This space is for the development specifications for the Home Health Services referrals based on 360X.

1. Background and Key Points

Currently there are no standards for managing the workflow and data exchange from the time it is determined that a patient needs home health services, to the time when a home health agency takes on the responsibility for providing these services. Enhancing the 360X specifications to address this use case will improve the care coordination and transitions of care in an area of healthcare that is increasingly important.

The following key points are addressed in this specification

1.1 Scope and closing the loop

The 360X referrals for home health covers the following general steps:

1. Initial request, and determining the agency which will provide home health services
2. Verifying the provider with authority to sign off on orders
3. Patient admission to the home health services (first visit with the patient)

The closing of the loop in this case is the first visit with the patient.

1.2 Care coordination and additional interactions

In many cases in order to satisfy regulation requirements, and the properly prepare for the services the patient, there needs to be the ability to exchange information about the exact nature if the services. For specific additional interactions there might be different processes for data exchange, and they should take advantage of linking their interactions to the referral via the patient and referral identifiers.

While out of scope of this Implementation Guide, of particular note is the need to communicate requests for orders, which would go from the Home Health organization to the responsible clinician.

1.3 More than one potential recipients initially

This requirement is addressed in the same way that the referrals to SNF specification (360X-L).

2. Home Health Services Referrals Workflow

2.1 Specific steps for HH referrals

• Request initiation and determination of "responsible physician"
  • From an acute setting, the process starts before discharge, a physician at the hospital  may sign the initial request, but may not be the "responsible physician" for the duration of the home health services
  • From an ambulatory setting requires a "responsible physician" signature.
  • From a post-acute setting, a physician at the facility may sign the initial request, but may not be the "responsible physician" for the duration of the home health services
• Request may get to multiple home health agencies, one will be selected, but not likely (a single choice is made in advance due to geography or insurance requirements or prior experience)
• Notification of a scheduled first visit
• Notification of a completed first visit (visit summary, form 485, including new set of orders) - closing the loop, referral completed
• Ongoing orders and approvals continue past the first visit, which is is not within the scope. Pointing to the original referral at this point is nice to have, however until additional integrations are specified, this can't be mandated.
• Possible supplemental integrations may include event notification post each visit, order request interfaces.

2.2 State transitions

The following state transitions diagram is from the point of view of the Referral Initiator. It supports the following variations:

1. Multiple candidate agencies: in some cases there is a choice of agencies, and a request is sent to multiple agencies, then
   1. if more than one agency accepts, one is selected, the initiator sends a confirmation to the selected agency, and cancel notification to the non-selected ones
   2. if only one agency accepts, the initiator still sends a confirmation to it
   3. if no agency accepts, the process needs to start over with a new referral request.
2. Determination of responsible clinician:
   1. Responsible clinician is determined before the referral request is sent - in this case the scheduling of the first home visit can take place after the confirmation is received by the agency
   2. Responsible clinician is determined after the referral request is sent - in this case the agency expects a notification about who the responsible clinician is after the confirmation is received. The first home visit can be scheduled only after the responsible clinician has been determined.