Final Contract Report
This report describes the effect of a redesigned, electronic version of the "Home Health Certification and Plan of Care" (Form CMS-485) on the completeness of patient referral information and provision of evidence-based home health care. It also describes the development and pilot testing of a Web-based system ("e-transitions") that provides electronic access to this information and allows alerts to be designed and generated when appropriate.
Prepared by Mark Callahan, M.D., Eugenia Siegler, M.D., Hirsch Ruchlin, Ph.D., Kawai Oneda, M.P.H., and Renee Razzano, M.A., Weill Medical College of Cornell University/New York Presbyterian Hospital; Christopher M. Murtaugh, Ph.D., Robert Rosati, Ph.D., Rocco Napoli, B.A., Sally Sobolewski, RN, M.S.N., Theresa Schwartz, B.A., Penny Feldman, Ph.D., Amy McGuire, B.A., and Janice Foust, RN, Ph.D., Center for Home Care Policy and Research, Visiting Nurse Service of New York.
Background and Purpose
Evaluation of One-Way Discharge Form (e-485)
Development of e-485
Analysis of e-485
Evaluation of Web-Based System (e-transitions)
Development of e-transitions
Pilot and Focus Group Testing of e-transitions
Conclusion and Lessons Learned
Diagram 1. Overview of Development Process for E-transitions
A. Side-by-Side Comparison of a Home Health Plan of Care Form
B. Sample e-485 Form
C. Mapping of CMS-485 and e-485 to the Continuity of Care Record
D. E-transitions Sample Screen Shots
E. VNSNY Workflow Diagrams for Pilot Testing e-transitions
This project was funded by the Agency for Healthcare Research and Quality under Contract No. 290-00-0013.
AHRQ Publication No. 07-0045-EF
Current as of September 2007
Development of Electronic Transition Tools for Home Health Care: Final Contract Report. AHRQ Publication No. 07-0045-EF, September 2007, Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/qual/etransitions/