Transitional Care (Transfers)

Discussion of FSA instruments appropriate for exchanging information between health care settings (i.e. hospital to skilled care, home care or nursing home)

Use Case Posting:

Hospital Discharge to Nursing Home: A hospital discharges an elderly patient to the nursing home following treatment for a fractured hip. Which FSA instruments or measurements are appropriate/desireable for inclusion in a CCR/CCD data exchange?

Home Care Referral: A person is being referred for Home Care. The referrer can be a hospital, nursing home or physician's office. Signed physician's orders are required for admission to Home Care and can be sent as a CCD. Any functional status information collected by the referrer can be stored in a CCD that is sent to the Home Care Agency. This info can either be appended to the signed physician's orders or translated into the functional status section of the signed physician's orders (RN).

Home Care Discharge: A person is discharged from a Home Care Agency and is either going home, to a nursing home, to a hospital, etc. The home care agency may be required to collect periodic OASIS assessments if the payer is Medicare or may use OASIS or a similar instrument as an assessment tool. The functional status section of that assessment will be put into a CCD. This CCD may contain the patient's personal health record if the patient is discharged to home or a particular document required for the destination provider (for example the PRI for a nursing home admission). The functional status content of the home care assessment may be appended to the CCD or may feed the functional status section of the relevant admission form (PRI). (RN)

Nursing Home Transfer to Acute Care Setting: (hospital direct admit or emergency room)

Nursing Home Transfer to another Nursing Home, to Assisted Living, or to Home: