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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 is not within the scope. Pointing to the original referral at this point is nice to have, but 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:
- Multiple candidate agencies: in some cases there is a choice of agencies, and a request is sent to multiple agencies, then
- if more than one agency accepts, one is selected, the initiator sends a confirmation to the selected agency, and cancel notification to the non-selected ones
- if only one agency accepts, the initiator still sends a confirmation to it
- if no agency accepts, the process needs to start over with a new referral request.
- Determination of responsible clinician:
- Responsible clinician is determined before the referral request is sent - in this case the scheduling of the first home visit can take place after the confirmation is received by the agency
- Responsible clinician is determined after the referral request is sent - in this case the agency expects a notification about who the responsible clinician is after the confirmation is received. The first home visit can be scheduled only after the responsible clinician has been determined.
