- Proposed Use Case Template
Use Case Name
Home Health to Acute Care
Use Case Category
Use Case Actors
Home Care Agency and Acute Care Provider
Use Case Scenario
The following scenario is based on a U.S. setting but can be generalized. Just substitute for OASIS the relevant assessment done on discharge from home care.
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.
Use Case Reference
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