Discharge Plan

The Discharge Plan includes the structured information captured by the hospital staff that is required by the other staff in the Transfer of Care Hubs (ToC Hubs) to arrange the appropriate support on discharge. The FHIR CarePlan will be used to model the Discharge Plan

The Discharge Plan will comprise of the following attributes

Attribute Cardinality Type Details
meta.profile 1..1 url Fixed: https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-CarePlan-1
id 1..1 string Unique id for updates and referencing
status 1..1 code If relevent Encouter.status='in-progress' ... use D2A Sign-off field in Nervecentre to determine CarePlan.status: 'unknown' when D2A Sign-off is NULL; 'draft' when D2A Sign-off is "Awiating IDT"; 'active' when D2A Sign-off is "Awaiting Hub" or "Signed-Off"
If Encouter.status='finished' ... CarePlan.status='completed'
intent 1..1 code Use D2A Sign-off field in Nervecentreto determine CarePlan.intent: 'proposal' when D2A Sign-off is NULL or "Awiating IDT"; 'plan' when D2A Sign-off is "Awaiting Hub"; 'order' when D2A Sign-off is "Signed-Off"
category.coding 1..1 code Fixed:
"system": "https://fhir.nottscr.nhs.uk/CodeSystem/D2A-ArtifactCode-1",
"code": "d2a-dischargePlan",
"display": "D2A Discharge Plan"
description 0..* string Text string from Hub D2A Recommendation field in Nervecentre - note these will only be completed after the hub review (i.e. AssessmentStatus = 'Signed-Off'
subject 1..1 Reference Reference to the relevant Patient FHIR Resource
context 1..1 Reference Reference to the relevant Encounter FHIR Resource
period 1..1 DateTime(s) START will be added when the plan is created (which could be assumed to be the addmission date), the END when the plan is completed (i.e. Patient Discharged)
author 1..1 Reference Reference to the relevant Organization (i.e. Hospital) that created the Plan
note 0..* annotation In most cases will just be a single multi-line text string (e.g. from Discharge Information field in Nervecentre), however multiple notes each with a text, author and date could be used
Extension-D2A-AssessmentStatus 0..1 Code/String SHOULD be provided once the D2A Assessment Form has been completed, value will from D2A Sign-Off field in Nervecentre, i.e. ... Awaiting IDT | Awaiting Hub | Signed-Off
Extension-D2A-Pathway 1..1 Code/String Hub D2A Pathway field in Nervecentre, i.e. ... To Be Determined | Pathway 1 | Pathway 2 | Pathway 3
Extension-D2A-D2A-NoReasonToReside 0..1 Code/String details from the No Reason to reside field, if recorded on Nervecentre
Extension-D2A-ResponsibleLA 1..1 Reference Reference to Organization that would be responsible for providing social care (i.e. based on their home address or historic provision)

Example

Example of a CarePlan for a D2A Discharge Plan:

{
    "resourceType": "CarePlan",
    "meta": {
        "profile":  [
            "https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-CarePlan-1"
        ],
        "tag":  [
            {
                "code": "D2A"
            }
        ]
    },
    "id": "D2A-Discharge-Plan-Example",
    "status": "active",
    "intent": "plan",
    "category":  [
        {
            "coding":  [
                {
                    "system": "https://fhir.nottscr.nhs.uk/CodeSystem/D2A-ArtifactCode-1",
                    "code": "d2a-dischargePlan",
                    "display": "D2A Discharge Plan"
                }
            ]
        }
    ],
    "description": "Text string from Hub Recommendations field in Nervecentre - note these will only be competed after the hub review (i.e. business status = 'signed-off'",
    "subject": {
        "reference": "Patient/9999999999"
    },
    "context": {
        "reference": "Encounter/acute-inpatient-encounter"
    },
    "period": {
        "start": "2024-01-06"
    },
    "author":  [
        {
            "reference": "Organization/RX1"
        }
    ],
    "note":  [
        {
            "text": "Large multi-line text sting from Discharge Information field in Nervecentre"
        }
    ],
    "extension":  [
        {
            "url": "https://nottscr.nhs.uk/StructureDefinition/Extension-D2A-AssessmentStatus",
            "valueCodeableConcept": {
                "text": "Awaiting Hub"
            }
        },
        {
            "url": "https://nottscr.nhs.uk/StructureDefinition/Extension-D2A-Pathway",
            "valueCodeableConcept": {
                "text": "To Be Determined"
            }
        },
        {
            "url": "https://nottscr.nhs.uk/StructureDefinition/Extension-D2A-NoReasonToReside",
            "valueCodeableConcept": {
                "text": "Individual/family not in agreement with discharge plans"
            }
        },
        {
            "url": "https://nottscr.nhs.uk/StructureDefinition/Extension-D2A-ResponsibleLA",
            "valueReference": {
                "reference": "Organization/511"
            }
        }
    ]
}

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