Referral and Transition/Transfer of Care

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Introduction

Clinical medicine and health care have evolved from a simple patient-physician-nurse care delivery model to a multi-disciplinary, collaborative care delivery model. Patient's in today's complex care environment are often referred to the care of other specialized or super-super-specialized health care providers or provider organizations; or their care may required to be transitioned from one care setting/facility to another.

For complex care delivery models involving multi-disciplinary and multi-facilities to be effective, it is necessary that activities of the variety of health care providers and provider organisations are effectively coordinated.

The Referral processes and transition of care processes together with supporting administrative/financial and clinical data have been developed internationally to support the effective implementation of complex coordinated care delivery models.

Project Leadership

• Project Lead:

- Stephen Chu

• Domain Experts:

- Stephen Chu

- Russ Leftwich

- David Hay

- Laura Heermann Langford

- Elaine Ayres

- Kevin Coonan

- Emma Jones

Referral and Transition/Transfer of Care Project Scope Statement and Resources Proposal

• Project Scope Statement:

Referral FHIR Resoruces PSS - Approved 2014-07-15

• Link to Referral FHIR Resource Proposal (on FHIR wiki):

Referral FHIR Resource Proposal

FHIR Referral Resource project

• Referral FHIR Resource - Draft for Review:

http://hl7-fhir.github.io/referralrequest.html

Referral/Transfer of Care Codeable Elements valuesets

• Links to FHIR Referral resource Blog:

http://fhirblog.com/2014/08/04/referral-requests-in-fhir/

http://fhirblog.com/2014/03/31/referrals-orders-and-fhir/

• Link to FHIR Resources Proposals wiki:

http://wiki.hl7.org/index.php?title=Category:FHIR_Resource_Proposal

• Link to FHIR Clinical Resources wiki:

http://hl7.org/implement/standards/fhir/clinical.html

Definitions

Referral

Referral is the process, with the intention of initiating care transfer, from the provider making the referral to the receiver.

NOTE: The essential components of referral are the intent and facilitation of transferring patient care in whole or in part from one health care provider or organization to another provider or organization. Self referral is also possible: a person, the subject of care, may be the referrer or the referee. Referral is normally accompanied by clinical information to responsibly enable takeover of such care by the referee.

Referral can take several forms most notably:

(a) Request for management of a problem or provision of a service e.g. a request for an investigation, intervention, or treatment.

(b) Notification of a problem with hope, expectation, or imposition of its management e.g. a Discharge Summary in a setting which imposes care responsibility on the recipient.

The common factors in all of these are a communication whose intent is the transfer of care.

(Source: Standards Australia AS4700.6 - HL7 v2.x Referral Messaging Specification. NOTE - the first sentence of this definition is slightly modified: the original statement - "Referral is the communication ..." is modified to - "Referral is the process...")

Transition of Care

• The term "care transitions" refers to the movement patients make between health care practitioners and settings as their condition and care needs change during the course of a chronic or acute illness.

For example, in the course of an acute exacerbation of an illness, a patient might receive care from a PCP or specialist in an outpatient setting, then transition to a hospital physician and nursing team during an inpatient admission before moving on to yet another care team at a skilled nursing facility. Finally, the patient might return home, where he or she would receive care from a visiting nurse. Each of these shifts from care providers and settings is defined as a care transition

(Source: http://www.caretransitions.org/definitions.asp)

• A position statement from the American Geriatrics Society defines transitional care as follows:

For the purpose of this position statement, transitional care is defined as a set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location. Representative locations include (but are not limited to) hospitals, sub-acute and post-acute nursing facilities, the patient's home, primary and specialty care offices, and long-term care facilities. Transitional care is based on a comprehensive plan of care and the availability of health care practitioners who are well-trained in chronic care and have current information about the patient's goals, preferences, and clinical status. It includes logistical arrangements, education of the patient and family, and coordination among the health professionals involved in the transition. Transitional care, which encompasses both the sending and the receiving aspects of the transfer, is essential for persons with complex care needs.

(Source: Coleman EA, Boult CE on behalf of the American Geriatrics Society Health Care Systems Committee. Improving the Quality of Transitional Care for Persons with Complex Care Needs. Journal of the American Geriatrics Society. 2003;51(4):556-557)

• Meaningful Use Stage 2 Measures - (Eligible Hospital and Critical Access Hospital Meaningful Use Core Measures Measure 12 of 16) defines "Transition of Care" as:

"The movement of a patient from one setting of care (hospital, ambulatory primary care practice, ambulatory specialty care practice, long-term care, home health, rehabilitation facility) to another"

(Source: Eligible Hospital and Critical Access Hospital Meaningful Use Core Measures: Measure 12 of 16 - 2013-Nov, p.1)

• The Joint Commission has defined a “transition of care” as the movement of a patient from one health care provider or setting to another

(Source: The Joint Commission: Transition of Care Document - 2013, p.2)

• Key concepts that can be discerned from these definitions of "Transition of Care" are:

- coordination actions/processes

- transfer/transition of patient that occurs between

~ different levels of care within the same location (e.g. from ICU to general medical unit)

~ different locations/care settings (e.g. from acute care setting/facility to long term care or skilled nursing facility); or

• NOTE:

- "Transition of Care" is different from another concept "Transition Care" (in Australia)

- "Transition Care" in Australia is a program funded by the Australian Federal Department of Health

o Transition Care provides short-term care that seeks to optimise the functioning and independence of older people after a hospital stay.

o Transition Care is goal-oriented, time-limited and therapy-focussed.

o It provides older people with a package of services that includes low intensity therapy such as physiotherapy and occupational therapy, as well as social work, nursing support or personal care

o It seeks to enable older people to return home after a hospital stay rather than enter residential care prematurely.

o The Program facilitates a continuum of care for older people who have completed their hospital episode, including acute and subacute care2 (e.g. rehabilitation, geriatric evaluation and management), and who need more time and support to make a decision on their long term aged care options.

(Source: Australian Government Department of Health and Ageing: Transition Care Program Guidelines 2011)

Transfer of Care

Transfer of care is the process whereby a physician who is providing management for some or all of a patient’s problems relinquishes this responsibility to another physician who explicitly agrees to accept this responsibility and who, from the initial encounter, is not providing consultative services. The physician transferring care is then no longer providing care for these problems though he or she may continue providing care for other conditions when appropriate

(Source: http://www.med.wisc.edu/files/smph/docs/compliance/compliance-transfer-of-care-definition-2011.pdf)

• Key concepts that can be discerned from this definition of "Transfer of Care" are:

- actions/processes

- relinquish of care responsibility by one provider to another

- explicit agreement of accepting clinician to take over this responsibility

- the relinquished responsibility is for some or all of a patient's problems

- if the relinquished responsibility is for some problems only, the original provider retains care responsibility for patient's all other problems

Relations between "Referral", "Transfer of Care", "Transition of Care"

Referral
"Referral" is a process starts with a request followed by a set of activities/events and completed with a conclusion of the process.

• The types of referral include:

- Referral for second opinion (aka "consult"/"consultation")

o There is partial transfer of care responsibility from the referring provider to the referred to provider on the health issue/problem for which the referral is made

- Referral for specific procedure(s) (e.g. bronchoscopy, gastroscopy, +/- biopsy; endodontic procedures)

o There is also partial transfer of care responsibility from the referring provider to the referred to provider for the duration of the procedure and any follow-up management considered necessary/appropriate by the referred to provider

- Referral for management of specific issues/problems

o There is a complete transfer of care responsibility from the referring provider to the referred to provider with regard to the health issue/problem for which the referral is made.

o The referring provider retains complete care responsibility of all other health issues/problems that this patient may have

o The referred to provider may need to manage those other health issues/problems as co-morbilities during the duration the patient is under his/her care (e.g. when the patient requires hospital care away from the referring provider)

• The Referral process has three main components:

- Referral Request

o A referral letter/document or referral message will be sent from the referring provider to the referred to provider

o The referral request resource may also be used for referral updates (i.e. referrer sending additional information relevant to referral)

- Cancel Request

o A referral request may be cancelled by a provider (e.g. as a result of change of patient clinical status; or at patient's request)

- Referral Fulfillment

o Acceptance (after triaging by the referred to provider/organization) / Acceptance + Appointment

~ handled by FHIR "Order Response" resource

o Request for more information (also after triaging). The type of information requested may include: financial, administrative and clinical

~ More analysis required to determine whether a new resource is required

o Rejection (with reasons given)

~ handled by FHIR "Order Response" resource

o On referral to a third party provider/organization handled by FHIR "Order Response" resource

~ handled by FHIR "Order Response" resource; plus

~ new referral to third party provider/organization

o Recommendation(s)

~ May consider the use of "Care Plan" resource; or

~ May need a new resource

o Progress report

~ handled by FHIR "Order Response" resource + "Composition" (progress report contents)

o Separation summary/discharge summary (which concludes the referral process)

~ handled by FHIR "Order Response" resource + "Composition" (separation summary/discharge summary contents)

Transfer of Care

• "Transfer of Care" (used independent of other contexts such as "referral" or "transition of care") is a process by which the care responsibility of a patient is transfer from a carer/provider/organization to another carer/provider/organization
• Similar to referral, "Transfer of Care" is a process which starts with a request to transfer care responsibility and concluded when the transfer of responsibility to another provider/organization is completed
• Types of Transfer of Care:

- Short term transfer

o The transfer of care responsibility is temporary

o When the care responsibility is returned to the original carer/provider/organization, another transfer of care activity is initiated

o This may also be referred to "handover"

o Examples:

~ A patient is transferred from an aged care/skilled nursing facility to an acute care hospital to manage a complex short term health problem, e.g. an episode of acute urinary tract infection, brochopneumonia

~ A patient is transferred from a carer/family to respite care to give weekend relief to the carer/family

~ A clinician provides after hours/overnight or weekend coverage

~ (A referral may result in short term transfer of care)

- Long term/Permanent transfer:

o A carer/family/provider/organisation agrees to and takes over the care responsibility of a patient permanently or for an extended period of time

o Examples:

~ A provider (e.g. GP, PCP or specialist) takes over the care responsibility of a patient permanently because the patient wants to be cared for by a different provider; or when the primary/specialist provider retires

~ A rehabilitation facility/aged care or skilled nursing facility takes over the care responsibility of a patient when discharged from acute care hospital

• The "Transfer of Care" process also has three components:

- Transfer of Care Request

o A Transfer of Care request form/document or message sent from the requesting provider/organization to the receiving provider/organization

o Transfer of care request update: may use the "transfer of care request" resource to send additional information relevant to the request

- Cancel transfer of care request

o A transfer of care request may be cancelled due to change in patient's status or at patient/family request

- Transfer of Care Fulfillment

o Acceptance (after assessment of the request by the receiving provider/organization)

~ handled by FHIR "Order Response" resource

o Request for more information (also after assessment). The type of information requested may include: financial, administrative and clinical

~ New resource may be required

o Rejection (with reasons given)

~ handled by FHIR "Order Response" resource

o Recommendation of another more suitable provider/organization

~ Consider adapting "Care Plan" for sending recommendations

~ May require new resource

Transition of Care

• It is indicated that "Transition of Care" is a MU2 specific concept
• It is also recommended that the concept of "Transfer of Care" should be used
• Decision: No further analysis on this concept will be conducted beyond what has already been done

Comments from Russ Leftwich, MD (19 May 2014):
Would prefer the terms Referral and Transfer of Care, as less ambiguous.

From a US centric view, Transition of Care in the Meaningful Use programs has included referral. And as Dr O'Malley has outlined, there are 196 possible transitions of care. Referral is defined in MU as a closed loop referral.

FHIR Resources for Referral and Transfer of Care

The analysis works lead to the conclusion/agreement that two types of FHIR resources may be needed to meet the workflow requirements:

• Referral/Transfer of Care Request resource
• Referral/Transfer of Care Fulfillment resource

Referral/Transfer of Care Request Resource

The scope of referral/Transfer of Care request covers the following:

- Medical referral (to medical or medical and dental specialties)

- Community/District nursing referral (for community/district nursing services)

- Allied health referral (for physiotherapy, occupational therapy, nutrition services, etc)

- Community/social services referral

- Rehabilitation services referral

- Aged care/skilled nursing facilities placement request

NOTE - Medication review requests and diagnostic orders/requests [referral] are excluded from the scope of referral/transfer of care request

All these referral/transfer of care request types share the following common data set:

• Administrative Date:

- Patient and Demographic information (including language, cultural, level of education, ethnic and religious information)

- Contact details (including guardian and emergency contacts)

- Pension / health benefit scheme entitlements

- Insurance status

- Referrer details (provider and organization)

- Referred to provider details (provider and organization)

- GP/PCP details (who may not be the referrer)

The clinical data set components vary according to the types of referral.

Referral/Transfer of Care Fulfillment Resource

Referral/Transfer of Care fulfillment process include the following workflow components:

- Acceptance / Acceptance + Appointment

- Rejection

- Request for more information

- Recommendation

- Progress reporting

- Separation/discharge with summary reporting

Discussions at 29 May 2014 PCWG-FHIR conference call determined the need to explore the merits for developing "request for [more] information" and "recommendation" resources. "Order Response" and "Composition" resources are considered adequate to meet the requirement of other workflow components.

• Request for [more] information:

In the context of referral request or transfer of care request, the target provider/organization (i.e. the party receiving the request) may request additional information to help determine whether to accept or reject the request

The additional information requested may be of the following nature:

- Administrative

o For example: emergency contact person and contact mode details; community/social support received by patient

- Financial

o For example: insurance coverage type and level; or special health program entitlement information

- Clinical

o For example: medical history; family history; certain medication history; diagnostic tests results

• Recommendation:

In the context of referral request or transfer of care request, the target provider/organization may recommend that the requester perform certain administrative or clinical activities to better prepare the patient for the specialist care or for placement in rehabilitation/aged care/skilled nursing care facility

Examples of recommendation may include:

- Request certain diagnostic test(s) and forward the results to the target provider/organization (or have the target provider included in the result recipients list)

- Place the patient on a recommended management program, assess the outcome (and send an updated referral request with outcome information)

- Modify current management regime (e.g. medication therapy), assess the outcome (and send an updated referral request where necessary)

Referral and Transition of Care Data Requirements/Data Sets

Referral

The following data requirements are identified from detailed analysis of data set of international referral programs (e.g. from Australia, Canada, NHS):

• Administrative Date:

- Patient and Demographic information (including language, cultural, level of education, ethnic and religious information)

- Contact details (including guardian and emergency contacts)

- Pension / entitlements

- Insurance status

- Referrer details (provider and organization)

- Referred to provider details (provider and organization)

- GP/PCP details (who may not be the referrer)

- Referral acknowledgement

• Clinical Data:

- Presenting issues, symptoms, complaints

- Reasons for referral

- Alerts

- Physical examination findings

- Activities of daily living/self care assessments

- home and safety assessments

- Mental status assessment (e.g. behavioral, cognition, perception, mood, affect, sleep, memory, etc)

- Medical history

- Relevant family history

- Relevant social history

- Medication

- Allergy/Intolerance and Adverse Reactions

- Relevant investigations and results

- Care plan/relevant care plan components

- Current services/Requested services (including formal and informal [e.g. social clubs, churches, friends] services)

- Priority of service requested

- Patient consent to share information

• Sources:

- Australia-Western Victoria Referral Dataset 2011-08

- Australian Capital Territory (ACT) referral record

- Australian (Queensland) mental health referral form

- Canada Heart Failure Referral Form

- NHS Referral - minimal data set 2012

- Irish College of General Practitioner - Referral Template

Transition/Transfer of Care

• MU2 appears to specify that the Summary Care Record is to be used for information exchanges to support Transition of Care

A summary of care record is specified in the MU2 Measure (2013 Nov) document to include the following elements:

Patient name.

Referring or transitioning provider's name and office contact information (EP only).

Procedures.

Encounter diagnosis

Immunizations.

Laboratory test results.

Vital signs (height, weight, blood pressure, BMI).

Smoking status.

Functional status, including activities of daily living, cognitive and disability status

Demographic information (preferred language, sex, race, ethnicity, date of birth).

Care plan field, including goals and instructions.

Care team including the primary care provider of record and any additional known care team members beyond the referring or transitioning provider and the receiving provider.

Discharge instructions

Current problem list (Hospitals may also include historical problems at their discretion).

Current medication list, and

Current medication allergy list.

(Source: Eligible Hospital and Critical Access Hospital Meaningful Use Core Measures Measure 12 of 16 - 2013-Nov, p.2)

• The The Massachusetts Technology Collaborative has published a "Transfer of Care (CDA) Implementation Guide".

This implementation guide specifies the following sections:

5.1 Advance Directives Section (entries optional)

5.2 Allergies Section (entries optional)

5.2.1 Allergies Section (entries required)

5.3 Assessment Section

5.4 Chief Complaint and Reason for Visit Section

5.5 Encounters Section (entries optional)

5.5.1 Encounters Section (entries required)

5.6 Family History Section

5.7 Functional Status Section

5.8 History of Past Illness Section

5.9 History of Present Illness Section

5.10 Hospital Discharge Diagnosis Section

5.11 Immunizations Section (entries optional)

5.11.1 Immunizations Section (entries required)

5.12 Medical Equipment Section

5.13 Medications Section (entries optional)

5.13.1 Medications Section (entries required)

5.14 Payers Section

5.15 Physical Exam Section

5.16 Plan of Care Section

5.17 Problem Section (entries optional)

5.17.1 Problem Section (entries required)

5.18 Procedures Section (entries optional)

5.18.1 Procedures Section (entries required)

5.19 Results Section (entries optional)

5.19.1 Results Section (entries required)

5.20 Social History Section

5.21 Vital Signs Section (entries optional)

5.21.1 Vital Signs Section (entries required)

(Source: Massachusetts Technology Collaborative - Transfer of Care Implementation Guide 2013-03)

Related Documents

Storyboards and Use Cases

• Referral and Transfer of Care Scenarios (from Jim McClay, MD; Larry Garber, MD; Kevin Coonan, MD)

Relevant References

• Referral Process Diagram:

Referral Process - Referrer-ReferredTo Providers Interactions

• Data sets for Transfer of Care - keynote presentation:

2013 HL7 Plenary Keynote by Dr Terry O'Malley - as zip file