PACIO Transitions of Care Implementation Guide, published by HL7 International / Patient Care. This guide is not an authorized publication; it is the continuous build for version 1.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/fhir-transitions-of-care-ig/ and changes regularly. See the Directory of published versions

Use Cases, Personas, and Scenarios

Outside of an Acute or Ambulatory care setting the deployment of services and products supporting patient care tend towards more centralization where one office may cover administrative responsibility for locations hundreds of miles apart. This means that when transitioning care between post-acute settings, an immense amount of record processing, qualification, and ultimately deploying services is completed by administrative staff often with no formal clinical qualifications. These actors are not part of any direct reimbursement, but much of the labor involved coordinating with the referring provider or entities providing parallel care are completed by this workforce.

In addition while Physicians are certainly involved in post-acute care, in most cases they are not part of the post-acute organization. This may mean a significant amount of coordination between the physician offices and post-acute intake and records teams at the point of transition with all parties using different technologies; as a result, this kind of communication is still majority fax and phone based.

Personas

Specific roles are involved in transtion of care between different settings. These roles are a critical part of ensuring data is transmitted and received, which enables staff to maintain continuity of care.

• Intake staff - Intake staff can consist of multiple different roles including case managers working out of hospital, as well as data entry clerks working from home. However, what groups them together is their singular but complex job of transitioning a patient into the care of their organization. Key responsibilities include financial and clinical qualification, data entry, and coordination with the patient and family.
• Care team - A majority of this group is comprised of various clinical disciplines required to deliver post-acute care, including but not limited to nurses, physical therapists, occupational therapists, and social workers. There are often a number of non-clinical roles on the care team that can include volunteers and religious figures. These team members are responsible for providing care in continuity with treatments and therapies prescribed by the referring organization; each discipline has different responsibilities, and therefore requires different clinical context at the point of transition and for initial patient interactions, particularly to expedite critical clinical patient care at transition.
• Medical records team - The medical reords team plays a role in processing a discharge and may facilitate transitions to the next setting of care. Key responsibilities include completing administrative tasks like quality measure submission, obtaining physicians signatures, and scheduling.

Scenarios

• Skilled Nursing to Home Health Agency - A patient has been in a skilled nursing facility (SNF) for the last week following a significant invasive surgery. Acuity has reduced to a point of transition to home. An MDS (Minimum Data Set) assessment is completed at the start of their stay, and at the end as the organization discharges. The care team and medical records team begin the transition to home by coordinating with the intake staff at the home health agency. This coordination is performed with a variety of tools, with fax and phone remaining the dominant method. Services needed (RN, PT, OT, etc.) are determined based on patient condition and with collaboration from the responsible physician. The patient transitions on the appointed date, ideally with key care products and services scheduled for the same day, e.g., the initial home health visit, and any needed home medical equipment. An OASIS (Outcome and Assessment Information Set) is completed by the RN or PT completing the initial visit, the OASIS is based on the same quality measure question sets as the MDS completed in SNF; the MDS assessment should inform the clinician completing the OASIS to ensure continuity of care.
• Rehab to Home Health Agency - A patient has suffered an acute event and has been in the hospital recovering. Based on ongoing assessment at the rehabilitation facility, their acuity has lowered to the point of transitioning to a post-acute setting, e.g., Home Health. The rehabilitation facility care team coordinates the transition with the Home Health intake team, including the transition of information through a variety of tools like portals, referral management platforms, but also still a high volume of phone and fax based care transitions. Services needed (RN, PT, OT, etc.) are determined based on patient condition with collaboration from the physician signing off on the discharge. Information captured by the rehabilitation facility is often dense, and both the intake and medical records teams pour over accompanying documentation to properly inform the care team. The initial visit is scheduled in accordance with the rehabilitation facility discharge and any home medical equipment delivery. An OASIS is completed by the RN or PT conducting the initial visit, and while the rehabilitation facility is capturing using IRF-PAI which helps the intake and records team inform their intake and treatment decisions and inform the clinicians completing the Home Health assessment forms.

High-Level Use Case Examples

Intake staff

• As a member of the intake team, I need a referral sent to my desired system electronically (EHR, CRM, etc.)
• As a member of the intake team, I need a consolidated record from the referring provider that reduces or eliminates the effort spent searching for clinical documentation to qualify the referral and ensure a smooth transition.
• As a member of the intake team, I need the ability to bring information into my health record including key information like Diagnosis, Allergies, Insurance, Lab results, and prior vital signs.

Care team

• As a member of the care team, I need to be able to drill down exclusively on the referral information that concerns my clinical discipline to inform my role based treatment.
• *As a member of the care team, I need clinical information captured by the previous provider in order to provide efficient and effective care.
• As a member of the care team, I need the ability to review and edit, within my own system the clinical information captured by the referring provider like medications, problem list, care plans, etc. to expedite the provision of patient care, reduce my documentation burden and reduce transcription errors which might lead to adverse events.
• As a member of the care team, I need the ability to review relevant quality measures captured by the referring provider to inform the completion of my organization's measures (OASIS, MDS)

Medical records team

• As a member of the medical records team, I need the ability to compare quality measures captured in the previous setting to quality measures captured by the care team (OASIS, MDS), as significant disparities may result in audits.