IHE Patient Care Coordination Technical Framework Vol I

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PCC Technical Framework V3.0, vol. 1 ________________________________________________________________________ 3.10.4.1 Long-Term Care to Acute Care 2265 2270 Table 3.10-2 Long Term Care to Acute Care Process Flow Primary Actor(s): Discharge nurse in LTC facility, Admitting nurse in acute care facility Stakeholder(s): Primary Care Physician, Hospitalist Use Case Overview: A diabetic nursing home patient is transferring from the LTC environment to an in-patient acute care hospital based on deteriorating functional status assessments. _____________________________________________________________________ 79 Revision 3.0 Public Comment — June 25, 2007 Copyright © 1997-2007: ACC/HIMSS/RSNA
PCC Technical Framework V3.0, vol. 1 ________________________________________________________________________ 2275 2280 2285 2290 2295 2300 2305 Use Case Scenario 1. A 76 year old resident/patient of a LTC facility has become increasingly weak, lethargic and has a low-grade fever. Resident refuses to get out of bed and is complaining of chills and the nurse noted reddened area on coccyx during assessment. Resident's glucose level is elevated and the maximum sliding-scale dose indicated in medication order is not controlling blood sugar. 1. Nurse documents vital signs. 2. Nurse documents finger-stick glucose measurement. 3. Nurse documents current functional assessment. 4. Nurse documents braden score. 5. Nurse initiates phone collaboration with Primary Care Provider (PCP). 6. Primary care provider(PCP)and nurse review patient status information on the electronic health record (EHR). Note: Interdisciplinary collaboration supports evaluation of physiologic changes and critical thinking leading to early intervention. 7. PCP enters transfer order to acute care facility via computerized physician order entry (CPOE). 2. The patient's baseline and serial functional assessment data is sent to the acute care hospital via a document exchange server. 1. Nurse admission coordinator reviews transfer documents via the EHR. Note: Early comprehensive patient information availability allows the admission coordinator to assign appropriate unit and adjust staffing based on potential acuity. Appropriate nurse to patient acuity staffing ratios support both staff and patient safety, reducing risk of errors. 2. Bed is assigned on medical floor at acute care facility, pending admission is sent to charge nurse on the medical floor. 3. Charge nurse reviews the patient's functional status assessment data, VS, glucose values and braden score from LTC facility. Note: The charge nurse is provided additional time to reassign other patients and/or allowing the admitting nurse more time to prepare for the patient admission. 1. Based on the information reviewed, Charge nurse adjusts shift assignment based on patient’s level of care. 4. Patient arrival to medical floor at acute care facility. 1. Admitting nurse takes patient VS and completes admission assessment in EHR. Note: Nurse compares serial EHR preadmission assessments to new admission assessment data. Serial EHR assessments allow nurse to compare _____________________________________________________________________ Revision 3.0 Public Comment — June 25, 2007 80 Copyright © 1997-2007: ACC/HIMSS/RSNA
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IHE Patient Care Coordination Technical Framework Vol I

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