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Use Case # 1 LTC to Acute Care

Integrating the Healthcare Enterprise™ (IHE) Patient Care Coordination Functional Status Assessments. Use Case # 1 LTC to Acute Care. Use Case #1 Workflow Diagram. 1. 2. 3. 4. Nurse initiates phone collaboration withPCP. Pt acuity & staffing levels rvw. Nurse assesses resident.

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Use Case # 1 LTC to Acute Care

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  1. Integrating the Healthcare Enterprise™ (IHE)Patient Care CoordinationFunctional Status Assessments

  2. Use Case # 1LTC to Acute Care

  3. Use Case #1Workflow Diagram 1 2 3 4 Nurse initiates phone collaboration withPCP Pt acuity & staffing levels rvw Nurse assesses resident PCP reviews patient status Hosp admit nurse reviews transmitted EHR data Transfer Patient? PCP & Attending collaboration Unit placement Yes 9 8 7 6 5 Care providers address pt’s medical issues & POC leading to discharge Attending reviews patient status Patient regains strength, progressing well Unit RN assesses patient on admission to unit Patient transferred to acute care hosp 10 Discharge planning prepares patient for discharge 11 Discharge Patient to LTC? Patient transferred to long-term care facility Yes Decision Collaboration Key: Process End of Process

  4. Key: Nurse EHR End of Process Physician EHR Ancillary EHR Use Case #1Dataflow Diagram 1 2 3 4, 5, 6 Document Exchange Server LTC assesses patient; enters data in EHR for functional assessment, braden scale and glucose level. LTC nurse discusses findings from functional assessment and labs with patient’s PCP PCP reviews patient data via EHR; assessment & labs Hosp admit nurse compares current functional assessment to LTC EHR data and initiates POC 10 9 8 7 Unit RN updates daily assessments in the EHR and Plan of care Unit RN updates daily assessments in the EHR and plan of care Discharge planner and nurse collaborate, review functional assessment Attending reviews progress notes, functional assess- ments; writes orders Document Exchange Server Patient transferred to LTC facility

  5. Use Case # 2Assisted Living to ED to Acute Care to Rehab

  6. Use Case #2Workflow Diagram 1 2 3 4 5 7 PCP & Nurse collaborate on patient injury Assisted living resident falls and Injures himself Nurse assesses patient Patient transferred by ambulance to acute care facility Patient evaluated in emergency department by RN Patient evaluated in emergency department by doc 12 6 Attending, nurse, surgeon, patient, family collaborate Surgery needed? Yes Transfer Patient? Patient to radiology for x-ray Yes 13 11 10 9 8 Patient has surgery Surgical consult Unit RN assesses patient on admit to unit; POC initiated Patient admitted to orthopedic floor ED doctor reviews patient data 18 14 Transfer patient? Discharge Patient? Patient transferred by ambulance to rehab facility Admit Patient? Patient begins physical therapy 1 day post-op 19 17 21 Yes 15 Care providers address pt’s medical issues & POC pre- paring for discharge 22 23 Rehab admit nurse reviews transmitted EHR data Patient care conference; patient not able to function independently Discharge planning prepares patient for discharge Rehab doctor recommends transfer to assisted living Patient transferred To assisted living facility 16 20 Surgeon recommends transfer to rehab Patient regains strength; requires minimal assistance Decision Collaboration Key: Process End of Process

  7. Key: Nurse EHR End of Process Physician EHR Ancillary EHR Use Case #2Dataflow Diagram 2 3 5 6, 7, 8 Document Exchange Server Assisted living staff charts accident de- tails, VS, pain, and functional assessment Assisted living nurse discusses findings from assessment and patient pain level with patient’s PCP ED nurse assesses patient; charts VS, accident info, level of pain (NRS) in EHR ED doctor assesses patient; orders x-ray; writes admission orders & surgical consult 15 14 12 11 9, 10 Nurse and therapist collaborate and review patient’s functional assessment and POC Physical therapist evaluates patient, establishes rehab plan & sets goals Physician, nurse, family and patient collaborate x-rays are shown; discuss procedure pros & cons; sign consent Surgeon reviews EHR data on patient; functional assessment, level of pain, labs, and x-rays Hosp admit nurse does functional assessment, assesses level of pain; reviews EHR data; initiates POC Using functional assessment and pain scale 17 16 19 20 Document Exchange Server Rehab RN updates Functional assessments in the EHR including level of pain Surgeon assesses patient status; reviews EHR data; writes order for transfer to rehab Discharge planner and nurse collaborate; review functional assessment Rehab admit nurse assesses patient runctional status, reviews EHR data; assigns bed 22 21 Document Exchange Server Rehab doctor reviews patient status and EHR data; writes order for discharge to assisted living Care providers collaborate; review functional assessments and update POC Patient data available for review via EHR

  8. Use Case # 3Behavioral Health Hospital to Home Health

  9. Use Case #3Workflow Diagram 1 2 3 4 5 Patient admitted to adult unit in behavioral health hospital Hosp admit nurse screens patient for depression Psychiatrist meets with patient and orders medication Social work evalu- ates patient’s social & financial support Unit RN assesses patient daily for depression 9 7 6 Discharge Patient to home? Patient care conference; preparing for discharge Home health nurse reviews patient data via EHR Patient progressing well & respond -ing to therapy Yes 10 Home health nurse visits patient 11 Outpatient psychiatrist reviews patient data in EHR Decision Collaboration Key: Process End of Process

  10. Key: Nurse EHR End of Process Physician EHR Ancillary EHR Use Case #3Dataflow Diagram 1 2 3 4 Psychiatrist reviews ED data; assesses patient and enters info in EHR; admits patient to adult unit of behavioral health hospital Behavioral health nurse documents geriatric depression scale and initiates POC Psychiatrist orders anti-depressants & mood stabilizers via CPOE Social worker documents social and financial assessment information into EHR 9 7 5,6 Document Exchange Server Patient care team meets; reviews geria- tric depression scores and prepare for discharge Unit RN documents geriatric depression scale score daily & updates POC in EHR Home health nurse reviews geriatric depression scores in EHR and plans home health visit 10 11 Home health nurse visits patient; docu- ments geriatric de- pression scores in EHR Outpatient psychiatrist reviews geriatric de- pression scores from home health and follows up w/patient Patient data available for review via HER future visits

  11. Back-up Slides

  12. Use Case #1Workflow Diagram 1 2 3 4 5 Nurse assesses resident Nurse initiates phone Collaboration w/PCP PCP reviews patient status Patient transferred to acute care hosp Hosp admit nurse reviews transmitted EHR data Transfer Patient? Yes Pt acuity & staffing levels rvw 10 9 8 7 6 Attending reviews patient status Patient regains strength, progressing well Care providers address patient’s medical issues Unit RN assesses patient on admission to unit Unit placement decision based on current pt acuity, & staffing levels 11 Discharge Patient to LTC? Patient transferred to long-term care facility Yes Decision Key: Process End of Process

  13. Use Case #1Dataflow Diagram 1 2 3 6 RHIO Document Exchange Server LTC nurse identifies change in functional assessment, braden scale and glucose level. LTC nurse discusses findings from assessment and labs with patient’s PCP PCP reviews EHR Data on patient ; assessment & labs Hosp admit nurse compares current assessment to LTC EHR data and initiates POC 8 10 9 7 Unit RN updates daily assessments In the EHR Unit RN updates daily assessments In the EHR Unit RN updates daily assessments In the EHR Attending reviews progress notes and assessments; writes orders RHIO Document Exchange Server Patient transferred to long-term care facility Key: End of Process Nurse EHR Physician EHR

  14. Unit RN assesses Patient on admission to unit Patient transferred to acute care facility Nurse assesses resident Hospital Admission nurse reviews transmitted EHR data. Unit placement decision based on current patient acuity, staffing levels. PCP reviews status RHIO Document Exchange Server Progress note Med reconciliation Discharge summary Unit RN Updates daily assessments in the EHR Unit RN updates daily assessments In the EHR. RN initiates phone collaboration with the PCP. EHR reviewed, decision to transfer to acute care made. Identifies change in functional assessment , braden scale and glucose level. Patient regains strength; progressing well Preparing patient for discharge Care Providers addresses patient’s medical issues Patient transferred to long-term care facility RHIO Document Exchange Server Use Case #1 Workflow Diagram(Updated Audrey & Marcia) Unit RN compares current assessment to LTC EHR data and initiates POC.

  15. Identifies change in functional assessment, braden scale and glucose level. Discusses findings from assessment and labs Nurse compares Current assessment to LTC EHR data and initiates POC Unit RN updates daily assessments In the EHR Attending reviews progress notes and assessments Unit RN updates daily assessments In the EHR Unit RN updates daily assessments In the EHR Reviews EHR data Use Case #1Combined Workflow/Dataflow Diagram RHIO Document Exchange Server Nurse assesses resident Nurse initiates phone collaboration with PCP PCP reviews patient status Patient transferred to acute care facility Hospital admission nurse reviews transmitted EHR data Yes Transfer Patient? Pt acuity & staffing levels rvw Discharge Patient to LTC? Attending reviews patient status Patient regains strength, progressing well Care providers address patient’s medical issues Unit RN assesses patient on admission to unit Unit placement decision based on current pt acuity, & staffing levels Yes RHIO Document Exchange Server Patient transferred to long-term care facility Decision Key: Process End of Process Nurse EHR Physician EHR

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