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. |
|
|
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. |
|
|
Beechwood admissions & NH admissions. | |||
Home to NH: Patient is assessed by Beechwood for appropriateness of placement. |
|
|
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 |
|
Updated hospital information:
|
Hospital nurse to Beechwood admissions | ||
Transfer from home to Beechwood |
|
|
Physician to Beechwood | |||
Discharge from LTPAC to Another Provider | Transfer from another NH to Beechwood |
|
|
NH to Beechwood | ||
Discharge from Beechwood to another NH |
|
|
Beechwood to NH | |||
Discharge home from Beechwood Facility (with home health services) |
|
|
Beechwood nurse to home health nurse | |||
Transfer to Hospital from LTPAC | Transfer Beechwood to hospital |
|
INTERACTII Envelope:
|
Beechwood Nurse to Hospital (ED or receiving unit) | ||
Discharge Information from LTPAC to Patient | Discharge home from Beechwood facility (without home health 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 |
|
|
Social service to community service provider | ||
ADT Event Data to HIE Network | ADT message to HIE to communicate admissions & discharge information |
|
|
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. |
|
|
Beechwood nurse to Attending Physician | ||
Therapy order, evaluation & certification communicated with physician & mailed for signature. |
|
|
Beechwood Therapist to Attending Physician | |||
Communicate Physician Orders & medications to Pharmacy | Communicate admission orders & medications to pharmacy. |
|
|
Beechwood Nurse to Pharmacy | ||
Communicate orders for labs, radiology & special tests to service provider & return test results | Communicate lab orders to lab provider. |
|
|
Beechwood Nurse or Unit Coordinator to Lab | ||
Communicate Radiology orders to lab provider, |
|
|
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, |
|
|
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. |
|
|
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. |
|
|
Nursing/Unit Coordinator to Physician | ||
Care Plan Update with Patient/Family | Beechwood Interdisciplinary Team updates to patient & family POC. |
|
|
Social service to patient and/or Family | ||
Monitor, Followup, and Respond to Change | ||||||
Ongoing Physician Visits/Evaluation | Routine physician visit. |
|
|
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. |
|
|
Nursing to Physician | ||
Change in Condition/Status update to Patient/ Family/Caregiver | Change in condition, status updates & order changes. |
|
|
Depending on topic: Nursing, social service or interdisciplinary team member to patient/ family | ||
Specialist Visit/ Evaluation | Specialist visit (surgeon, neurologist, dentist, psychologist, etc.). |
|
|
Nursing/Unit Coordinator to Specialist | ||
Communicate physician order changes to pharmacy & order medications | Communicate physician order (including medication) changes to the pharmacy & order medications. |
|
|
Beechwood Nurse to Pharmacy | ||
Order changes for lab, radiology & special tests & return of results | Request new Lab or Radiology/Ultrasound or other specialized test. |
|
|
Nursing or Unit Coordinator | ||
Routine physician order review & recertification | Medicare/Medicaid certification/recertification forms sent to physician for signature. |
|
|
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. |
|
|
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. |
|
|
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. |
|
|
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. |
|
|
Admissions to ancillary service providers | ||
Communicate with Patient/Family for Payer Coverage | Medicare nurse to family to relay Medicare coverage start & stop, |
|
|
Medicare nurse to family/rep | ||
Payer Medical Record Requests | Remittance, medical review, or RAC request for medical records. |
|
|
HIM & Billing to Payer |
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