This use case supports sending notifications on the status of patients’ care transitions to every care team member interested in that patient.
Admission, discharge, transfer (ADT) notifications are widely regarded as a keystone to improving patient care coordination through health information exchange. ADT notifications are sent when a patient is admitted to a hospital, transferred to another facility, or discharged from the hospital. Notifications are then sent to update physicians and care management teams on a patient’s status, thus improving post-discharge transitions, prompting follow-up, improving communication among providers, and supporting patients with multiple or chronic conditions.
ADT notifications also help to identify patients who are frequent or high users of the healthcare system. This allows providers to steer those patients toward clinical and non-clinical interventions, reducing overutilization by preventing avoidable emergency department visits and hospital readmissions.
As of January 2020, the ADT Implementation Guide includes information for the System for Opioid Overdose Surveillance.
The following document(s) are available for this scenario:
The Persona Story
Billy Chen, the four-year-old son of Joan and William Chen, has been suffering from a number of health complications resulting from rubella he contracted before birth: cataracts, hearing loss, and a congenital heart defect. Billy and his parents’ lives revolve around doctors’ visits with Joan often taking Billy to specialists around Michigan and nationwide. Billy sees 13 different specialists and physicians each of whom needs to stay up to date with Billy’s condition to help coordinate his care.
Joan is relentlessly vigilant in managing Billy’s healthcare because she knows his condition puts him at a higher risk for infection, meningitis, and heart failure. Joan tries to keep all of Billy’s physicians and care team members on the same page with changes in Billy’s status, but this is an exhausting process. Joan hates feeling like she spends more time updating Billy’s specialists over the phone than she does with her sick child.
One night Joan wakes up to a sound that makes her heart drop: Billy crying out in pain. He has a high grade fever, confusion, and muscular pain so Joan frantically rushes him to a local emergency department. Immediately after Billy is admitted, hospital staff update Billy’s electronic chart to reflect his admission, an action that generates an ADT notification. Copies of the ADT notification are then automatically sent to each member of Billy’s care team because they have signed up to receive electronic updates on Billy’s status. Receiving real-time information on changes in Billy’s condition helps all of the providers on Billy’s care team make coordinated and informed decisions on Billy’s care plan. What’s more, when Billy is discharged, another notification will be sent to his care team members alerting them to his change in status including any medication changes so they can begin working to ensure Billy’s care transition is smooth and well-managed.
Joan knows they have a difficult night ahead of them, but it’s the first night in a long time that she hasn’t felt pulled between the two worlds of being a full-time mother and an unofficial care coordinator. Joan can find comfort in the knowledge that the next time she communicates with any provider on Billy’s care team, that provider will already be aware of Billy’s status and ready to further coordinate Billy’s care as he leaves the hospital. Having an entire support system working and coordinating behind the scenes helps Joan spend her time where it matters most – at Billy’s bedside making sure he feels safe and loved.