Multimodality Care Transition Optimization

Participating Organizations: Bamboo Health, eClinicalWorks, Epic, Kno2, MatrixCare, MedAllies, Mettle Solutions, Netsmart, Nextgen

Our patient, Donnie Boyd, is a 75-year-old morbidly obese man with a history of type II diabetes, chronic obstructive pulmonary disease (COPD), high blood pressure and hyperlipidemia with a 100-pack year smoking history. He had consistently refused COVID-19 vaccination until he was recently hospitalized, intubated and admitted to the ICU with complications from COVID-19. Prior to this hospitalization he had been living alone independently, however, he had received weekly home health services for assistance managing his multiple medical conditions. Unfortunately for Donnie, not only did his long hospitalization leave him very debilitated, but he also developed several long COVID sequelae: a rash, major depressive disorder and COVID headaches. Our demo begins with Donnie being discharged home from the hospital. As Donnie transitions across multiple healthcare facilities including home health, primary and specialty care, and admission to a skilled nursing facility his care is optimized as his providers use the latest multi-modality protocols, technology, and standards of interoperability. The patient’s trajectory to recovery is optimized through: IHE 360X enabled care transitions, Condition of Participation Admission Discharge and Transfer (ADT) alerting, FHIR and 360X Scheduling, DaVinci payer prior authorization and SMART on FHIR patient cost transparency. The standards used and demonstrated include C-CDA, HL7®, Direct, and HL7® FHIR®.