  5. CFO: monthly revenue by region, payer mix, cost per visit, and projected revenue based on census and growth.
  6. Ad-hoc reporting for authorized managers ensuring reports reflect only data they are authorized to see.

Integration Requirements

  1. Visit data, diagnosis codes, and clinician IDs flow automatically to MediBill Pro after visit finalization (~5,000 transactions/day), eliminating manual re-entry.
  2. Reconciliation mechanism confirms successful transmission; flags discrepancies for review.
  3. Architecture must accommodate a future health information exchange (HIE) connection without re-architecture, though HIE is out of scope for Phase 1.

Development Lifecycle Requirements

  1. 4-person IT team (sysadmin, DBA, BA, help desk) adding 2 developers and 1 QA analyst; no prior cloud platform experience.
  2. Training plan and documentation enabling the internal team to maintain and extend the system post-go-live without ongoing consultant dependence.
  3. Separate dev, test, and production environments with defined change migration processes; no patient data in non-production environments.
  4. Compliance officer must approve all changes affecting data access, security, or patient-facing features before production deployment.
  5. Go-live plan includes a parallel-run period with defined criteria before CareTrack decommission.

Additional Constraints

  • Data center lease expires in 16 months — all on-premise systems must be migrated or decommissioned by then
  • Clinicians use a mix of company iOS tablets, personal Android phones, and personal laptops; no MDM solution
  • ~20% of patient visits occur where cellular/Wi-Fi coverage is limited or unavailable
  • Current AD instance managed by a third-party provider whose contract may not be renewed

Implicit Requirements

This scenario contains unstated requirements implied by the company profile, data volumes, regulatory environment, and system descriptions. Pay attention to the numbers and what they mean for system design, regulatory mandates beyond what is stated, growth rate impacts on capacity, and multi-state effects on data partitioning and access control.