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Development of Electronic Transition Tools for Home Health Care: Appen

Referral via e-transitions Web site

Patient is assessed for post-discharge care by his or her MD. If no post-discharge care is required patient is discharged via usual discharge procedures. Patient requiring post-discharge care is then assessed for any home care needs. If home care at VNSNY is required, the referring MD from Cornell completes an e-485 using CLIMACS. Data is then encrypted and shipped to the e-transitions database. If the referring MD is not from Cornell the e-485 and e-transitions database is accessed via the web using a user ID and password.

After the transfer of data to the e-transitions database, an E-mail is generated notifying Central Admission Unit (CAU) staff that a patient has been referred to home care. CAU staff views the e-485 on e-transitions database. An E-mail is sent to the research team informing them that CAU received a referral. CAU staff can either accept the referred patient for home care or not. If the patient is not accepted into home care for whatever reason, the referring MD and primary MDs (if not the same) is notified. 

Intake by Visiting Nurse and Signing of CMS-485

Information on the patient accepted for home care is entered into the VNSNY electronic record by CAU staff. CAU accesses e-transitions and notes which of the two VNSNY Adult Care teams the patient is assigned. CAU then releases referral to selected VNSNY team. If the patient was not assigned to one of the two teams participating in the pilot an E-mail is sent through e-transitions notifying the referring/primary care MD that the case has been processed but will not be included in the pilot. If however, the patient qualifies to be part of the pilot, an E-mail is sent to the Patient Service Manager (PSM).* and facilitator alerting them that patient is part of the pilot. Case is assigned by teams PSM or facilitator to participating VN in pilot. At this point, the VN goes out into the field to complete an initial home care assessment with the patient.

*Nurse Manager for a team of nurses at VNSNY. 

Intake by Visiting Nurse and Signing of CMS-485 (continued)

The original plan of care (POC) from the e-485 is reviewed after home care assessment. If POC does not require modification or modifications that were made did not require approval by the primary care MD, an E-mail will be sent to the primary care MD on e-transitions that the patient was admitted to VNSNY and that POC initial orders require his or her verification. Primary care MDs access e-transitions database to view initial POC and sign off on initial orders. When paper copy of POC (or hard copy of e-485) is received by the primary care MD he or she will sign it and send it back to VNSNY for placement in record.

If POC was modified and these modifications require primary care MD approval, VNSNY first accesses 485 on e-transitions database and modify the POC. Primary care MD is sent an E-mail informing him or her that the patient was admitted to VNSNY and that a recommended change in POC requires his or her review. Primary care MD accesses e-transitions database and views changes.**

**If pilot MD says another MD must approve part of POC (e.g., medication and dose), usual procedure for processing modifier to cover orders not signed by primary MD will be followed. VN will notify Research Center and Research Center will update e-transitions database when approval (verbal or signed e-485) is received. 

Intake by Visiting Nurse and Signing of CMS-485 (continued)

If primary care MD agrees with the changes made to the POC and makes no further adjustments he or she will electronically approve the changes. An E-mail is then sent to the RN notifying the RN that the primary care MD has reviewed the POC and approved the modifications. The RN makes adjustments in tablet to reflect changes made on e-transitions and he or she documents communication with the MD. A new paper e-485 is sent by mail/fax to the MD for signature. Upon receipt of POC primary care MD signs the form and sends it back to VNSNY for placement in record.

If primary care MD does not agree with the changes to the POC and wants to make further modifications, an E-mail is sent to the RN notifying the RN that primary care MD has modified the POC. VN access e-transitions database and copies changes onto tablet and documents communication with primary care MD. Upon receipt of POC primary care MD signs the form and sends it to VNSNY for placement in record. 

Exchange of Information between Visiting Nurse and Primary Physician during Episode of Care

If POC does not require modification or modifications that were made did not require approval by the primary care MD, VN accesses e-485 on e-transitions database and modifies the POC and notes changes on tablet. An E-mail is sent to the primary care MD to alert him or her that POC has been changed. Primary care MDs access e-transitions database to view changes.

If POC was modified and these modifications require primary care MD approval, VN accesses e-485 on e-transitions database and modifies POC. An E-mail alert is automatically sent to inform the primary care MD that POC has been modified and requires his or her approval. Primary care MD accesses e-transitions database and views and signs off on changes to the POC. 

Exchange of Information between Visiting Nurse and Primary Physician during Episode of Care

If primary care MD agrees with the changes in the POC and makes no further changes, an E-mail is sent to the RN notifying the RN that primary care MD has reviewed the POC and approved the modifications. The RN makes adjustments in tablet. A new paper e-485 is sent by mail/fax to the MD for signature. Upon receipt of POC primary care MD signs the form and sent it back to VNSNY for placement in record.

If primary care MD does not agree with the changes to the POC and wants to make further modifications, he or she makes changes using e-transitions. An E-mail is sent to the RN notifying the RN that primary care MD has modified the POC. VN access e-transitions database and copies changes onto tablet. E-485 is automatically faxed/mailed to MD for signature as per regional procedure. Upon receipt of POC primary care MD signs the form and sent it back to VNSNY for placement in record.

Return to Appendix E

Page last reviewed September 2007
Internet Citation: Development of Electronic Transition Tools for Home Health Care: Appen. September 2007. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/long-term-care/resources/hcbs/etransitions/etransitionsapetext.html