Long-Term Care & Skilled Nursing Organizations

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. 

Service Descriptions 
  1. 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.
  2. 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
  3. 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.
  4. 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.
  5. 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
HSX Member Abramson Center for Jewish Life
Benefits 

By participating with HSX, long-term care organizations can:

  • 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

To learn more, download our Long Term Care fact sheet 

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