Integrating the Healthcare Enterprise™ (IHE) Patient Care Coordination Functional Status Assessments

Use Case # 1 LTC to Acute Care

Use Case #1 Workflow Diagram Nurse assesses resident PCP reviews patient status Transfer Patient? Yes Patient transferred to acute care hosp Hosp admit nurse reviews transmitted EHR data Pt acuity & staffing levels rvw Unit RN assesses patient on admission to unit Patient regains strength, progressing well Attending reviews patient status Discharge Patient to LTC? Yes Key: Process Decision End of Process Patient transferred to long-term care facility Unit placement PCP & Attending collaboration Discharge planning prepares patient for discharge Collaboration Care providers address pt’s medical issues & POC leading to discharge Nurse initiates phone collaboration withPCP 10

Use Case #1 Dataflow Diagram LTC assesses patient; enters data in EHR for functional assessment, braden scale and glucose level. LTC nurse discusses findings from functional assessment and labs with patient’s PCP Hosp admit nurse compares current functional assessment to LTC EHR data and initiates POC Document Exchange Server Unit RN updates daily assessments in the EHR and plan of care Attending reviews progress notes, functional assess- ments; writes orders PCP reviews patient data via EHR; assessment & labs Unit RN updates daily assessments in the EHR and Plan of care Document Exchange Server , 5, 6 89 Patient transferred to LTC facility Discharge planner and nurse collaborate, review functional assessment 10 Key: Nurse EHR Physician EHR End of Process Ancillary EHR

Use Case # 2 Assisted Living to ED to Acute Care to Rehab

Use Case #2 Workflow Diagram Assisted living resident falls and Injures himself Nurse assesses patient Transfer Patient? Yes Patient evaluated in emergency department by RN Patient begins physical therapy 1 day post-op Patient to radiology for x-ray ED doctor reviews patient data Patient admitted to orthopedic floor Unit RN assesses patient on admit to unit; POC initiated Surgical consult Surgery needed? Patient transferred by ambulance to acute care facility Patient evaluated in emergency department by doc Admit Patient? Yes Patient has surgery Rehab doctor recommends transfer to assisted living Transfer patient? Patient transferred by ambulance to rehab facility Rehab admit nurse reviews transmitted EHR data Patient regains strength; requires minimal assistance Surgeon recommends transfer to rehab Discharge Patient? Yes Patient transferred To assisted living facility PCP & Nurse collaborate on patient injury Attending, nurse, surgeon, patient, family collaborate Patient care conference; patient not able to function independently Discharge planning prepares patient for discharge Care providers address pt’s medical issues & POC pre- paring for discharge Key: Process Decision End of Process Collaboration

Use Case #2 Dataflow Diagram Assisted living staff charts accident de- tails, VS, pain, and functional assessment ED nurse assesses patient; charts VS, accident info, level of pain (NRS) in EHR ED doctor assesses patient; orders x-ray; writes admission orders & surgical consult Document Exchange Server Physical therapist evaluates patient, establishes rehab plan & sets goals Surgeon reviews EHR data on patient; functional assessment, level of pain, labs, and x-rays Document Exchange Server , 10 6, 7, Rehab RN updates Functional assessments in the EHR including level of pain 14 Patient data available for review via EHR Assisted living nurse discusses findings from assessment and patient pain level with patient’s PCP Hosp admit nurse does functional assessment, assesses level of pain; reviews EHR data; initiates POC Nurse and therapist collaborate and review patient’s functional assessment and POC 15 Surgeon assesses patient status; reviews EHR data; writes order for transfer to rehab 16 Rehab admit nurse assesses patient runctional status, reviews EHR data; assigns bed Rehab doctor reviews patient status and EHR data; writes order for discharge to assisted living 20 Document Exchange Server Key: Nurse EHR Physician EHR End of Process Ancillary EHR Using functional assessment and pain scale Physician, nurse, family and patient collaborate x-rays are shown; discuss procedure pros & cons; sign consent Discharge planner and nurse collaborate; review functional assessment Care providers collaborate; review functional assessments and update POC 2122

Use Case # 3 Behavioral Health Hospital to Home Health

Use Case #3 Workflow Diagram Patient admitted to adult unit in behavioral health hospital Psychiatrist meets with patient and orders medication Yes Patient progressing well & respond -ing to therapy Hosp admit nurse screens patient for depression Unit RN assesses patient daily for depression Social work evalu- ates patient’s social & financial support Home health nurse reviews patient data via EHR Discharge Patient to home? Key: Process Decision End of Process Outpatient psychiatrist reviews patient data in EHR Home health nurse visits patient Collaboration 10 5 Patient care conference; preparing for discharge

Use Case #3 Dataflow Diagram Psychiatrist reviews ED data; assesses patient and enters info in EHR; admits patient to adult unit of behavioral health hospital Behavioral health nurse documents geriatric depression scale and initiates POC Social worker documents social and financial assessment information into EHR Unit RN documents geriatric depression scale score daily & updates POC in EHR Psychiatrist orders anti-depressants & mood stabilizers via CPOE Patient care team meets; reviews geria- tric depression scores and prepare for discharge Document Exchange Server , Patient data available for review via HER future visits Home health nurse reviews geriatric depression scores in EHR and plans home health visit 10 Home health nurse visits patient; docu- ments geriatric de- pression scores in EHR Outpatient psychiatrist reviews geriatric de- pression scores from home health and follows up w/patient 11 Key: Nurse EHR Physician EHR End of Process Ancillary EHR

Back-up Slides

Use Case #1 Workflow Diagram Nurse assesses resident Nurse initiates phone Collaboration w/PCP PCP reviews patient status Transfer Patient? Yes Patient transferred to acute care hosp Hosp admit nurse reviews transmitted EHR data Pt acuity & staffing levels rvw Unit placement decision based on current pt acuity, & staffing levels Unit RN assesses patient on admission to unit Care providers address patient’s medical issues Patient regains strength, progressing well Attending reviews patient status Discharge Patient to LTC? Yes Key: Process Decision End of Process Patient transferred to long-term care facility

Use Case #1 Dataflow Diagram LTC nurse identifies change in functional assessment, braden scale and glucose level. LTC nurse discusses findings from assessment and labs with patient’s PCP Hosp admit nurse compares current assessment to LTC EHR data and initiates POC RHIO Document Exchange Server Unit RN updates daily assessments In the EHR Attending reviews progress notes and assessments; writes orders PCP reviews EHR Data on patient ; assessment & labs Unit RN updates daily assessments In the EHR RHIO Document Exchange Server Unit RN updates daily assessments In the EHR 10 Key: Nurse EHR Physician EHR End of Process Patient transferred to long-term care facility

Use Case #1 Workflow Diagram (Updated Audrey & Marcia) Hospital Admission nurse reviews transmitted EHR data. Unit placement decision based on current patient acuity, staffing levels. Nurse assesses resident Identifies change in functional assessment, braden scale and glucose level. PCP reviews status RN initiates phone collaboration with the PCP. EHR reviewed, decision to transfer to acute care made. Patient transferred to acute care facility Unit RN assesses Patient on admission to unit RHIO Document Exchange Server RHIO Document Exchange Server Patient transferred to long-term care facility Unit RN updates daily assessments In the EHR. Care Providers addresses patient’s medical issues Unit RN Updates daily assessments in the EHR Patient regains strength; progressing well Progress note Med reconciliation Discharge summary Preparing patient for discharge Unit RN compares current assessment to LTC EHR data and initiates POC.

Use Case #1 Combined Workflow/Dataflow Diagram Identifies change in functional assessment, braden scale and glucose level. Discusses findings from assessment and labs Nurse compares Current assessment to LTC EHR data and initiates POC RHIO Document Exchange Server Unit RN updates daily assessments In the EHR Attending reviews progress notes and assessments Nurse assesses resident Nurse initiates phone collaboration with PCP PCP reviews patient status Transfer Patient? Yes Reviews EHR data Patient transferred to acute care facility Hospital admission nurse reviews transmitted EHR data Pt acuity & staffing levels rvw Unit placement decision based on current pt acuity, & staffing levels Unit RN assesses patient on admission to unit Care providers address patient’s medical issues Unit RN updates daily assessments In the EHR Patient regains strength, progressing well Unit RN updates daily assessments In the EHR Attending reviews patient status Discharge Patient to LTC? Yes RHIO Document Exchange Server Key: Process Decision Nurse EHR Physician EHR Patient transferred to long-term care facility End of Process