EMHC staff described the clinical workflow processes for care and how information is used and exchanged. Table J-6 describes the process, information collected and/or exchanged and observations by staff.
TABLE J-6. Home Health Care Workflow Processes
|Process||Information Collected and/or Exchanged||Notes|
|Referral/Intake||Collect clinical, demographic & payment information on potential admissions.
Enter patient demographic into EMHS EHR to create a patient identifier which creates a record in Horizon Home Care for the patient.
Perform an additional level of screening of patients to ensure appropriateness of care.
Verify insurance coverage.
|Hospital nurse managers work with the post-acute care liaisons on the hospital unit to determine discharge plans. When the decision to admit to EMHC is made, central intake collects information on a patient & communicates with the relevant agency/sites. They maintain patient information on Cerner PowerChart & on a shared network drive for the home care nurse manager to access during their assessment at the start of care.|
|Start of Care||Nurse or therapist assesses the patient & develops a POC.
They admit the patient & call the physician from the patient's home.
Meds are verified from the discharge summary & the attending called when there are discrepancies. If there is a certain type of medication interaction alert EMHC requires a call to the physician.
The OASIS Start of Care & comprehensive assessment are completed.
|The nurses & therapists have laptops & document at the point-of-care in the patient's home.
The ACO is beginning a new pilot program where the pharmacist sends pharmacy students with the physical or speech therapist to assist with medication reconciliation when they are completing the start of care visit.
|Home Care Plan of Care
(Certification & Recertifications)
|The POC includes demographic, insurance, medications, diagnoses, physician orders & visit schedule, care plan goals, & specific assessments.
The Comprehensive Assessment & OASIS Start of Care data flows into the Home Care POC (485).
The POC is available for physician review & signature.
Recertifications are completed based on the required schedule based on an update of a subset of information the comprehensive assessment.
|EMHC has developed a physician portal to their McKesson EHR system. Physicians using the portal log in to access the health record documents & orders requiring their review & signature. The physician has the option to annotate, sign or reject.
In the portal the physicians can view:
The system also collects care plan oversight data & tracks how much time the physician has spent per patient reviewing their orders & POC. The physician can print out this report & give it to their billing staff (it is not electronic).
If the physician is not on the portal, EMHC prints out the POC & faxes it to the physician for signature.
|Home Health Visits||Home health staff (nurses, therapists, aids) document at the patient's home using laptops and/or telephony.
Aide documentation is completed via telephony.
Nurses complete their documentation on their laptop including their clinical notes & plan for the next visit. The clinical notes reflect the nursing care plan.
|Aides call in & an automated care plan is read to the aides who use buttons on their phone to identify if a task was complete or not. A telephony report is created for the record & the visit shows up as completed.
If there are incidents or concerns, staff complete documentation at the agency not from the patient's home.
|Order & Medication Changes||The physician is called for new order requests. The nurse/therapist enters the orders into the EHR. Physicians using the portal can sign in the EMHC EHR.
Assistants print out the orders for non-portal physicians. The orders are printed out & faxed to the physician.
|Orders not signed in the portal, but faxed & maintained in the paper-based medical record.|
|Lab, Radiology & Other Tests||Orders for labs are tracked & when required are drawn & brought to the lab.
Lab results are currently in paper format & maintained in the paper-based medical record.
Electronic lab results are available on HIN (the lab provider reports results directly to HIN).
|Discussed the use of document imaging, but there is not a plan to use scanning to include the lab results in the electronic record.|
|Telehealth||Patients upload data daily to telehealth nurse in Caribou Maine.
Data collected is based on patient condition & may include:
Responses to individualized questions, for example, shortness of breath, dietary compliance, endurance, etc.
|Information is accessed on the Phillips cloud-based application. An interface is currently under development to make telehealth data available in the McKesson EHR.|
|Multidisciplinary Care Plan||Currently EMHC has a care plan (separate from the POC (485)). Each discipline maintains a separate care plan based on the discipline & problem.
The hospice care plan is multidisciplinary.
|EMHC is starting a new multidisciplinary care plan based on the OMAHA system. The care plan will flow from the comprehensive assessment & OASIS to identify preliminary care plan problems, goals & interventions.|
|Discharge||A discharge POC is developed for the patient. A discharge order is obtained from the physician & a discharge summary completed if requested. EMHC may coordinate with community services as needed to assist with care transitions.|
|Hospice-Specific Functions||An interface has been created with Hospice Pharmacia. Demographic & medication information is exchanged with Hospice Pharmacia.||Hospice Pharmacia is a national company that provides hospice medications & pharmacy management. They cover the cost for some meds.|
"HIEengage.pdf" (pdf, 976.86Kb)
"HIEengageA.pdf" (pdf, 122.65Kb)
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