HL7 FHIR® Implementation Guide: Transitions of Care for Post-Acute Providers, Edition 1- US Realm

DESCRIPTION

The PACIO Project’s Transitions of Care Implementation Guide provides a standards?based solution for patient care transitions and coordination across Long?Term Post?Acute Care (LTPAC) settings.

ALTERNATIVE NAMES

HL7 FHIR® Implementation Guide: Transitions of Care for Post-Acute Providers, Edition 1- US Realm may also go by the following names or acronyms:

BENEFITS

• Reduces provider burden by enabling structured, role-based exchange of coded patient data at transitions of care;
• Minimizes transcription errors and associated patient safety risks; supports interoperable data exchange across PAC settings in alignment with federal interoperability requirements;
• Enables receiving providers to access clinically relevant context needed for timely and accurate initial assessments.

IMPLEMENTATIONS/CASE STUDIES

The PACIO Transitions of Care IG has been tested at multiple HL7 and CMS FHIR Connectathon events from May 2024 through January 2026. Sponsoring agencies and known implementers include:

• Centers for Medicare & Medicaid Services (CMS) — Center for Clinical Standards & Quality (project sponsor)
• MITRE Corporation (PACIO Project managers and Pseudo EHR system developer)
• Patient Centric Solutions (ToC bundle receiver)
• Washington State Department of Health (ToC bundle receiver)

DEVELOPMENT BACKGROUND

The PACIO Transitions of Care IG was developed by the PACIO Project, a collaborative initiative under the HL7 Patient Care Work Group, in response to longstanding gaps in interoperable data exchange during patient transitions to and from post-acute care settings. Development was informed by clinical stakeholders across PAC disciplines, regulatory requirements including the IMPACT Act of 2014, and the CMS Data Element Library. The IG builds upon existing PACIO IGs for Personal Functioning and Engagement, Advance Directive Interoperability, the Standardized Medication Profile, as well as US Core.

RELATED DOCUMENTS

HL7 FHIR® Implementation Guide: Transitions of Care for Post-Acute Providers, Edition 1- US Realm

STU DOCUMENTS

HL7 FHIR® Implementation Guide: Transitions of Care for Post-Acute Providers, Edition 1- US Realm See the standard at '>http://hl7.org/fhir/us/pacio-toc/STU1'>.

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TOPIC

• Patient Care

BALLOT TYPE

• STU

STATUS DATE

2026-05-12

RESPONSIBLE WORK GROUP

PRODUCT TYPE

• Implementation Guide

STAKEHOLDERS

• Health Care IT Vendors
• Regulatory Agency

FAMILY

• FHIR

CURRENT STATE

• Active

REALM

• US Realm