In organizations representing the continuum of care, there can be significant challenges coordinating care as patients are transitioning between various care settings. By having access to hospital and provider data, long-term care and skilled nursing facilities are able to have a clearer picture about a patient’s clinical history.
HealthShare Exchange (HSX) currently has 2 long-term care organizations are members who are utilizing services to bridge gaps and provide quality care.
- Direct Secure Messaging (DIRECT)/ Provider Directory (PD)
- Point-to-point exchange of clinical information between providers’ direct addresses using the national Direct Project standards — included, but not limited to, sending of continuity of care (C-CDA) documents with discharge information and referrals for transitions of care. HSX can offer direct addresses to providers and facilities, as needed.
- The HSX PD contains more than 8,000 direct addresses for healthcare providers who actively participate with HSX for direct messaging; interoperability testing is completed before providers’ direct addresses are added to the PD to ensure employed providers within hospitals and health systems can engage with Direct in a meaningful way.
- Clinical Data Repository
- Collects and retains medical-records data about patients, permitting a patient’s provider and/or care-team members to query for clinical information about the patient.
- Long-term care / skilled nursing organizations have the opportunity to access the CDR through the HSX query portal or through EHR integration.
- Clinical Data Repository (CDR) Overview
- Encounter Notification Service (ENS) – For Long-Term Care Organizations
- Once an organization supplies Admit, Discharge, Transfer (ADT) feeds to HSX, HSX can automatically subscribe discharged patients from the facility for a period of time.
- ENS auto-subscription then can provide notifications back to the participating HSX-Member organization about these discharged patients who are subsequently admitted within a defined timeframe (e.g. 90 days) to other HSX-Member emergency departments and hospitals, which can be valuable for care coordination and bundled payment programs.
- Automated Care Team Finder (ACTF)
- Uses the patient’s member identification with his or her healthcare insurer to identify the patient’s primary care provider and route continuity of care (C-CDA) documents, containing discharge information, leveraging the HSX PD.
- Skilled nursing / short stay rehab organizations that are able to generate ADT feeds and want to automatically route information to patient’s external care providers are eligible to participate with this service.
- Clinical Activity History (CAH)
- Collects recent clinical history about a patient from the patient’s healthcare insurer, based on the patient’s member identification within the health plan and translates this claims/utilization data to a clinical care document — returning this information to the requesting provider organization.
- Admission, discharge, transfer (ADT) feeds trigger the clinical activity history documents to be delivered to the requestor.
- Download our Clinical Activity History Overview
By participating with HSX, long-term care organizations can:
- Electronically share continuity of care documents post-discharge to help patients connect with downstream providers
- Receive documents electronically from hospitals to assist with the admissions process into skilled nursing, short stay rehab or long-term care.
- Improved care coordination with notifications for residents who have been discharged from a facility and subsequently present to a HSX-Member emergency department or hospital within a specified period of time
- Secure access to a centralized repository of health information from multiple hospitals and providers
- Receive timely information about patient encounters with the healthcare system within a defined period post-charge to improve care management and decrease potential for readmissions