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1. Provider EHR to CBO with referral management software
2. Provider EHR to SDOH Hub which functions as CBO referral management software
1. CBO selected by provider
2. CBO NOT selected by provider, Hub identifies best match CBO
3. Patient identifies CBO, Hub monitors CBOs watching for patient to reach out for services (OOS for 360X and up to the Hubs)
3. Provider EHR to SDOH Hub which makes referral to another SDOH Hub OR to CBO which uses its own referral management software
1. CBO selected by provider
2. CBO NOT selected by provider, Hub identifies best match CBO
4. Provider EHR to SDOH Hub which makes referral to another SDOH Hub OR to CBO which uses its own referral management software
5. Provider EHR to SDOH Hub which identifies additional SDOH needs of the patient and makes additional referrals to CBO(s) beyond the one requested by the provider
6. Self-referrals by patient outside of any clinical context - Out of Scope

Use Case #1 - Provider EHR to Identified CBO with Referral Management Software (Most Simple EHR Requirements)

1. Requirements
   1. Clinical EHR has push referral capabilities with Direct Account
   2. CBO having software with referral management capabilities and own direct account
       
2. Referral Initiation & Receipt
   1. Sendingclinical EHR pushes referral to selected CBO
      1. Referring provider selects a specific CBO
      2. Unique referral ID is generated
      3. EHR sends HL7V2 message, per 360X IG, with structured patient demographics
      4. Unique referral ID is generated
      5. , and either default procedure codes:
         1. "Referral to assessment service," SNOMED CT 307378001
         2. "
         Default procedure code (306238000, SNOMED CT,
         1. Referral to Social Services
         (or one of the specific intervention SNOMED codes developed by Gravity) and appropriate, selected
         1. ," SNOMED CT, 306238000
         2. SDOH diagnosis code, ICD
         )
         1. -10 CM/SNOMED CT
      6. Referring provider sends any necessary forms or data (PDF if necessary) as applicable 
         
         
   2. Referral received by CBO with referral management software
      1. It is possible for the CBO system to automatically accept (CBO open to all comers) or decline (CBO has no capacity for additional clients for services) a referral
      2. If there is no auto accept of referral, then Patient eligibility is checked by CBO staff
      3. CBO Staff will send either an “Accept” or “Decline” response back to referring provider: 
         
         
3. Decline Referral Response:
   1. “Decline” response pushed back to referring provider’s EHR
   2. Following decline response, further communication between referring provider, patient and CBO may be required for eligibility.
   3. Once eligibility is granted a new referral can be made (This communication is OOS for 360X)
      
      
4. Accepted Referral Response:
   
   1. CBO management software pushes message back to referring provider
      1. “Services rendered”
      2. “no show”
      3. with SNOMED CT Procedure Code(s) that are used in the Gravity Project.
      4. “No Show”
      5. ((Could there be an “opt out” possibility for providers, so they no longer receive notifications)? 
   2. Once the patient is no longer enrolled in the program, CBO sends message to EHR
      1. “Services discontinued complete”
      2. “Services discontinued incomplete” (Referral Loop Closed).
   3. Initiator systems (clinical EHRs) will develop workflow and GUI based on their client feedback.  Directing EHRs on workflow following receipt of these exchanges is OOS for 360X.
      
      
5. Patient is enrolled in an ongoing program (i.e., Meals on Wheels)
   1. Repeat steps a. i-iii - b. i-ii until services discontinued complete / services discontinued incomplete.
      
      
6. One time service for patient
   1. CBO referral management software pushes either a “services rendered” or a “no show” HL7v2 message which includes OBR/OBX segment that can include a SNOMEDCT SNOMED CT Procedure Codes to the referring provider (Referral loop closed).
   2. Patient is deemed ineligible for referred services
      1. CBOs referral management pushes “Decline” message with reason of “ineligibility” back to referring provider’s EHR (Referral loop closed).
   3. Patient is referred to additional services by CBO
      1. No notification of additional referral
      2. Out of scope for 360x
         
         
7. “No Show” : Unsolicited “No Show” notification
   1. Patient does not go to organization for services in predetermined time frame, specific to each organization
   2. “No Show” message is sent to referring Provider’s EHR
   3. Unlike clinical 360X referrals, there is no expectation of previous appointment information being shared prior to the “No Show” notification being sent.
   4. This does not close the referral loop

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1. Sendingclinical EHR pushes referral of a selected CBO to a Hub (unique referral ID is generated)
   1. Referring provider selects a specific CBO, without referral management software 
   2. Clinical EHR has push referral capabilities to Hub 
   3. EHR sends HL7V2 message, per 360X IG, with structured patient demographics, and either default procedure code (306238000, SNOMED CT, codes:
      1. "Referral to assessment service," SNOMED CT 307378001
      2. "Referral to Social Services
      and
      1. ," SNOMED CT, 306238000,  and appropriate, selected SDOH diagnosis code, ICD
      )
      1. -10 CM
   4. Referring provider sends any necessary forms or data (PDF if necessary) as applicable 
      
      
2. Receiving referral by Hub with referral management software
   1. It is possible for the Hub to automatically accept (CBO open to all comers) or decline (CBO has no capacity for additional clients for services) a referral
   2. Patient eligibility is checked by Hub staff
   3. Hub Staff will send either an “Accept” or “Decline” response back to referring provider
      
      
3. Decline Referral Response:
   1. Patient is deemed ineligible for services requested by all CBOs, per Hub. “Decline” response pushed back to referring provider’s EHR. Following decline response further communication between referring provider, patient and CBO may be required for eligibility and once eligibility is granted a new referral can be made. (This communication is OOS for 360X)
   2. If Hub finds patient ineligible for specific CBO that provider identified, but identifies CBO where patient is eligible - this will trigger one of the “Accepted” response below with message/correction of newly identified CBO
      
      
4. Accepted Referral Response:

...

1. Patient is accepted with several possible outcomes - as follows:
   1. CBO management software pushes message back to referring provider, through Hub software, regarding patient enrollment (need to make consistent with title)
   1. CBO referral management software pushes “services rendered” or  “no show” messages, through Hub software, in ongoing fashionthat can include SNOMED CT Procedure Code(s) that are used in the Gravity Project.
   2. (Could there be an (Could there be an “opt out” possibility for providers, so they no longer receive notifications) 
   2. Once the patient is no longer enrolled in the program, CBO marks the patient as “services discontinued complete” or “services discontinued incomplete”  which pushes a message to the provider's EHR, through Hub software
   3. This closes the referral loop
1. Patient is enrolled in an ongoing program (i.e., Meals on Wheels)

• One time service to be received by patient

1. 1. 1. CBO referral management software pushes either a “services rendered” or a “no show” message to the referring provider, through Hub software
This closes the referral loop
2. 1. 1. that can include SNOMED CT Procedure Code(s) that are used in the Gravity Project. (Referral loop closed).
   2. Patient is deemed ineligible for referred services
This closes the referral loop
3. 1. (Referral Loop Closed)
      1. CBOs referral management pushes “Decline” message with reason of “ineligibility” back to referring provider’s EHR, through Hub software
   2. Patient is referred to additional services by CBO
      1. No notification of additional referral
      2. Out of scope for 360x

• “No Show”

1. Patient does not go to organization for services in predetermined time frame, specific to each organization
2. “No Show” message is sent to referring Provider’s EHR, through Hub software
3. This does not close the referral loop

...

1. Referring provider DOES NOT select a specific CBO, but referral to HUB includes
   1. SDOH ICD diagnosis code “program type”type” 
   2. Unique referral ID is generated
   3. HL7V2 with structured patient demographics, default procedure code (306238000, SNOMED CT, Referral to Social Services and appropriate, selected SDOH ICD diagnosis code)
2. Referring provider sends any necessary forms or data (PDF if necessary) as applicable
   1. Patient eligibility is checked by Hub staff
   2. Hub Staff will send either an “Accept” or “Decline” response back to referring provider
   3. Receiving referral by Hub with referral management software
      
      
3. Decline Referral Response:
   1. Patient is deemed ineligible for services requested by all CBOs, per Hub. “Decline” response pushed back to referring provider’s EHR. 
   2. This communication is OOS for 360X: Following decline response further communication between referring provider, patient and CBO may be required for eligibility and once eligibility is granted a new referral can be made
      
      
4. Accepted Referral Response:
   1. Patient’s referral is pushed to the specific CBO identified by the Hub, though Hub software (several options):
      1. CBO management software pushes message back to referring provider, through Hub software, regarding patient enrollment (Enrollment Notice).
      2. CBO referral management software pushes “services rendered” or “no show” messages, through Hub software, in ongoing fashion (any “opt out” for providers viewing these messages is OOS for 360X, but might be configurable for the provider in her/his EHR)
      3. Once the patient is no longer enrolled in the program, CBO marks the patient as “services discontinued complete” or “services discontinued incomplete”  which pushes a message to the provider's EHR, through Hub software (Referral loop closed)
         
         
5. Patient is enrolled in an ongoing program (i.e. Meals on Wheels)
   
   
6. One time service to be received by patient

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

http://hl7.org/fhir/us/

sdoh-clinicalcare/StructureDefinition/

SDOHCC-

Procedure)

Gravity Project Clinical Care IG Value Sets

• Task for Referral Management
  • Task.priority

• • TaskStatus

task.focus - The request being actioned or the resource being manipulated by this task. (Reference Any)

Information Exchange

Initiation of Referral

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