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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
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- 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, but that which is is not within the scope. Pointing to the original referral at this point is nice to have, but , 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:
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