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.

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

• Project Scope Statement:

Referral FHIR Resoruces PSS - Approved 2014-04-29

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

Referral FHIR Resource Proposal

Definitions

Referral

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)

• 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 locations; or

~ different levels of care within the same location

Transfer of Care

Related Documents

Storyboards and Use Cases

Relevant References

FHIR Resources relevant to Referral project

• 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

• This is the link to a blog on Referrals created by David Hay on Referral:

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