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http://hl7.org/fhir/us/sdoh-clinicalcare/StructureDefinition/SDOHCC-Procedure)

Information Exchange

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Initiation of Referral

Scope

• limited to referral Process and Tracking (see below)

Outline

• Send referral
• Receive referral
• Respond to referral
  • Accept/Decline (best practice recommendation: receiving edge system functionality would ideally be able to auto-accept or auto-decline based on organization parameters (e.g. capacity))
• Decline - closes the loop

• Accepted Referrals
  • Acknowledge receipt and accept, but no further information to be provided to referrer - loop closed (example patient referred to Narcotics Anonymous by PCP)
  • Indicate outcome if services are rendered (will vary depending on the scenario)
    • One time only service – e.g. patient education – patient receipt of service closes the loop
    • Ongoing services
      • Indicate services rendered following each service - Optional per base 360X Best Practice protocol would be information back to referrer if there is significant information
      • Close loop when services no longer will be rendered - Required

• Scheduling Status (may apply in some scenarios)
• Scheduled
• No show
• Reschedule
• Cancel
• Drop in (may apply in some scenarios when scheduled appointments to receive the service is not required)
• Referring provider tracks the time lapse in the edge system.  May define time frames for different referrals, edge system alerts referrer after time lapse if no notification of services rendered is received.  For example, the edge system of the referring provider tracks that a month has elapsed and sends an alert to the referring provider or his/her delegate in the system.  AND/OR, the extraclinical edge system tracks that a month has elapsed since an “Accept” notification was sent to the referring provider and sends a “No Show” notification to the referring provider.

Initiation of Referral

• Referral Initiators
  • Ambulatory Care (e.g. Primary Care, Specialist Provider, (Care Management/Social Work - also acute))
  • Hospitals
  • Home Health Agency
  • LTPAC (e.g. Adult Day Centers, Assisted Living)

Technical Specifications

(Note: all other technical specifications from 360X not listed here would apply).

No C-CDA requirement for initial request

All necessary information is included in the HL7v2 attachment (see “what information needs to be included for Extra-Clinical Referrals” below). In this use case, any fully structured C-CDA will likely include more information than is appropriate to share.

Remove the base 360X requirement for initial referral to include a C-CDA, allow all transactions to simply include HL7v2 status messages.

Optional Initially use: the Unstructured Document Template in C-CDA (2.16.840.1.113883.10.20.22.1.10) includes structured patient demographics and allows for a variety of forms of embedded attachments (e.g. PDF, Word, gif, jpeg, tif, png, txt, rtf, html). 

If/As the C-CDA templates and SDOH standardized vocabulary improve/are adopted, related to SDOH, we can incorporate these.

Code to indicate that this is an SDOH referral

LOINC/ICD/SCT codes?

Proposal for 4 levels:

1. Overall purpose of the request (XD metadata)
   content type code: 57164-6 LOINC
2. Specific purpose of the request (ORC/OBR order code)
   Gravity/ Snomed referral
3. Reason for referral
   Food insecurity determination: ICD-10-CM: Z59. 4
   Pre-Diabetes: R73. 03
4. Expected outcome
   Gravity/Snomed provision

Note: These are not to be considered as requirements for independent data entry at each level

Direct Transport

HL7 V2 Status Messages

Standard 360X Messages, with the following constraints:

<TBD>

Unique Patient and Referral ID

Referral ID terminates when the loop is closed

What information (patient data, reason for referral, etc.) needs to be included for Extra-Clinical Referrals

All Cases: patient demographics (C-CDA and HL7v2), reason for referral (if using C-CDA Unstructured Document Template - this information would be only in an HL7v2 message), individual making the referral and organization making the referral (may be in C-CDA Unstructured Document Template and would be in HL7v2 message)

Specific Cases:  eligibility information

Potentially included as an attachment e.g. completed SNAP form as a PDF

(See the reference below to the work that BSer has done relative to this, which could be included, as necessary, as an attachment)

Generalized workflow for an extra-clinical referral use case

...

1. Patient Demographics
2. Reason for referral - the previously identified need
3. Individual and organization making the referral
4. Additional data and documentation as needed
1. E.g. PDF of SNAP form
5. Unique referral and patient ID

1. SDOH need identified (process - out of scope ((oos) for 360X)
2. HIT system sends, using existing 360X standards, to extra-clinical organization 

...

1. Receipt and view of all above data
2. Maintain the unique patient and referral ID
3. Send and receive HL7v2 messages

1. System with a Direct account able to support all of the 360X standards

...

1. If additional data are required, the extraclinical organization sends notification of the specific additional information that is required [Does an HL7V2 message exist to support this? - VASSIL to Review]
   1. Sends required additional data
   2. Delegates sending the additional information to the patient
   3. Unable to send additional information
1. Referrer 

1. Determines eligibility (as needed)

...

1. Sends accept/decline

...

1. Ongoing services
1. [What patient information can the extraclinical organization send to update the referrer?] Is there an HL7 V2 Message that the patient received services, can the extraclinical return a C-CDA, other data?] - Ideally information could be sent for the referrer to update the patient care plan]
2. Loop closed after services terminated
2. One time service
1. Loop closed after services terminated

• Referral Initiators
  • Ambulatory Care (e.g. Primary Care, Specialist Provider, (Care Management/Social Work - also acute))
  • Hospitals
  • Home Health Agency
  • LTPAC (e.g. Adult Day Centers, Assisted Living)

Technical Specifications

(Note: all other technical specifications from 360X not listed here would apply).

No C-CDA requirement for initial request

All necessary information is included in the HL7v2 attachment (see “what information needs to be included for Extra-Clinical Referrals” below). In this use case, any fully structured C-CDA will likely include more information than is appropriate to share.

Remove the base 360X requirement for initial referral to include a C-CDA, allow all transactions to simply include HL7v2 status messages.

Optional Initially use: the Unstructured Document Template in C-CDA (2.16.840.1.113883.10.20.22.1.10) includes structured patient demographics and allows for a variety of forms of embedded attachments (e.g. PDF, Word, gif, jpeg, tif, png, txt, rtf, html). 

If/As the C-CDA templates and SDOH standardized vocabulary improve/are adopted, related to SDOH, we can incorporate these.

Code to indicate that this is an SDOH referral

LOINC/ICD/SCT codes?

Proposal for 4 levels:

1. Overall purpose of the request (XD metadata)
   content type code: 57164-6 LOINC
2. Specific purpose of the request (ORC/OBR order code)
   Gravity/ Snomed referral
3. Reason for referral
   Food insecurity determination: ICD-10-CM: Z59. 4
   Pre-Diabetes: R73. 03
4. Expected outcome
   Gravity/Snomed provision

Note: These are not to be considered as requirements for independent data entry at each level

Direct Transport

HL7 V2 Status Messages

Standard 360X Messages, with the following constraints:

<TBD>

Unique Patient and Referral ID

Referral ID terminates when the loop is closed

What information (patient data, reason for referral, etc.) needs to be included for Extra-Clinical Referrals

All Cases: patient demographics (C-CDA and HL7v2), reason for referral (if using C-CDA Unstructured Document Template - this information would be only in an HL7v2 message), individual making the referral and organization making the referral (may be in C-CDA Unstructured Document Template and would be in HL7v2 message)

Specific Cases:  eligibility information

Potentially included as an attachment e.g. completed SNAP form as a PDF

(See the reference below to the work that BSer has done relative to this, which could be included, as necessary, as an attachment)

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Clinical to Human Service Provider Referral Models

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