PACIO Transitions of Care for Post-Acute Providers (Jira PSS-2311)

The purpose of the LTPAC Transitions of Care (TOC) Implementation Guide is to provide a standards-based solution to support care transitions and coordination for LTPAC patients across all settings of care. The five traditional Post-Acute Care (PAC) settings, Hospice, Home Health, Skilled Nursing, Long Term Care Hospitals, and Inpatient Rehab facilities employ many types of clinicians, practitioners, therapists, and allied professionals who each require different information to provide the best and most efficient services to their patients. This information may include standardized assessments, patient preferences, observations, and other important data. Many of these items are valuable during a transition of care from one setting to another, including settings outside of Post Acute Care such as Acute Inpatient, Emergency Department, and Home and Community Based Organizations (HCBOs). This critical information is often not exchanged, resulting in gaps in care information during initial assessments and reassessments in new or parallel settings, and the data is never available as a specific role-based data set. This leads directly to potentially unsafe transition and coordination of care for these most vulnerable patients as well as information overload, additional documentation, errors in the patient record, incorrectly reconciled data, and a burden on families and patients to carry physical records with them during transitions.

This project will use a consensus driven process among a wide variety of practicing clinicians such as physicians, nurses, Physical / Occupational / Respiratory Therapists, Speech Language Pathologists, Paramedics, and other allied providers like HCBO Professionals, Quality Measurement Experts, Administrators, and Payers to identify where essential information overlaps and build a meaningful method for exchanging it. Particular emphasis will be placed on off-the-shelf concepts and vocabulary, e.g., the Data Element Library. This work will be done by the PACIO Project community. The PACIO (Post-Acute Care Interoperability) Project, established February 2019, is a collaborative effort between industry, government, and other stakeholders, with the goal of establishing a framework for the development of FHIR implementation guides to facilitate health information exchange.

The CMS Data Element Library provides the reference data (questions and answers) for key quality instruments in post-acute care, notably the MDS and OASIS. Today, most if not all information that could help inform the completion of these assessments is captured at the referral source, but not in a manner that can be meaningfully presented to the post acute provider. Without this context and properly mapped information, providers in Post Acute care settings are piecing together information from scratch through clinical observation or laborious review of narrative and other documentation that accompanies a referral. The challenge is similar outside of these instruments - stretching into areas like Advance Directives or Personal Care preferences.

Goals

Using the consensus process, define both the WHAT and HOW a transition of care should occur, with multi-disciplinary information defined based on the services need for a given patient, and provide a structure for referring providers to transition key information to post acute organizations enabling them to rapidly assess inbound referrals, quickly and accurately complete clinical assessments, quality instruments, and build care plans.

Produce implementation guide(s) supporting transition workflows paired with key clinical data for specific post-acute care disciplines to care for a patient entering a post-acute setting.

Exclusively use existing resources and profiles.