LTPAC providers frequently coordinate and share care with other health care and service providers. When sharing care, there are related HIE processes to support assessment, care planning, and ongoing monitoring. A summary of HIE activities to support shared care is described below along with the type of data shared. During instances of shared care, information is typically exchanged by telephone, fax/e-fax, or electronically such as via secure e-mail, use of HIEOs, or customized portals/data entry processes when available.
Assess Needs and Goals. There are multiple processes related to assessing needs and goals at the start of care that require HIE.
Initial assessment and development of admission care plan (such as at times of hospital discharge): To complete the assessment and initial care plan development, nurses, therapists and other interdisciplinary team members require recent hospital information and past medical history information to evaluate the patient. Information needed includes the hospital discharge summary, recent H&P, operative report, recent labs, summary of care records, past assessments, social history, and advanced directives. Typically, LTPAC receives the information needed to help complete the initial assessment and develop the admission POC via paper copies sent with the patient or via fax or telephone. In some cases, LTPAC providers electronically access the hospital EHR (if protocols have been established) and/or the HIEO. Medical record information needed, but not exchanged by the hospital or available from the HIEO must be requested from the hospital (e.g., discharge summary not sent at transfer) and is typically received via mail.
Coordination with physician at start of care: The admission transfer summary, physician orders, medications, treatment orders, therapy evaluation, and home care POC content are all reviewed and signed by the physician. For a SNF patient, the physician completes a face-to-face visit, documents a progress note, and reviews and signs the POC and physician orders. Two sites were implementing customized physician portals to the LTPAC EHR to streamline information exchange. The physician logs into the LTPAC EHR portal to access and review patient information and sign their orders. When an HIEO was available with medication history information, it could be accessed electronically to help with the admission medication reconciliation process, although not a guaranteed source of complete medication history information.
Communication with pharmacy, lab, and other service providers: The LTPAC provider communicates physician admission orders to the pharmacy, lab and/or other service providers as appropriate. Data exchanged includes demographic and payer information and the detailed orders for medications or services. Typically this is done via telephone, fax or custom web-based portal set up by the pharmacy or lab/radiology service provider. Results received from lab and radiology providers were sent via fax, dedicated printer to LTPAC, or available on the provider's web portal. One HIEO, HIN, was establishing an interface to route results from the lab/radiology provider through the HIE to the SNF's EHR using HL7 results reporting message standards.
Create, Maintain, Update, and Implement Care Plan. After initial assessment, a care plan is established and maintained over time. The care plan is typically developed by the interdisciplinary team and communicated to the attending physician and the patient/family initially and with updates. The physician may review the POC during routine patient visits to a SNF. In home care, the care plan updates are communicated via the home care POC document. Care plan information and updates are communicated to the family in person, via telephone or through a narrative summary mailed to the representative.
Monitor, Followup and Respond to Change. LTPAC providers monitor the ongoing care needs of patients, respond to changes in the patient's condition and followup on care and services required. HIE is required to support multiple care processes.
Transmission of telehealth data: Patient's transmit telehealth data from their device and base station in their home to a cloud-based application. The telehealth nurse in home care accesses clinical data including blood pressure, weight, blood sugar, pulse, oxygen saturations, and responses to individualized questions. Home care nurses monitor the telehealth data on the cloud-based telehealth system. The data was not available in the home care EHR (although an interface was being developed at one site). The use of telehealth in an SNF was not observed during the site visits. EMHS had a telepsychiatry pilot program that could not be maintained due to reimbursement issues.
Ongoing communication and coordination with physicians: LTPAC providers update the physician with status changes. Information exchanged includes test results, requests for new or revised orders, telephone orders, physician order renewals, home care POC recertification, and physician visit progress notes. These types of updates occur by telephone, fax, and/or secure e-mail. Two sites established physician portals to their LTPAC EHRs to facilitate the review and signature process.
Order changes for medications, labs, and radiology tests: When the LTPAC provider communicates change in patient status, the LTPAC provider may obtain from the physician a new order or an order to change a medication (or another intervention). The LTPAC provider typically receives these order changes verbally from the physician via telephone. The physician signs the telephone orders in person, sent via mail, or through the physician portal to the LTPAC EHR.
For SNFs, there is also a communication process in which medication and other order changes are sent to the long-term care pharmacy. The pharmacy receives the physician order information from the SNF, often via telephone or fax. The pharmacy verifies the medication prescription with the ordering physician. The long-term care pharmacy enters the order in the pharmacy's electronic medication order system and dispenses the medications to the SNF.
New or changed orders for labs and radiology tests are communicated via telephone, fax, or through a custom web portal as a requisition to the appropriate ancillary service provider by the LTPAC provider. In home care, the nurse may draw the lab. In a SNF, a facility nurse or lab technician draws the lab or gathers the specimen. Results are returned from the lab and radiology provider to the LTPAC provider often by fax or dedicated printers or custom web portal. In Western New York, the HIEO was in the process of developing and implementing an electronic results delivery process to route results from the lab/radiology service providers through the HIEO to the LTPAC EHR.
Change of Status and Updates with Patient and Family. When there is a change in status, the patient and/or their family is notified by the LTPAC provider of the change and related care/treatment plans. This is frequently communicated in person, by telephone or e-mail based on preference.
Specialist Visits, Evaluations, and Referrals. LTPAC providers may identify and schedule visits with specialists (cardiologist, audiologist, psychologist, etc.) or set up a referral for community services to support the patient in their home. Information is exchanged to set up the service including demographic, payer, and service requirements. When applicable, progress notes or visit summary records are shared with the LTPAC provider.
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