Health information is shared and exchanged to support a number of care processes as a patient transitions between care providers. The type of data shared to support transitions in care and the methods of exchange are summarized below. During transitions, information is typically exchanged face-to-face, by telephone, fax, and on some occasions, electronically.
Referral and Preadmission Assessment. The information typically exchanged during referral and for preadmission assessments includes patient demographics, problems/diagnoses, medications, allergies, treatment orders, activity level, diet, isolation precautions, labs, progress notes (e.g., 3 days of narrative notes), recent H&P, operative reports and pertinent assessments/evaluations including cognitive and functional status. The referral and preadmission assessment information is exchanged using multiple methods -- face-to-face meetings potentially including participation in hospital discharge planning rounds, telephone, fax, access to the hospital EHR (depending on hospital policy) and if available access to community HIEOs.
Referral for Community Services. The community care coordinators obtain information on patient goals and care plan information, patient demographics, problems/diagnoses, medications, allergies, treatment orders, progress notes, recent history, and physical and pertinent assessments/evaluations such as a cognitive status exam and functional status assessments. Setting up community services requires the exchange of information unique to the service provider. Typical information includes demographic and payer information, services requested, and when relevant, clinical information such as diagnosis and medications.
If the community care coordinator is an employee of the IDS, they access that information from the EHR system (hospital or physician practice) and communicate that information with the HCBS provider, typically by telephone, fax, and sometimes e-mail. If the community care coordinator is not an employee (e.g., they provide community care coordination through an AAA/Aging and Disability Resource Center (ADRC)), they have additional challenges in obtaining the necessary information from the hospital discharge planners by telephone or fax and relaying the information to HCBS providers by telephone, fax, and e-mail at times. In the Rush CCTP funded by CMS (discussed in the Rush Site Visit report in Appendix H), some of the BCCs are employees of organizations like the AAA and ADRC and are able to make special arrangements to access the hospital EHR to obtain necessary information on the patient.
Transfer/Admission to LTPAC. The transferring provider (often an acute care hospital) sends a comprehensive set of updated health information at the point of transfer. The information may include an order for discharge to the LTPAC provider, a transfer summary, medication orders, updated medication administration records, treatment orders, key lab results, discharge summary, recent progress notes, special nursing care instructions (e.g., ostomy, wound, catheter care, dressings, IV), fall risk assessments, rehab/restorative progress and treatment plans, infection control/safety precautions, equipment and supplies needed, advanced directives and/or limited treatment orders and followup care contact information. The transferring provider usually communicates this information via paper documents, telephone, and fax. For hospital transfers, some information may be accessed by the LTPAC provider directly from the hospital EHR prior to admission when security measures and protocols have been established between the organizations.
Transfer to Hospital or Another Health Care Provider from LTPAC. The LTPAC provider sends a comprehensive set of updated information at the point of transfer with the patient when they go to the hospital or to another health care setting. This information typically includes a transfer summary (which includes diagnosis/problems, medication orders, treatment orders, allergies, vital signs, functional and cognitive assessment data), pertinent recent labs, recent narrative progress notes, copies of current medication administration records, and advanced directive/do not resuscitate (DNR) orders. SNFs may send the items identified in the INTERACTII protocols when sending the patient to the hospital (e.g., transfer form, SBAR/nurses notes, recent physician orders and current medications, advanced directives). When sending to another LTPAC organization, they may also send the latest MDS or OASIS data set. This information is typically sent in paper format.
Discharge Information from LTPAC Provider to Patient and Community Service Provider. When patients are discharged from LTPAC they are provided with a detailed discharge POC and instructions including information on discharge medications, self-care instructions, and followup care. As part of the discharge planning process, the LTPAC provider may also assist the patient with identifying and setting up community-based services to support a successful transition. In these circumstances, the discharging LTPAC provider typically communicates this information via telephone, fax, and sometimes e-mail to the community-based service provider.
ADT Event Reporting to HIEOs. The two sites that participated in an HIEO electronically transmitted and received ADT events via an electronic interface with the HIE. The events reported included the patient identifier, the event (admission or discharge/transfer), date, and time. HIEOs use the ADT event reports to monitor changes and alert other treatment providers to a change in status.
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