This use case covers the transfer of Skilled Nursing Facility patients to an Emergency Department and the subsequent possible transitions to an acute care facility and eventually back to the SNF.

Background

Transfers from Skilled Nursing Facilities (SNF) to an Emergency Department (ED) are the result of a clinical emergency. The goal of this implementation guide is to enable the information sharing from the SNF to the ED, and the information sharing as the result of the two general outcomes of the ED visit: return to the SNF, or admission to the hospital.

TODO: Why 360X, what does it mean

General Flow Diagram

Interaction details

SNF Sends Transfer to ED package


SNF Receives Transfer ED to SNF package


SNF Received Hospital Admission notification


SNF Sends Care Assessment Package

Use Interact's forms as guidance

SNF Receives a Discontinuation


SNF Receives a SNF Transfer Request



The SNF to ED Transfer 

Transfer notification


Clinical information


The ED to SNF Discharge 

Closing the loop


ED Clinical Summary

TODO: Can be a Consultation Note, an after-visit summary (CCD), could be a C-CDA Discharge summary

What needs to be there: Holly Miller, MD 

The Hospital Admission

Open question: How do we keep the ED information and the hospital information in sync for the following steps to occur? Do we need to specify an (optional?) transaction?

Admission notification

TODO: Use the admission notification from the Direct Standards Notification IG

Supplemental Clinical Information from SNF

TODO: Review the contents of this Nursing Unit-centered information.

Discharge to Facility - Same SNF

Discharge Notification

TODO: Add notification information

Clinical Information

TODO: In many cases a Discharge summary is available

Discharge to Facility or Home - Different SNF

Notification to Initiating SNF

TODO: what to send

Start a 360XL referral/transfer to the new SNF


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