Contributing or Reviewing Work Groups:
Patient Care Work Group (sponsor)
Community-Based Care and Privacy Work Group (sponsor)
Patient Administration Work Group (interested party)
FHIR Development Project Insight ID:
Develop a FHIR R4 IG that leverages the eLTSS work to provide the profiles and necessary extensions required to specify how to syntactically and semantically exchange
cognitive status post-acute care assessment data between care settings.
Poor quality discharge information is a major barrier to safe and effective transitions. With 45% of Medicare beneficiaries requiring post-acute care (PAC) services after hospitalization, the need for a seamless exchange of health information is great.
In 2014, the Social Security Act was amended to include the Improving Medicare Post-Acute Care Transformation (IMPACT) Act, which required the standardization and interoperability of patient assessment in specific categories for post-acute care (PAC) settings, including long-term care hospitals (LTCHs), home health agencies (HHAs), skilled nursing facilities (SNFs), and inpatient rehabilitation facilities (IRFs). It focuses on standardizing data elements in specified quality measure domains and patient assessment domains for cross setting comparison and clinical information exchange, respectively. The Act requires:
- Reporting of standardized patient assessment data through commonly used PAC assessment instruments for LTCHs, SNFs, HHAs, and IRFs
- Minimum Data Set (MDS) for SNFs
- Inpatient Rehabilitation Facility – Patient Assessment Information (IRF – PAI) for IRFs
- LTCH Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) for LTCHs
- Outcome and Assessment Information Set (OASIS) for HHAs
- Implementation of data elements specified in each assessment domain using standardized data elements to be nested within the assessment instruments currently required for submission by LTCH, IRF, SNF, and HHA providers
- 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.
Required assessment content includes standardized questions and response options (aka “data elements”) for assessing a patient’s cognitive status.
This FHIR R4 IG
leverages the eLTSS work to provide the profiles and necessary extensions required to specify how to syntactically and semantically exchange
that cognitive status post-acute care assessment data between care settings.
This implementation guide is being developed by the clinical, EHR, and client app organizations as part of the PACIO Project.