During the site visit, interviews were conducted with Beechwood staff to discuss key processes/workflows that require the exchange of information. Interviews were conducted with the department representatives from admissions, nursing, social service, rehab, Medicare liaisons and billing, and HIM. Based on the interviews Table I-3 summarizes discussions by workflow process, highlights the information exchange process, and shares other notes/insights.
TABLE I-3. Skilled Nursing Facility (SNF) Workflow Processes
|Process||Information Collected and/or Exchanged||Additional Notes from Discussions|
|Preadmission/ Admissions||Admission provides daily updates to the area hospitals with the number of beds open. Currently this information is relayed by telephone to hospital discharge planners to facilitate relationship-building & enhanced communication.
Beechwood reviews & obtains hospital information to assist in the preadmission assessment & admission/transition of care. They use multiple mechanisms to collect & review the information including on-site visits, hospital EHR access, secure e-mail/e-fax with attachments, telephone. The hospital information needed includes:
Internally, the Admissions staff sends electronic documents (e.g., PDF) of hospital medical record information as attached to the electronic admitting notice sent to Beechwood departments to ensure they have pertinent information to start care.
|The admissions department has the ability to log into 1 of the area hospitals EHRs through portals to assist in the admission process. This is useful for updates during a patient's stay.
Another area hospital does not have the capability for remote access to the EHR through a portal (must be on-site). In this second hospital discharge planners must use extra steps to make information available remotely to support the transfer/preadmission process. Frequently the information is not updated & there have been delays with the decision-making & discharge process.
At times the hospital discharge summary is not available at the time of transfer from the hospital & admission to Beechwood. Sometimes the hospital will fax the discharge summary after admission to Beechwood or the HIM department will request the missing information from the hospital. This process requires Beechwood to complete a written request for information from the hospital & may take significant time to receive. HIM will begin using HEALTHeLINK to check for availability first & then use the written request process if the information is not available.
|Nursing Admission/ Start of Care||Nursing receives information from hospital prior to admission (see Admissions above for type). The nurse manager accesses HEALTHeLINK for additional patient information including past history particularly after admission during the assessment & care planning process.||The admission process has opportunity for improved efficiency. Beechwood had a meeting with their area hospitals to identify the type of information needed from the hospital:
|Physician Order process including Medications||The nurse manager contacts the physician typically by phone to review admission orders from the hospital & obtain new verbal orders.
The orders including medications are written out & sent by fax to pharmacy.
HIM manages the physician order signature process by sending the orders to physicians & tracking for their timely return. This includes verbal/telephone orders initiative by nursing & therapy as well as regular orders. The physician is mailed the order to obtain his/her signature or kept in a folder at the Beechwood front desk that the physician picks up & signs when he/she is at the facility.
|Beechwood is working on a project to communicate physician orders including medications to the pharmacy electronically through AOD.
Beechwood is looking into the use of a physician portal to AOD to provide a mechanism for physicians to log into Beechwood's EHR to sign orders & complete documentation.
|Status updates to the physician||Nursing communicates status updates to the physician via multiple routes--phone updates, folder for followup during routine physician visit. The status updates are communicated for many reasons such as change in the patient's condition or communication of a lab or test result.|
|Physician visits||HIM maintains the regulatory required physician visit schedule & communicates with the physician by mail notifying them when their patients are due for a visit.|
|Lab & Special Tests||Lab & radiology/ultrasound physician orders are communicated to the providers by telephone. Results are delivered in multiple ways depending on the service provider--by fax, by mail, via a dedicated printer sent from the provider to Beechwood, access to results on the provider's web portal, or through HEALTHeLINK. An interface is under development to delivery results through HEALTHeLINK directly into AOD.|
|Nursing Patient Referral to Specialist||A referral document is completed by nursing in paper format & sent with the patient when scheduled for a specialist visits. The specialist returns a refer/consult visit (either a paper form that comes with the patient or mails the consult report to Beechwood after completion).|
|Transfer to the Hospital||At transfer to the hospital from Beechwood, nursing completes the INTERACTII envelope of information & sends information to hospital with the patient. (This is a paper-based process at this time).
The INTERACTII envelope includes the following information: transfer form, face sheet, recent H&P, recent physician orders, current MAR, advanced directives & care limiting orders, relevant lab/radiology reports, & personal belongings sent.
|INTERACTII is used; however, nursing is not using the SBAR because of the amount of time to complete the information.
Administration has identified this process for re-evaluation & completion in AOD (the capabilities are available in AOD, but Beechwood has not begun using this functionality yet).
|Rehab Services||Rehab staff complete an admission assessment which requires the following hospital information:
Physician orders are written to evaluate & therapy evaluation/certification either mailed to physician for signature or kept in a folder at Beechwood that the physician picks up when he/she is at the facility.
Physician orders (such as equipment, treatment changes) are called to physician as a verbal order. The order is written on paper & mailed for signature or kept in a folder at Beechwood that the physician picks up when he/she is at the facility.
Rehab develops a written summary (on paper) for a doctor/specialist consultation that includes information on the patient's status such as an update on wound healing or orthopedic rehab progress. The information is provided with the referral when a patient is sent to a specialist. Rehab receives a copy of the consultation report/result. This information is typically returned with the patient (in paper format) or mailed to Beechwood.
|It is important for therapy to have an accurate picture of the patient, their condition, & their goals before they begin treatment. At times they do not have all of the information they need to assess the patient's status at admission if hospital records were not sent or available at transfer.
Therapy has not been using HEALTHeLINK, but will be trained. When information is needed they ask the HIM department to request the information from the hospital (often it is the operative report). Paper copies are returned by mail.
|Medicare Coverage Determinations & Communication with Family||The Medicare nurse evaluates the patient for coverage, makes coverage decisions & communicates with the interdisciplinary team by e-mail. They monitor the patient's status over time & make continued coverage decisions.
The Medicare nurse verifies insurance coverage & related coverage criteria, they communicates by e-mail coverage & clinical criteria to interdisciplinary team. The Medicare nurse develops monitoring tools for nursing such as clinical flow sheets & documentation guidelines for nurse's progress notes (this information is not in AOD).
The Admissions Coordinator sends an update to pharmacy, ultrasound/radiology & lab via fax regarding Medicare coverage. When lab & test results are returned, they receive a paper copy from the unit coordinator (the information not in the AOD system at this time).
The Medicare nurse monitors the patient's status for continued coverage. They review the Nursing 24-Hour Reports are maintained in AOD & alerts/messages sent designated staff.
The Medicare nurse communicates with patient/representative at end of coverage by telephone & with a written letter that specifies the end of coverage date & appeal information.
The Medicare nurse communicates with Medicare HMO case manager sending status updates & continued coverage information (e.g., the type of skilled nursing or rehab services the patient is receiving). These updates are by phone & fax.
The HIM department mails the Medicare Certification/Recertification form to the physician for signature according to the required schedule while the patient is on Medicare. The physician signs & returns the certification by mail. Some physicians who see patients at Beechwood routinely have a folder at the front desk that holds the orders & forms that require their signature to eliminate the mailing process.
|Monitoring tools/guidelines are developed & kept in a notebook at the nursing station. This process has been identified for evaluation by the IT team to determine opportunities to utilize AOD more fully for incorporation of customized flow sheets & documentation guidelines related to Medicare cover.
Beechwood reported an increase in the number of patients with Medicare HMOs (e.g., Medicare Advantage). These plans have different coverage criteria & 2 no longer require a 3-day hospital stay. Medicare nurses communicate with coverage & change of status updates. They use the nursing 24-hour report & therapy reports as tools to identify patients with new conditions that would affect coverage.
|Care Planning & Communication with Family||Social service communicates with the family on admission & during multiple times during the patient's stay--this communication is typically by phone, mail & sometimes e-mail based on family preference. They provide written information mailed to the family on care conference dates & provide an update of the care plan team's recommendations if they were not present at the conference.||The social service department uses the AOD system for their documentation including progress notes & assessments. They also use HEALTHeLINK for additional supporting documentation in conducting their initial assessment & care plan.|
|Discharge Planning & Discharge Process||They also work with the family in planning for discharge. The communication is primarily by phone & mail. They review teaching & instructions with patient & family at the time of discharge & provide a paper copy of the information.
Discharge instructions are developed for the patient by nursing, therapy, social service & other members of the interdisciplinary team. The instructions are reviewed with the patient & family/caregiver prior to discharge. A copy of the discharge instructions are sent with the patient.
Social services may assist with the transition home by identifying HCBS. They may also initiate services on behalf of the patient/family. Typically they communicate via telephone & fax with the community service provider.
|Census/ADT Events||HIM enters the census/ADT events in the AOD systems each morning for the prior day ending at midnight (e.g., ADTs, room changes). Certain ADT events used by the HIE are electronically communicated from AOD to HEALTHeLINK.|
|Billing||HIM prints and/or copies medical record documentation for billing. Request for medical record documentation is mailed in following situations:
Medical review & other requests such as RAC audits require mailing of copies of medical records.
|All claims are electronically billed except a select few.
Some insurance companies require medical documentation (e.g., workman's compensation or no fault insurance)--documentation is copied & mailed with claim.
Request for medical records via e-remittance has been problematic as there are concerns with missing a request (e.g., e-mail printout cuts off information).
"HIEengage.pdf" (pdf, 976.86Kb)
"HIEengageA.pdf" (pdf, 122.65Kb)
"HIEengageB.pdf" (pdf, 132.47Kb)
"HIEengageC.pdf" (pdf, 62.72Kb)
"HIEengageD.pdf" (pdf, 64.52Kb)
"HIEengageE.pdf" (pdf, 71.74Kb)
"HIEengageF.pdf" (pdf, 67.17Kb)
"HIEengageG.pdf" (pdf, 128.62Kb)
"HIEengageH.pdf" (pdf, 1.02Mb)
"HIEengageI.pdf" (pdf, 264.75Kb)
"HIEengageJ.pdf" (pdf, 663.47Kb)
"HIEengageK.pdf" (pdf, 126.77Kb)
"HIEengageL.pdf" (pdf, 141.17Kb)