Referral and Transition/Transfer of Care
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Contents
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:
- Link to Referral FHIR Resource Proposal (on FHIR wiki):
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
- (Definition source: http://www.caretransitions.org/definitions.asp)
Transfer of Care
Related Documents
Storyboards and Use Cases
Relevant References
FHIR Resources relevant to Referral project
- Link to FHIR Resources Proposals wiki:
- Link to FHIR Clinical Resources wiki:
- This is the link to a blog on Referrals created by David Hay on Referral:
