PACIO Transitions of Care Implementation Guide
0.1.0 - ci-build
PACIO Transitions of Care Implementation Guide
0.1.0 - ci-build
PACIO Transitions of Care Implementation Guide - Local Development build (v0.1.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions
| Official URL: http://hl7.org/fhir/us/pacio-toc/ImplementationGuide/hl7.fhir.us.pacio-toc | Version: 0.1.0 | |||
| Draft as of 2024-05-13 | Computable Name: PACIOTransitionsOfCare | |||
The purpose of the LTPAC Transitions of Care (TOC) Implementation Guide is to provide a standards-based solution to support care transitions and coordination for LTPAC patients across all settings of care. The five traditional Post-Acute Care (PAC) settings, Hospice, Home Health, Skilled Nursing, Long Term Care Hospitals, and Inpatient Rehab facilities employ many types of clinicians, practitioners, therapists, and allied professionals who each require different information to provide the best and most efficient services to their patients. This information may include standardized assessments, patient preferences, observations, and other important data. Many of these items are valuable during a transition of care from one setting to another, including settings outside of Post-Acute Care such as Acute Inpatient, Emergency Department, and Home- and Community-Based Organizations (HCBOs). This critical information is often not exchanged, resulting in gaps in care information during initial assessments and reassessments in new or parallel settings, and the data is never available as a specific role-based data set. This leads directly to potentially unsafe transition and coordination of care for these most vulnerable patients as well as information overload, additional documentation, errors in the patient record, incorrectly reconciled data, and a burden on families and patients to carry physical records with them during transitions.
The CMS Data Element Library provides the reference data (questions and answers) for key quality instruments in post-acute care, notably the MDS and OASIS. Today, most if not all information that could help inform the completion of these assessments is captured at the referral source, but not in a manner that can be meaningfully presented to the post-acute provider. Without this context and properly mapped information, providers in Post-acute care settings are piecing together information from scratch through clinical observation or laborious review of narrative and other documentation that accompanies a referral. The challenge is similar outside of these instruments—stretching into areas like Advance Directives or Personal Care preferences.
The PACIO Project is a collaborative effort to advance interoperable health data exchange between PAC and other providers, patients, their caregivers, and key stakeholders across healthcare and to promote health data exchange in collaboration with policy makers, standards organizations, and industry through a consensus-based approach.
The primary goal of the PACIO Project is to establish the technical foundation for data exchange within PAC and partner organizations across the spectrum of care. It seeks to do so by creating a framework for and community through the development of Fast Healthcare Interoperability Resource (FHIR©) technical implementation guides (IGs) and reference implementations that will facilitate health data exchange through standards-based use case-driven application programming interfaces (APIs).
Information covered in this IG is relevant to providers across the full spectrum of patient care, including acute, sub-acute, long-term post-acute care (LTPAC), community-based organizations, and private practice practitioners. The PACIO community brings together healthcare providers with a deep understanding of patient functioning that makes them uniquely suited to author this IG. This understanding comes out of providers’:
The scope of this guide is intentionally broad, as the nature of specific conditions and the disciplines required to care for them require varying sets of information. This guide relies predominantly upon the existing body of work supported by the PACIO project using CMS’s data element library and using these structures to define key pieces of information needed by a post-acute provider receiving a referral.
One impetus for this IG is the amendment to the Social Security Act in 2014 to include the Improving Medicare Post-Acute Care Transformation (IMPACT) Act. The IMPACT Act requires the standardization and interoperability of patient assessments in specific categories for PAC settings, including long-term care hospitals (LTCHs), home health agencies (HHAs), SNFs, and inpatient rehabilitation facilities (IRFs). It focuses on the standardization of data elements in specified quality measure and patient assessment domains for cross-setting comparison and clinical information exchange, respectively.
The Act requires:
Data to be standardized and interoperable to allow exchange of data between PAC providers, among others, using common standards and definitions to provide access to longitudinal information and facilitate coordinated care.
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There are no Global profiles defined
Package hl7.fhir.uv.extensions.r4#5.1.0 This IG defines the global extensions - the ones defined for everyone. These extensions are always in scope wherever FHIR is being used (built Sat, Apr 27, 2024 18:39+1000+10:00) |
Package hl7.fhir.us.core#4.0.0 The US Core Implementation Guide is based on FHIR Version R4 and defines the minimum conformance requirements for accessing patient data. The Argonaut pilot implementations, ONC 2015 Edition Common Clinical Data Set (CCDS), and ONC U.S. Core Data for Interoperability (USCDI) v1 provided the requirements for this guide. The prior Argonaut search and vocabulary requirements, based on FHIR DSTU2, are updated in this guide to support FHIR Version R4. This guide was used as the basis for further testing and guidance by the Argonaut Project Team to provide additional content and guidance specific to Data Query Access for purpose of ONC Certification testing. These profiles are the foundation for future US Realm FHIR implementation guides. In addition to Argonaut, they are used by DAF-Research, QI-Core, and CIMI. Under the guidance of HL7 and the HL7 US Realm Steering Committee, the content will expand in future versions to meet the needs specific to the US Realm. These requirements were originally developed, balloted, and published in FHIR DSTU2 as part of the Office of the National Coordinator for Health Information Technology (ONC) sponsored Data Access Framework (DAF) project. For more information on how DAF became US Core see the US Core change notes. (built Mon, Jun 28, 2021 19:09+0000+00:00) |
Package hl7.fhir.uv.extensions#1.0.0 This IG defines the global extensions - the ones defined for everyone. These extensions are always in scope wherever FHIR is being used (built Sun, Mar 26, 2023 08:46+1100+11:00) |
Package hl7.fhir.uv.extensions.r4#1.0.0 This IG defines the global extensions - the ones defined for everyone. These extensions are always in scope wherever FHIR is being used (built Sun, Mar 26, 2023 08:46+1100+11:00) |
Package hl7.fhir.us.pacio-adi#1.0.0 PACIO Advance Directive Interoperability Implementation Guide (built Thu, Jan 11, 2024 17:40+0000+00:00) |
Package hl7.fhir.uv.bulkdata#2.0.0 FHIR based approach for exporting large data sets from a FHIR server to a client application (built Fri, Nov 26, 2021 05:56+1100+11:00) |
Package hl7.fhir.r4.examples#4.0.1 Example resources in the R4 version of the FHIR standard |
Package hl7.fhir.uv.sdc#3.0.0 The SDC specification provides an infrastructure to standardize the capture and expanded use of patient-level data collected within an EHR. |
Package hl7.fhir.us.core#5.0.1 The US Core Implementation Guide is based on FHIR Version R4 and defines the minimum conformance requirements for accessing patient data. The Argonaut pilot implementations, ONC 2015 Edition Common Clinical Data Set (CCDS), and ONC U.S. Core Data for Interoperability (USCDI) v1 provided the requirements for this guide. The prior Argonaut search and vocabulary requirements, based on FHIR DSTU2, are updated in this guide to support FHIR Version R4. This guide was used as the basis for further testing and guidance by the Argonaut Project Team to provide additional content and guidance specific to Data Query Access for purpose of ONC Certification testing. These profiles are the foundation for future US Realm FHIR implementation guides. In addition to Argonaut, they are used by DAF-Research, QI-Core, and CIMI. Under the guidance of HL7 and the HL7 US Realm Steering Committee, the content will expand in future versions to meet the needs specific to the US Realm. These requirements were originally developed, balloted, and published in FHIR DSTU2 as part of the Office of the National Coordinator for Health Information Technology (ONC) sponsored Data Access Framework (DAF) project. For more information on how DAF became US Core see the US Core change notes. (built Wed, Jun 22, 2022 19:44+0000+00:00) |
Package hl7.fhir.us.pacio-pfe#1.0.0 FHIR Implementation Guide to exchange assessments of and data on a person's functioning, including body functions, activities, and participation, between post-acute care (PAC) and other providers, patients, and key stakeholders (built Fri, Jan 5, 2024 16:53+0000+00:00) |
Package ihe.formatcode.fhir#1.1.0 Implementation Guide for IHE defined FormatCode vocabulary. (built Thu, Feb 24, 2022 16:55-0600-06:00) |
Package hl7.fhir.us.core#6.1.0 The US Core Implementation Guide is based on FHIR Version R4 and defines the minimum conformance requirements for accessing patient data. The Argonaut pilot implementations, ONC 2015 Edition Common Clinical Data Set (CCDS), and ONC U.S. Core Data for Interoperability (USCDI) v1 provided the requirements for this guide. The prior Argonaut search and vocabulary requirements, based on FHIR DSTU2, are updated in this guide to support FHIR Version R4. This guide was used as the basis for further testing and guidance by the Argonaut Project Team to provide additional content and guidance specific to Data Query Access for purpose of ONC Certification testing. These profiles are the foundation for future US Realm FHIR implementation guides. In addition to Argonaut, they are used by DAF-Research, QI-Core, and CIMI. Under the guidance of HL7 and the HL7 US Realm Steering Committee, the content will expand in future versions to meet the needs specific to the US Realm. These requirements were originally developed, balloted, and published in FHIR DSTU2 as part of the Office of the National Coordinator for Health Information Technology (ONC) sponsored Data Access Framework (DAF) project. For more information on how DAF became US Core see the US Core change notes. (built Fri, Jun 30, 2023 14:02+0000+00:00) |
This is an R4 IG. None of the features it uses are changed in R4B, so it can be used as is with R4B systems. Packages for both R4 (hl7.fhir.us.pacio-toc.r4) and R4B (hl7.fhir.us.pacio-toc.r4b) are available.
This publication includes IP covered under the following statements.
