Descriptive Name

Personal Health Communication, Transfer of Care, Coordination of Care.

see Use Case Actors

Mrs. A was admitted from a local nursing home after falling and breaking her hip. Her surgery was uneventful although she is now suffering post-op delirium from the anesthesia and pain medicine. Physical therapy has started working with her. At this point, she is only able to take a few steps to the chair at her bedside. Mrs. A forgets that she is in the hospital and has suffered a broken hip. She tries to walk so the hospital staff has provided her with a sitter after seven in the evening. During the daytime she sits in a chair near the nursing station. While in the hospital, her blood sugars began running higher than previously so Mrs. A is now on insulin. Mrs. A now is ready to return to the nursing home for rehabilitation and will be covered under Medicare as she rehabilitates following her fractured hip.

To ensure accurate reimbursement under Medicare, the NH requests copies of the hospital record (or access to) including – medication records, therapy records, surgical and diagnostic reports completed while in the hospital.

On admission to the NH, the nursing staff reviews the transfer information and orders and contacts the attending physician to approve the continuation of orders. Because of the fractured hip, therapy is notified immediately of the admission and begins their assessment and treatment process. The other team members also begin their process of assessing and documenting a treatment plan, coordinated by the MDS coordinator.