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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