Development of a Continuity of Care Document with Functional Status and Wellness Content

 

 

I. Introduction

 

II. Background

The Center for Aging Services Technologies (CAST), a program of the American Association of Homes and Services for the Aging (AAHSA), is leading the national charge to develop and deploy emerging technologies that can improve the aging experience in America. Established in 2003, CAST has become a national coalition of more than 400 technology companies, aging services organizations, research universities, and government representatives.

 

The American Health Information Management Association (AHIMA) is the premier association of health information management (HIM) professionals in the United States. AHIMA's 51,000 members are dedicated to the effective management of personal health information needed to deliver quality healthcare to the public. AHIMA is committed to advancing the HIM profession in an increasingly electronic and global environment through leadership in advocacy, education, certification, and lifelong learning.

 

CAST has worked for two years to scope out a set of work that would materially advance the ability for aging services organizations to leverage standards based health information exchange. It is our contention that aging services organizations must leverage existing and emerging standards to support sharing of electronic personal health and wellness information across aging services care settings both within and across organizations and, most importantly, with consumer’s own personal health records. We believe that an HL7 approved CCD for aging services with support for functional status and wellness content will be an important foundation for realizing health and wellness information sharing. Our goal is to initiate work that will result in an HL7 approved implementation guide, progress standards related to functional status and wellness content, and complete formal interoperability demonstrations of vendor, provider and consumer uses.

 

III. Defining Functional Status and Wellness

Functional Status describes the patient’s status of normal functioning at the time the Care Record was created. Functional statuses include information regarding the patient relative to:

• Ambulatory ability

• Mental status or competency

• Activities of Daily Living (ADLs), including bathing, dressing, feeding, grooming

• Home / living situation having an effect on the health status of the patient

• Ability to care for self

• Social activity, including issues with social cognition, participation with friends and acquaintances other than family members

• Occupation activity, including activities partly or directly related to working, housework or volunteering, family and home responsibilities or activities related to home and family

• Communication ability, including issues with speech, writing or cognition required for communication

• Perception, including sight, hearing, taste, skin sensation, kinesthetic sense, proprioception, or balance

 

Any deviation from normal function that the patient exhibits and is observed and recorded in the record should be included. Of particular interest are those limitations that would in any way interfere with self care or the medical therapeutic process. In addition, an improvement, any change in or noting that the patient has normal functioning status is also valid for inclusion.<>.

 

The working group identified 47 Assessments that measure some or all elements of functional status (see Appendix A). In order to privilege, or identify the five most critical assessments, the working group developed criteria to apply to the identified assessments. The term "privilege" was used by the work group to assign priority to those instruments identified as candidates for interoperability demonstrations.

 

Assessment Privilege Criteria

 

• Prevalence of Use

o Required vs. Recommended

o International vs. Local

• Use Case Fit and Priorities

o Use case prioritization such as transfer of care

o Gap Analysis

o Criticality/use of content for service planning

o Mitigates Risk, Promotes Safety

• Evidence Based

• Applicability across settings

• Variety to meeting meet diverse needs for health care

 

The Five Privileged Assessments

 

After a process of evaluation of the assessment catalog, the working group then privileged five of those assessments. The working group accomplished this through several discussions and a series of multi-voting. The Five Privileged Assessments identified were:

 

Long Term Care Minimum Data Set (MDS)

 

The MDS assessment provides a core set of screening, clinical and functional status elements for residents residing in long-term care facilities certified to participate in the Medicare or Medicaid programs. The items in the MDS standardize communication about resident problems and conditions within facilities, between facilities, and between facilities and outside agencies. The MDS is one of three components of the Resident Assessment Instrument (RAI) developed to be an interdisciplinary standardized assessment tool . The MDS is used to identify resident strengths and weaknesses, develop and revise goals, and to develop an individualized plan of care for the resident . The ultimate objective of this data collection is to assist the resident in achieving or maintaining the highest practicable level of well being. The original impetus for requirements for the MDS was the Omnibus Budget Reconciliation Act of 1987 (OBRA 1987). This legislation called for the creation of a comprehensive assessment tool to provide the foundation for planning and delivering care to nursing home residents. The MDS was developed in 1995 under CMS contract with the Hebrew Rehabilitation Center for Aged (HRCA). The Centers for Medicare & Medicaid Services (CMS) maintains, updates and provides guidance on the use of this tool. Found at http://www.cms.gov.

 

Outcome and Assessment Information Set (OASIS)

 

The OASIS was created by the Center for Health Services Research at the University of Colorado under contract to the Centers for Medicare and Medicaid Services (CMS). Functional status is a subset of the assessment. The OASIS is not meant to serve as a comprehensive assessment instrument but rather as a tool to measure patient outcomes. OASIS is a subset of the full home care assessment that Home Health Agencies must complete. Home Health Agencies must do a comprehensive assessment including  the OASIS to obtain Medicare coverage of the service for benificiaries.

 

Geriatric Depression Scale (GDS)

 

The GDS measures the presence and severity of depression. This includes institutionalized, community-based, cognitively intact and mildly impaired elders. It requires 5-7 minutes to administer a series of 15 or 30 questions with all answers in a yes/no format. It was developed by T. L Brink and Jerome Yesavage, M.D. at Stanford Univeristy, but is in the public domain.

 

interRAI Home Care

 

The interRAI HC is primarily an assessment that guides care and service planning. When used on multiple occasions, it provides the basis for an outcome-based assessment of the person’s response to care or services. The interRAI HC has been designed to be compatible with the suite of interRAI assessment and problem identification tools. Such compatibility advances continuity of care through a “seamless” assessment system across multiple health care settings, and promotes a person-centered evaluation rather than fragmented site-specific assessments. The home care instrument has been adopted nationally in 2 countries and mandated regionally in 12 countries.

 

Functional Independence Measure (FIM)

 

The FIM is an 18-item, seven level ordinal scale. It is the product of an effort to resolve the long standing problem of lack of uniform measurement and data on disability and rehabilitation outcomes. The FIM emerged from a thorough developmental process overseen by a National Task Force of rehabilitation research. The National Task force reviewed 36 published and unpublished functional assessment scales before agreeing on an instrument. Subsequent evaluation of the metric properties of the FIM have been reported extensively. confirming its evidence based status from a research base.

 

IV. A Reference Set of Use Cases

Continuity of care information is used in many different kinds of circumstances. As care in general has become more complex and specialized, so has the process of ensuring proper communication of care issues. Use cases where it is critical that personal health information(PHI) is shared in appropriate circumstances is as follows:]

 

• Personal Health Communication: Care record summaries should be provided to and from individuals and or their caregivers or agents (such as a Personal Health Record vendor or health record bank).

• Transfer of Care: PHI must always be shared in transitions between care providers and care settings.

• Coordination of Care: As the number of chronic and acute conditions increase in the elderly individual, the complexity of the care and the number of care providers also increases. PHI needs to be effectively coordinated among all caregivers and agents.

• Health Management: Relatively new areas of care management are developing as the population ages. As Chronic Care management and longitudinal care coordination are increasingly employed by managed care organizations, continuity of care information becomes critical to their processes.

• Interdisciplinary Care: Much like coordination of care, sharing of information across interdisciplinary care teams within a care network or provider must be effectively coordinated.

• Orders: In the context of requesting tests, evaluations and other orders, provision of health record summaries is important as the request for some health service does not assume the transfer or shared oversight of care.

• Administrative Uses: Continuity of care information also needs to be available for uses such as billing and pre-certification for services.

 

Use Case Actors

Use case actors are defined as persons, informal caregivers, care practitioners, care providers, payers and researchers.

• Persons are consumers, clients, patients, receivers of care, and their families and agents.

• Informal caregivers are family and other personal caregivers.

• Care Practitioners include licensed allied health professionals  and other caregivers typically affiliated with care providers. Included in this group are physicians, registered nurses, nurse practitioners, nursing assistants, social works, psychologists and other health care workers.

• Care Providers include skilled nursing facilities, home health agencies, hospice, post acute and other systems and organizations that provide care services.

• Payers include the government, insurance, and other entities that directly or indirectly pay for care.

 

Use Cases

The Continuity of Care Workgroup identified and developed many use cases for different scenarios of information exchange. The entire catalog may be found in Appendix B.

 

A. MDS Use Cases

 

1. Nursing Home to Hospital

Mr. F has been a resident at XYZ Nursing Home for the past six years. Prior to this he lived independently at home. He was initially admitted to the NH following a fall at home where he suffered a fractured hip. Following this fall and surgical repair at the local hospital he was admitted to the NH for continuing rehabilitation. During the course of his rehabilitation, Mr. F and his family decided it would be best that he remain at the NH for long term care. In addition to the history of the fractured hip, he has Diabetes, CHF, Atrial Fibrillation and Hypothyroidism.

Mr. F is transferred to the hospital for evaluation of a GI Bleed. One week prior to transfer he was noted to have a 5 lb weight loss and low iron levels. His attending physician ordered a colonoscopy as there was no prior history of his having had one. During this week prior to transfer, and while awaiting scheduling of the colonoscopy, resident was alert and oriented x 3, required stand by assist for transfers, and was independent with eating and bed mobility. Though he did not complain of pain per se, he did complain of “aching all over”. The day of transfer he was noted to have a black, tarry stool, with some bleeding. The Attending Physician ordered ortho blood pressure checks and transfer to the hospital emergency room for evaluation.

Upon transfer the NH provided a Continuity of Care Document (CCD) to the hospital reflecting the resident’s condition, including –

1. reason for transfer – probable GI bleed, black tarry stool, low Hgb, weight loss

2. current and usual vital signs

3. listing of current medications and treatments

4. recent diagnostic results

5. demographics, insurance information and advance directives

As part of the CCD, the MDS was updated to reflect -

6. restorative nursing needs

7. continence status (bowel and bladder)

8. current mental status, sensory impairments and physical disabilities – alert and oriented x3

9. ambulatory and weight bearing status and safety concerns – standby assist for transfers

10. communication level and types of appliances the resident uses.

11. ADL status – independent with eating, bed mobility and dressing, assist with bathing

Upon admission to the hospital and with the CCD, the ER staff was able to review recent and prior labs, medications and vital signs significantly reducing time taken to diagnosis Mr. F and eliminating the potential of duplicating diagnostics recently completed. The nursing staff on the unit where Mr. F was transferred from the ER was able to review the CCD and particularly the MDS section and knew his status in terms of ADL abilities and cognition. Staff was able to provide assistance where needed without being overly intrusive.

During the course of Mr. F’s three day hospitalization GI bleed was confirmed and treatment initiated. Mr. F returned to the Nursing Home along with an updated CCD reflecting the care and treatment he received at the hospital.

2. Nursing Home to Nursing Home

 

Mrs. L was admitted to her first nursing home stay following an acute episode of CHF for short term rehabilitation. In addition to the acute exacerbation of her CHF, she has hypertension, chronic constipation, Vitamin B12 deficiency. She also admitted to some recent periods of confusion and daily forgetfulness, not being able to recall where she was going or what she had intended to get. On several occasions she had also found the range still on in the morning when she awoke, after having fixed dinner the previous evening. While at the nursing home, Mrs. L received physical and occupational therapy once each day to increase her strength and endurance. Early on in her stay the social worker visited Mrs. L to complete the Geriatric Depression Scale (GDS), a standard assessment for new admissions to the facility. The GDS scored at a 9 indicating strong signs of depression.

Mrs. L was making steady progress with her therapy though she was by no means at a level to return to independent living. She still required transfer assistance and assistance with other ADLs such as bathing, toileting and dressing. During her four weeks at the nursing home her daughter was commuting 160 miles r/t twice a week to be with her mother and monitor her rehabilitation. While Mrs. L’s strength was increasing, her daughter was no longer feeling comfortable with her mother living alone due to her increasing confusion. With her daughter so far away and with young children at home who needed her care and attention as well, it was determined it would be better for mom to be closer to her daughter and a transfer was arranged to another nursing home closer to the daughter’s home.

Prior to transfer to the new nursing home Mrs. L’s MDS was updated to reflect her current level of care. She is now able to ambulate 125’ with stand by assist and a rolling walker, she is able to transfer herself from her wheelchair to bed with sit to stand assistance, she requires moderate assistance with bathing – getting into and out of the shower, supervision with toileting, moderate assistance with dressing and feeds herself with supervision/cueing.

Attending physician orders on transfer included an order to continue physical and occupational therapy at the new facility. A Continuity of Care Document (CCD) which included an updated MDS reflecting current ADL status, cognitive, mood and communication status, medication list, therapy notes, recent chest x-ray and labs was electronically forwarded to the new facility to ensure a successful transition of care for Mrs. L.

Upon admission to the new nursing home and with the information obtained from the CCD, the nursing staff and new physician were immediately able to put into place medical and restorative orders for continuing care. Physical and occupational therapy was begun the same day as admission with a plan to continue treatment as outlined by the prior facility. The nursing staff, including licensed nurses, nursing assistants and restorative staff were immediately aware of the assistance Mrs. L required with ambulation, bathing, toileting and dressing and a care plan was begun the day of admission to reflect these needs and the appropriate cues were posted on the bedside care plan. The Social Worker completed a new GDS assessment which reflected less signs of depression, scoring a 7 on this assessment. Mrs. L actually expressed relief at being closer to her daughter and not having to worry about daily chores such as grocery shopping and cooking on her own. She was also looking forward to visiting with her grandchildren more often and the Activity staff assisted her with putting together a collage of family pictures and showed her where games were kept that she might play during her grandchildren’s visits.

With the current and complete history available from the CCD, treatment was able to commence immediately upon admission, care plans were immediately put in place and the MDS staff had a complete history with which to begin their admission assessment. The daughter expressed gratitude to the staff at both facilities for such an easy transition of care.

3. Nursing Home to Personal Health Record (PHR)

 

 

B. OASIS

 

1. Home Care to Hospital

Data exchange: Functional status information was collected on the start of care assessment and will have also been collected on a follow up assessment if one was done. Depending on whether the hospitalization was planned and the patient was discharged from the home care agency before going to the hospital then a discharge assessment was done and will also contain functional status information. The home care agency takes the most recent functional status information and encodes that into a CCD that is electronically sent to the hospital. This functional status content is then integrated into the hospital clinical information system and is available for clinicians to view.

The functional status information available via the CCD is:

sensory status

integumentary status

respiratory status

elimination status

neuro/emotional status

ADL/IADL

patient management of medications and equipment

Clinical example: A patient receiving home care services is hospitalized:

Patient A is suffering from chronic pain (daily intractable pain as coded on the OASIS). When admitted to the hospital this information is passed from the home care agency to the hospital's information system. This informs the hospital staff that this pain is not new and helps them in their pain management for this patient. They can see what previous medications and treatments have already been tried and work from there.

2. Home Care to Personal Health Record (PHR)

No Use Case Developed

 

3. Home Care to Primary Care Provider

A patient has a primary physician and is currently receiving home care services. OASIS assessments are completed by home care agency clinical staff at start of care, every 60 days (follow-up) and on termination of home care services. These assessments contain the following functional status information:

sensory status

integumentary status

respiratory status

elimination status

neuro/emotional status

ADL/IADL

patient management of medications and equipment

The home care agency encodes the functional status information (along with other information on the patient) into a CCD. This CCD is sent electronically to the physician's office and processed by the clinical management system used at the physician's office. The functional status information is available to be viewed by the physician.

Based on responses to the OASIS item for Depressive Feelings (M0590), the home care RN suspects the patient is depressed. He uses the Geriatric Depression Scale (GDS) to obtain more information on the patient's depressive feelings and determines that the patient is moderately depressed. The physician did not mention that the patient was depressed when making the initial referral, or on subsequent phone calls with home health agency staff. The agency RN contacts the physician by telephone to discuss the findings from the GDS. The physician requests a copy of the GDS, which is sent electronically. The physician is able to use the GDS findings to determine possible treatment options for the patient.

Another use case could be a patient that is starting to become cognitively impaired (this would be recorded in thje latest OASIS). This information can be sent to the physician's office system and inform the physician that when giving treatment instructions to the patient that these instructions be written and that possibly a caregiver should be present.

 

 

4. Home Care to Nursing Home

CASE #1

The following scenario is based on a U.S. setting but can be generalized. Just substitute for OASIS and MDS the relevant assessments done on discharge from home care and admission to nursing home.

A person receives home care services for a specified time. The discharge plan completed by the home care agency for this person specifies that when home care services are completed that she will be discharged from home care and admitted to a nursing home. On discharge from home care, the home care agency completes an OASIS discharge assessment. This assessment contains the following functional status information:

sensory status

integumentary status

respiratory status

elimination status

neuro/emotional status

ADL/IADL

patient management of medications and equipment

The home care agency encodes the functional status information (along with other information on the patient) into a CCD. This CCD is sent to the nursing home. The nursing home uses the functional status content of CCD to initially populate the MDS functional assessment sections. This data is available to be viewed by staff at the nursing home.

Use Case - fall prevention: On discharge from home care it is recorded on the OASIS discharge assessment that a patient needs a cane or walker to ambulate. On admission to the nursing home the staff know (from CCD passed to them from the home care agency) that a cane or walker must be available for this patient and that they can take any additional fall prevention measures.

CASE #2

Home Care to Nursing Home

Mrs. H is an 85 year woman whose 88 yr old husband has just died. Her daughter is temporarily living with her and has called the case manager for an urgent assessment review.. Mrs H and her husband were receiving home making and home health aide services from the agency and were monitored by the case worker over several years. Mrs. H has moderate cognitive impairment. She has showed a gradual decline in cognitive status and communication over several years. There has been no acute change. Her vision has deteriorated and she has been bumping into objects which may have contributed to her 2 falls in the past month. During the interview, Mrs H appears anxious, keeps repeating concerns about the next meal and checking that her daughter not leave her. The case manager notes the presence of these indicators of depression and includes a note to the nursing home to continue to assess for depression based on the recent life stressing loss of her husband and the new onset of mood indicators. The high fall risk will also be signaled to the nursing home with a potential suggestion for evaluating the underlying reasons for the fall risk including vision or physical changes. In addition, the nursing home will receive a detailed listing of her performance in each ADl task and the type of assistance needed eg set up help, supervision and cuing or physical assistance. Mrs. H has recently decreased her activity level. Her husband used to walk around the block with her regularly. She enjoyed walking with him and it seemed to calm her. She is independent on stairs but is easily disoriented and prone to wandering if left alone.

C. Functional Independence Measure

1. PT/OT to Nursing Home: No Use Case Developed

2. PT/OT to Home Health: No Use Case Developed

D. Geriatric Depression Scale (GDS)

1. CCRC Transfer of Care Setting: No Use Case Developed

2. Home Health to Family Physician

A patient has a primary physician and is currently receiving home care services. OASIS assessments are completed by home care agency clinical staff at start of care, every 60 days (follow-up) and on termination of home care services. These assessments contain the following functional status information:

sensory status

integumentary status

respiratory status

elimination status

neuro/emotional status

ADL/IADL

patient management of medications and equipment

The home care agency encodes the functional status information (along with other information on the patient) into a CCD. This CCD is sent electronically to the physician's office and processed by the clinical management system used at the physician's office. The functional status information is available to be viewed by the physician.

Based on responses to the OASIS item for Depressive Feelings (M0590), the home care RN suspects the patient is depressed. He uses the Geriatric Depression Scale (GDS) to obtain more information on the patient's depressive feelings and determines that the patient is moderately depressed. The physician did not mention that the patient was depressed when making the initial referral, or on subsequent phone calls with home health agency staff. The agency RN contacts the physician by telephone to discuss the findings from the GDS. The physician requests a copy of the GDS, which is sent electronically. The physician is able to use the GDS findings to determine possible treatment options for the patient.

Another use case could be a patient that is starting to become cognitively impaired (this would be recorded in thje latest OASIS). This information can be sent to the physician's office system and inform the physician that when giving treatment instructions to the patient that these instructions be written and that possibly a caregiver should be present.

3. Coordination of Care for Cancer diagnosis: No Use Case Developed

V. Standardizing the Assessments (Gap Analysis by Assessment)

A. Gap analysis for OASIS-B1 functional status information and the HL7 Continuity of Care document (CCD)

 

The functional status information from the OASIS B1 is: (M0220, M0250 - M0825)

 

Sensory status

integumentary status

respiratory status

elimination status

neuro/emotional status

ADL/IADL

patient management of medications and equipment

 

 

The overall process: The standardization process proposed by Tom White et al. 1 is the framework for this discussion. The encoding steps for sending an OASIS assessment would be:

 

Step 1: Encode to a standard coding system: Encode all OASIS-B1 items into LOINC (LOINCification)

 

Step 2: Concept Matching to a standard medical terminology: Where possible match LOINC codes of the OASIS items with one or more equivalent terms from a standard medical terminology. The suggested medical terminology is SNOMED. Use semantic matching to do the matching. Initially this is done using a panel of experts on OASIS and SNOMED.

 

Step 3: Insert the LOINC codes of the OASIS (and their SNOMED equivalents) into the functional status section of the CCD

 

Step 4 (Messaging): The CCD is an HL7 document (CDA) that is sent as a sequence of HL7 messages.

 

 

 

 

 

Work done on OASIS:

 

Step 1 (LOINCification): The goal here to capture the entire content of the assessment. To do this, as with other assessment instruments, OASIS requires that certain information be stored with the responses.

 

• the entire assessment be encoded

• each question, its text, special instructions, and order within the assessment

• each response, its text, special instructions, and order within the question

• Versions: the ability to encode versions of any of the above.

 

LOINC has already done this for MDS by adding supplementary axes to LOINC:2

The supplementary axes are:

1. SurveyQuestionText

2. AnswerList

3. Formula

4. SurveyQuestionSource

5. Comments

Work has been done encoding OAISIS items into LOINC.3

 

Step 2: (Semantic Matching)

 

Does SNOMED have all the terms to cover the concepts covered by OASIS?

 

Work has been to done to map OASIS to the medical vocabulary (MED) used at Columbia.3

 

 

Step 3: Insert the LOINC codes of the OASIS (and their SNOMED equivalents) into the functional status section of the CCD

 

The information will be placed into the Functional Status section of the ASTM/HL7 CCD.

 

Is the syntax for the functional status section complete so that multiple semantic equivalents of a LOINC coded assessment response can be represented?

 

 

Step 4 (Messaging): The CCD is an HL7 document (CDA) that is sent as a sequence of HL7 messages.

 

Is the work done for representing LOINC encoded MDS2 into an HL7 document (The CCD) sufficient for LOINC encoded OASIS?

 

 

 

 

1 White, T, Harvell J, et al. Modifying the HL7 Continuity of Care document (CCD) to Improve eporting of Results form Functional Status Instruments.

2 Carter J, White T., Harvell J, Making the "Minimum Data Set" Compliant with Health Information Technology Standards.

3 Choi J., et al. Towards Semantic Interoperability in Home Health Care: Formally representing OASIS items for integration into a Concept-oriented Terminology.

 

Appendix A

Catalog of Assessments

 

Aggressive Behaviour Scale

The ABS was developed by interRAI (a not-for-profit international research group with substantial experience in creating comprehensive assessment instruments for nursing homes, home care, acute care, assisted living, palliative care, and rehabilitation settings) to detect frailty and instability in health in a nursing home population. Because the items comprising the ABS are present across many interRAI instruments, the ABS may be used in many sectors, for assessment of individuals with a broad range of mental and physical health needs.

 

AmPac

Developed by Drs. Alan Jette and Steve Haley at Boston University’s Health & Disability Research (HDR) Institute, the AM-PAC™ is a state-of-the-art computerized instrument that measures function in three domains: physical and mobility, personal care and instrumental and applied cognitive. The AM-PAC™ can be used for quality improvement, outcomes monitoring, and research activities in inpatient and outpatient rehabilitation, home care, nursing homes and long-term acute care. This innovative approach to measuring rehabilitation outcomes overcomes the limitations of other measurement systems.

 

Berg Balance Scale (BBS)

The BBS is a staff-completed assessment scale of ability to maintain balance and comprises 14 observable tasks common to everyday life.

 

CamAssessment

 

The Center for Epidemiological Studies-Depression Scale (CES-D)

The CES-D, developed by Lenore S. RAdloff, is a 20-item instrument that was developed by the National Institute of Mental Health to detect major or clinical depression in adolescents and adults. The CES-D has 4 separate factors: Depressive affect, Somatic symptoms, Positive affect, Interpersonal relations. The CES-D takes approximately 10 minutes to administer during a client interview or via self-report and is effectively used in a variety of mental health areas including primary care, psychiatric, and related clinical and forensic settings.

 

Changes in Health, End-stage disease, and Signs and Symptoms (CHESS)

The CHESS was developed by interRAI to detect frailty and instability in health in persons residing in residential or complex continuing care settings. It has since been adapted for use in home care and inpatient psychiatry settings. The CHESS attempts to identify individuals at risk of serious decline and can serve as an outcome where the objective is to minimize problems related to frailty (e.g., declines in function) in the elderly population. Higher CHESS scores are predictive of adverse outcomes like mortality and hospitalization.

Cohen-Mansfield Agitation Inventory (CMAI)

Developed by Jiska Cohen-Mansfield Ph.D, the CMAI is a 29-item caregiver rating questionnaire for the assessment of agitation in elderly persons. It includes descriptions of 29 agitated behaviors, each rated on a 7-point scale of frequency. Inter-rater agreement rates ranged between .88 and .92

 

Depression Rating Scale (DRS)

DsmAssessment DSM-I assessment: Long Term and Managed Care Program

ElderlyLifeSatisfaction Elderly life satisfaction index A and B

EpeseBattery (EPESE) Battery Established Populations for the Epidemiologic Studies of the Elderly

Functional Independence Measure (FIM)

The FIM is an 18-item, seven level ordinal scale. It is the product of an effort to resolve the long standing problem of lack of uniform measurement and data on disability and rehabilitation outcomes. The FIM emerged from a thorough developmental process overseen by a National Task Force of rehabilitation research. The National Task force reviewed 36 published and unpublished functional assessment scales before agreeing on an instrument. Subsequent evaluation of the metric properties of the FIM have been reported extensively.

FrailtyAssessment Frailty Assessment

FunctionalStatusQuestionnaire Functional Status Questionnaire

GaitSpeed Gait Speed

Geriatric Depression Scale (GDS)

The GDS measures the presence and severity of depression in institutionalized, community-based, cognitively intact and mildly impaired elders. It requires 5-7 minutes to administer with all answers in a yes/no format. It was developed by T. L Brink and Jerome Yesavage, M.D., but is in the public domain.

www.stanford.edu/~yesavage/GDS.english.long.html

GoldbergAnxietyScale Goldberg’s anxiety scale

HearingScreen Hearing Screen

KatzAdl Katz: Index of independence of activities in daily living

InterRai interRAI Assessment Instruments: www.interrai.org

The interRAI Post Acute Care

The interRAI for Mental Health

InterRAI Acute Care

interRAI Home Care

The interRAI HC is primarily an assessment that guides care and service planning. When used on multiple occasions, it provides the basis for an outcome-based assessment of the person’s response to care or services. The interRAI HC has been designed to be compatible with the suite of interRAI assessment and problem identification tools. Such compatibility advances continuity of care through a “seamless” assessment system across multiple health care settings, and promotes a person-centered evaluation rather than fragmented site-specific assessments. The home care instrument has been adopted nationally in 2 countries and mandated regionally in 12 countries.

The interRAI Community Health Assessment

IrfPai IRF-PAI: Rehab Assessment

LawtonMoraleScale Lawton's Morale Scale www.abramsoncenter.org/PRI/documents/PGC_morale_scale.pdf

MajorIcdDepressionInventory Major (ICD-10) Depression Inventory

Long Term Care Minimum Data Set (MDS)

The MDS assessment provides a core set of screening, clinical and functional status elements for residents residing in long-term care facilities certified to participate in the Medicare or Medicaid programs. The items in the MDS standardize communication about resident problems and conditions within facilities, between facilities, and between facilities and outside agencies. The MDS is one of three components of the Resident Assessment Instrument (RAI) developed to be an interdisciplinary standardized assessment tool used to identify resident strengths and weaknesses, develop and revise goals, and to develop an individualized plan of care for the resident with the ultimate objective being to assist the resident in achieving or maintaining her or her highest practicable level well being. The original impetus for the MDS was the Omnibus Budget Reconciliation Act of 1987 (OBRA 1987) which called for the development of a comprehensive assessment tool to provide the foundation for planning and delivering care to nursing home residents. The MDS was developed in 1995 under CMS contract with the Hebrew Rehabilitation Center for Aged (HRCA). The Centers for Medicare & Medicaid Services (CMS) maintains, updates and provides guidance on the use of this tool. Found at http://www.cms.gov.

 

 

MedicareHealthOutcomesSurvey Medicare Health Outcomes Survey (HOS) www.cms.hhs.gov/HOS

MoodDisorderQuestionnaire Mood Disorder Questionnaire (MDQ) http://www.toolsforthefight.com/tfp_index.jsp

NursingHomeBehavior The Nursing Home Behavior problem scale

OasisHomeHealth OASIS-B1 (12/2002) www.cms.hhs.gov/oasis

 

Outcome and Assessment Information Set (OASIS)

The OASIS was created by the Center for Health Services Research at the University of Colorado under contract to the Centers for Medicare and Medicaid Services (CMS). Functional status is a subset of the assessment. The OASIS is not meant as a comprehensive assessment instrument but as a tool to measure patient outcomes. OASIS is a subset of the full home care assessment that Home Health Agencies must complete. Under Medicare rules Home Health Agencies must do a comprehensive assessment which must include the OASIS.

 

Pain Subscale

PrimeMdPhq PRIME-MD PHQ for evaluation of mental disorders www.depression-primarycare.org/clinicians/toolkits/materials/forms/phq9

RockwoodAssessment Rockwood Assessment

SaamAssessment SAAM: Semi-Annual Assessment of Members - used for managed long term care. Adapted from OASIS

SclAssessment SCL-90 www.pearsonassessments.com/tests/scl90r.htm

Sf36SelfReportedHealthStatus SF-36 (self-reported health status) www.sf-36.org

SixMinuteWalkTest 6 Minute Walk Test (6MWT)

TimedUpAndGo Timed up and Go

TimedWalkTests Timed Walk Tests

TinettiBalanceAssessment Tinetti Balance Assessment Tool, Journal of American Geriatric Soc., anodynetherapy.com/PDF%20Files/Tinetti.pdf

TinettisPoma Tinetti's Performance Oriented Mobility Assessment (POMA)

VaGec VA GEC: VA Geriatrics and Extended Care: screening dataset for long term care placements (home care, nursing home, assisted living, etc.)

VisualAcuity Visual Acuity

VulnerableEldersSurvey Vulnerable Elders Survey (VES-13) www.rand.org/health/projects/acove/docs/acove_ves13.pdf

 

Appendix B

Use Cases

 

a. Personal Health Communication

i. Acute Care Summary of Care to Personal Health Record

ii. Family provides Health Summary to Adult Day Care Center

iii. Personal Health Advocacy and Management(completed by R. Scichilone)

iv. Lifespanning Health Records Kept by Individuals (Completed)

v. Nursing Home to Personal Health Record

vi. PT or OT to Personal Health Record

vii. CCRC to Personal Health Record for Personal Wellness

b. Transfer of Care

i. Nursing Home to Home Health(completed by K. Steele)

ii. Home Health to Acute Care(completed by C. Lundberg)

iii. Nursing Home to Emergency Room(completed by M. White)

iv. Hospital to Nursing Home(completed by M. White)

v. Hospital to Home Health(completed by K. Steele)

vi. Assisted Living to Nursing Home(completed by K. Steele)

vii. Nursing Home to Assisted Living(completed by J. Stutesman)

viii. PAC LTC to Hospital

ix. Nursing Home to Nursing Home(initiated by J. Stutesman)

x. Nursing Home to Hospital(initiated by J. Stutesman)

xi. Home Care to Home Care

xii. Home Care to Nursing Home

xiii. Home Care to Assisted Living

c. Coordination of Care

i. Attending Physician in a Nursing Home Setting(completed by J. Stutesman)

ii. Nursing Home Resident Regularly Visits Dialysis(Completed by M. White)

iii. Home Care Communication with Family Physician

iv. Home Health Care delivered to an Assisted Living Resident

v. Coordination of Care - Cancer

vi. Home Care to Acute Care

d. Health Management

i. Acute Care informs Family Physician(Completed by A. Richard)

ii. Chronic Care Management Over Time

e. Interdisciplinary Care

i. Physical Therapist Charts to Nursing Home or Home Health Health Record(completed by J. Stutesman)

ii. Interdisciplinary Care: Cancer Treatment Center(completed by R. Scichilone)

iii. PT or OT to Nursing Home

iv. PT or OT to Home Health

v. Rehab to Home Health

f. Orders/Consultations

i. Physician Requests Nutrition Consultation(completed by Knight Steele)

g. Administrative Uses

i. Managed Care Pre-Certification Request

ii. Part D Pre-Certification

iii. Billing Attachments

iv. Nursing Home Data Reporting

v. Home Care Data Reporting

h. System Uses

i. Research Uses

i. De-identified Health Record Summary provided to Researcher(Completed by A. Richard)

ii. Nursing Home to research

iii. Home Care to research

 

Appendix C: Members of Work Group

 

Rachael Bennett, University of Colorado at Denver and Health Sciences Center

Katherine Berg, Department of Physical Therapy, University of Toronto

Magnus Björkgren, Chydenius Institute, Finland

Sue Bravard, Des Moines University

Michelle Dougherty, American Health Information Management Association

Matthew Greene, Department of Veteran’s Affairs, Office of Information, Health Data Repository Project

George Margelis, Intel Australia Digital Health Group

Rocco Napoli, Visiting Nurse Service of New York

Sue Nonemaker, InterRai

Angela Richard, University of Colorado at Denver and Health Sciences Center

Roger Smith, Resource Systems

Ramesh Srinivasan, MedicAlert Foundation

Knight Steel, The Homecare Institute, Hackensack University Medical Center

Joanne Stutsman, Evangelical Homes of Michigan

Margaret White, Columbus Colony Elderly Care, Columbus, Ohio

Daniel Wilt, Erickson Retirement Communities, Baltimore, Maryland.

 

CAST

Peter Kress

Suzanne Maddox

 

AHIMA

Rita Scichilone

Jill Burrington-Brown