Development of Electronic Transition Tools for Home Health Care

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. 

Contents

Summary
  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
  References
Diagram 1. Overview of Development Process for E-transitions
Appendixes:
  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.