Long-Term and Post-Acute Care Providers Engaged in Health Information Exchange: Final Report. Health Information Exchange Information Flow

10/29/2013

Table I-5 describes the information exchange activities for Beechwood in three areas: (1) hand-offs in care; (2) shared care; and (3) other administrative exchange. The exchange scenarios are not limited to electronic exchange of information, but encompass any exchange workflow. The summary table provides a synopsis of the HIE activities from the perspective of a nursing home/SNF using the framework established by Westat.

TABLE I-5. HIE by Care Coordination Function and Partners, Beechwood Homes

Transitions of Care
Care Coordination Function Across Members of the Care Team Within Affiliated Organization Between Staff in an Organization and Other Non-Affiliated Care Providers Including Community Services Between Staff in an Organization and Patient/Family Members Type of Exchange Data Sender and Receiver
Referral/Assessment
Preadmission assessment   Hospital Stay: Patient is assessed by Beechwood staff while at the hospital to determine appropriateness of placement.  
  • Access to hospital EHR
  • Phone
  • Fax
  • Interview
  • Medications
  • Nurses notes
  • H&P
  • Diagnoses
  • Operative report
  • Other relevant clinical data such as functional status, therapy, skilled nursing services
  • Hospital discharge summary
Hospital nurse to Admissions in Beechwood.
  NH to NH: Patient is assessed by Beechwood while at another NH to determine appropriateness of placement. This may occur when a patient or family desires a change in facility.  
  • Phone
  • Fax
  • Interview
  • Recent hospital information
  • Medications
  • Nurses notes
  • MDS
  • Care plan
  • Lab
  • Other relevant assessments
Beechwood admissions & NH admissions.
  Home to NH: Patient is assessed by Beechwood for appropriateness of placement.  
  • Phone
  • Fax
  • Interview
  • Recent hospital information
  • Medications
  • Recent labs
  • Other progress notes
  • (Home health information if applicable)
Attending Physician & to Beechwood 

Admissions. Patient representative to facility admissions.

Transition of Care (transfer or discharge)
Transfer/Admission to LTPAC   Transfer from hospital to Beechwood  
  • Fax or scan
  • Paper copies
  • Hospital EHR access by Beechwood
Updated hospital information:
  • Transfer form
  • Medications
  • Nurses notes
  • H&P
  • Diagnoses
  • Operative report
  • Other relevant clinical data such as functional status, therapy, skilled nursing services
  • Hospital discharge summary
Hospital nurse to Beechwood admissions
  Transfer from home to Beechwood  
  • Fax or scan paper copies HEALTHeLINK
  • Order to admit & other admission orders
  • H&P
  • Past medical history information
Physician to Beechwood
Discharge from LTPAC to Another Provider   Transfer from another NH to Beechwood  
  • Fax or scan paper copies
  • Transfer form
  • MAR
  • Recent nurses notes
  • New labs
NH to Beechwood
  Discharge from Beechwood to another NH  
  • Fax or scan paper copies
  • Transfer form
  • MAR
  • Recent nurses notesNew labs
Beechwood to NH
  Discharge home from Beechwood Facility (with home health services)  
  • Fax or scan paper copies
  • See INTERACTII envelope content detailed above for transfer to hospital
Beechwood nurse to home health nurse
Transfer to Hospital from LTPAC   Transfer Beechwood to hospital  
  • Fax or scan paper copies
INTERACTII Envelope:
  • Transfer form
  • Face sheet
  • Most recent H&P & any recent hospital discharge summary
  • SBAR/Nurse's progress notes
  • Orders related to acute condition
  • Current medication list or current MAR
  • Advance directive
  • Care limiting orders
  • Relevant lab results
  • Relevant x-ray reports
  • Immunization records
  • PT notes
Beechwood Nurse to Hospital (ED or receiving unit)
Discharge Information from LTPAC to Patient     Discharge home from Beechwood facility (without home health services)
  • Fax or scan paper copies
  • Discharge instructions & discharge POC (includes meds, diagnoses, therapy notes, functional status, followup care/ appointments & services)
Beechwood social service, therapy, nursing to patient (or family or representative)
Discharge from LTPAC to Community Service Provider(s)   Social service assists with setting up community services to assist a patient with successful transition  
  • Phone
  • Fax
  • E-mail
  • Mail
  • Relevant information (demographics & type of services requested) related to community service
Social service to community service provider
ADT Event Data to HIE Network   ADT message to HIE to communicate admissions & discharge information  
  • Electronic message to HEALTHeLINK
  • ADT events
Beechwood to HIE
Followup Post Transfer/Discharge
    Generally Not Applicable--Followup is addressed in Shared Care Section        

TABLE I-6. Shared Care Information Exchange Activities

Transitions of Care
Care Coordination Function Across Members of the Care Team Within Affiliated Organization Between Staff in an Organization and Other Non-Affiliated Care Providers Including Community Services Between Staff in an Organization and Patient/Family Members Type of Exchange Data Sender and Receiver
Assess Needs and Goals
Coordination with physician at Start of Care including Medication Reconciliation & Orders, Evaluation/ Certification & Plan of Care   Admission orders & medication reconciliation --review transfer form & hospital information to reconcile medications & establish Beechwood facility orders & initial physician POC.  
  • Phone
  • Fax
  • Mail
  • HIE to assist with medication history
  • AOD (for limited number of physicians testing signing orders in system)
  • Telephone orders for all orders including medications that are to be implemented at the Beechwood
Beechwood nurse to Attending Physician
  Therapy order, evaluation & certification communicated with physician & mailed for signature.  
  • Mail
  • Therapy order
  • Therapy evaluation
  • Therapy Certification
Beechwood Therapist to Attending Physician
Communicate Physician Orders & medications to Pharmacy   Communicate admission orders & medications to pharmacy.  
  • Fax
  • Physician orders including medication
Beechwood Nurse to Pharmacy
Communicate orders for labs, radiology & special tests to service provider & return test results   Communicate lab orders to lab provider.  
  • Phone
  • Lab order
  • Diagnosis
  • Patient demographic
  • Face sheet
  • Payer information
Beechwood Nurse or Unit Coordinator to Lab
  Communicate Radiology orders to lab provider,  
  • Phone or web portal
  • Radiology/ ultrasound order
  • Diagnosis
  • Patient demographic
  • Face sheet
  • Payer information
Beechwood Nurse or Unit Coordinator to Radiology/ Ultrasound
Request additional medical record information from hospital to assist with admission assessment & care planning process   Beechwood Interdisciplinary Team request additional information from hospital to complete an assessment,  
  • Electronic access to HEALTHeLINK
  • Written request for information from hospital
  • Varies--Information not received such as Operative reportAssessment Tests & results
HIM to hospital
Communicate with patient and/or family/ caregiver for additional information & advanced directive     Beechwood Interdisciplinary Team interview patient/family for information to complete initial assessment.
  • In person interview or phone
  • Varies
Interdisciplinary team to Patient and/or family
Create and Maintain Plan of Care
Create & Maintain Patient's Plan of Care & Orders   Regular review & update of physician orders.  
  • Paper records mailed for review & signature or available in folder at Beechwood for physician to sign during on-site visit.
  • Physician order recap
  • Review care plan
Nursing/Unit Coordinator to Physician
Care Plan Update with Patient/Family     Beechwood Interdisciplinary Team updates to patient & family POC.
  • In-person participation in care conference
  • Phone
  • Mail
  • Care plan
Social service to patient and/or Family
Monitor, Followup, and Respond to Change
Ongoing Physician Visits/Evaluation   Routine physician visit.  
  • Mail
  • Phone
  • In-person
  • Notes with status updates & request (in folder for physician)
  • Physician visit due date (& patient's to visit)
  • Physician progress notes
  • Physician orders
  • Interdisciplinary progress notes
  • Care plan
Nursing (for status updates) & HIM (for scheduling) to Physician
Change in condition/status update and/or order change request to the attending physician   Change in condition, status updates & order changes.  
  • Phone
  • Fax
  • Telephone orders
  • Lab & other test results
  • Summary of change
Nursing to Physician
Change in Condition/Status update to Patient/ Family/Caregiver     Change in condition, status updates & order changes.
  • Phone
  • Summary of change, results, plan
Depending on topic: Nursing, social service or interdisciplinary team member to patient/ family
Specialist Visit/ Evaluation   Specialist visit (surgeon, neurologist, dentist, psychologist, etc.).  
  • Mail
  • Phone
  • Paper copies
  • Referral
  • Medication list or administration record
  • Face sheet
Nursing/Unit Coordinator to Specialist
Communicate physician order changes to pharmacy & order medications   Communicate physician order (including medication) changes to the pharmacy & order medications.  
  • Fax
  • Physician orders including medication
Beechwood Nurse to Pharmacy
Order changes for lab, radiology & special tests & return of results   Request new Lab or Radiology/Ultrasound or other specialized test.  
  • Phone and/or portal (for radiology)
  • Test type
  • Diagnosis
  • Face sheet/ demographic information
Nursing or Unit Coordinator
Routine physician order review & recertification   Medicare/Medicaid certification/recertification forms sent to physician for signature.  
  • Mail (in special circumstances by fax)
  • Medicare Certification/ Recertification Form
HIM to Attending Physician

TABLE I-7. Other Information Exchange Activities

Other Exchange Activities
Care Coordination Function Across Members of the Care Team Within Affiliated Organization Between Staff in an Organization and Other Non-Affiliated Care Providers Including Community Services Between Staff in an Organization and Patient/Family Members Type of Exchange Data Sender and Receiver
Quality Measures
Electronic submission of mandatory data sets which includes quality measures   Electronic submission of mandatory data set which includes quality measure data.  
  • Electronic submission via CMS required portal
  • Mandatory data set
Beechwood to CMS
Public Health
Public health & state registries for reportable conditions   Report required data to the State of New York through the state's Health Commerce System for & including required disaster preparedness reporting. This portal also provides messages to from the state such as emergency notifications.  
  • Through NY State HCS
  • Outbreaks
  • Immunization result data starting November 2013, Other reportable infections
  • Mandatory reporting such as emergency preparedness
  • Receipt of emergency notifications from state
Beechwood to State of New York for required reporting. 

Emergency notifications & other requests for data & communication are sent from the state through HCS to Beechwood.

Payment
Communication with Payer Case Manager   Billing/Medicare Nurse updates to payers regarding initial & continued coverage.  
  • Phone
  • Fax
  • Copies
  • Mail
  • Medical record information relative to coverage
Medicare nurse to payer case manager
Communication with Ancillary Service Providers for Billing   Relay billing information & Medicare/Medicaid coverage status to community providers--pharmacy, lab, radiology/ultrasound.  
  • Fax
  • Medicare coverage dates
Admissions to ancillary service providers
Communicate with Patient/Family for Payer Coverage     Medicare nurse to family to relay Medicare coverage start & stop,
  • Phone
  • Mail
  • Medicare coverage letters
Medicare nurse to family/rep
Payer Medical Record Requests   Remittance, medical review, or RAC request for medical records.  
  • Billing system
  • Copies
  • Mail
  • Relevant medical record documentation
HIM & Billing to Payer

 

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