Discharge to Assess

The Notts Care Record (NCR) will also be used to support the interoperable sharing of information that supports the discharge to assess (D2A) process.

D2A Interoperability will ensure that clinicians and social care practitioners can view and update the relevant data about a patients discharge in either their Line on Business System or the Notts Care Records (via a contextual link), without having to access and dual key into other organisations systems

Data Item Description Owner FHIR Resource
D2A Trigger Task The Trigger Task is used to identify that a patient will require, or is likely to require, support from either the community health or social care teams on discharge. Hospital Task
Inpatient Spell The inpatient spell will include information that is key to enabling a safe and timely discharge, such as the ready for discharge status and predicted safe for discharge date Hospital Encounter
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. Hospital CarePlan
D2A Assessment The full D2A Assessment undertaken by the hospital teams, detailing all the other information that that is required by the other staff in the ToC Hubs to arrange the appropriate support on discharge. Hospital DocumentReference (e.g. PDF)
D2A Parent Task The Parent Task builds on the CarePlan and details the high level tasks/activities that need to be undertaken to facilitate a safe and timely discharge and which organisation is responsible for them. The Parent Task will usually be agreed as part of the Triage process in the ToC Hub and recorded in the D2A section of the Notts Care Record (NCR). For those organisations that wish to automatically create workflow in their line of business systems (LoBS), the Parent task will act as the referral ToC Hub (in the NCR) Task
D2A Child Task The Child Task is a composite part of the Parent Task, and is used to record progress and outcome of the parent. The rationale for a separate task is to enable organisations to record the progress in a separate application (i.e. their LobS) Task Owners (in their LoBS or the NCR) Task

D2A Data Model

D2A Trigger Task

The D2A Trigger Task will be created as soon as a Patient is flagged as a Supported Discharge in the relevant hospital system (e.g. Nervecentre). The exact rules for creating the task may be different in each hospital system, in some cases it my by a check box/flag, in others it could be a drop down where multiple value equate to a support required flag.

The record of whether support is required may change, so the local processes will need to cater for patients being initially marked as requiring support and then this being changed.

The D2A Trigger Task will comprise of the following attributes

Attribute Cardinality Type Details
meta.profile 1..1 url Fixed: https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-Task-1
id 1..1 string Unique id for updates and referencing
status 1..1 code 'requested' when patient flagged as needing support
'cancelled' if patient subsequently flagged as NOT needing support
'completed' when patient has been successfuly discharged

Note if a patient is re-flagged as requiring support, following a task being cancelled, a new task should be created
intent 1..1 code Fixed: order
code.coding 1..1 code Fixed:
"system": "http://snomed.info/sct",
"code": "718524000",
"display": "Referral to discharge planning team"
authoredOn 1..1 DateTime Date/Time that the supported flag was set
for 1..1 Reference Reference to the relevant Patient FHIR Resource
context 1..1 Reference Reference to the relevant Encounter FHIR Resource
owner 1..1 Reference Reference to the Organisation FHIR Resource for the relevant ToC Hub

Example

Example of a D2A Trigger Task :

{
    "resourceType": "Task",
    "id": "D2A-Trigger-Task-Example",
    "meta": {
        "profile":  [
            "https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-Task-1"
        ]
    },
    "status": "requested",
    "intent": "order",
    "code": {
        "coding":  [
            {
                "code": "718524000",
                "display": "Referral to discharge planning team",
                "system": "http://snomed.info/sct"
            }
        ]
    },
    "authoredOn": "2024-02-15T16:02:28.289Z",
    "for": {
        "reference": "Patient/9999999999"
    },
    "context": {
        "reference": "Encounter/acute-inpatient-encounter"
    },
    "owner": {
        "reference": "Organization/F1L4Q",
        "display": "SOUTH NOTTS TRANSFER OF CARE HUB"
    }
}

Inpatient Spell

The FHIR Encounter for the Inpatient Spell will already be maintained, however, to support D2A, hospitals will also need to ensure they are maintaining the MedicallySafeForDischarge Extension within the Hospitalization element.

The key attributes on the extension are:

Attribute Description Comments
status ready | notready | unknown MANDATORY, use unknown if status not recorded
predictedDate Date when it is predicted the patient will be READY for discharge. MUST be provided if recorded in the Hospital system.
actualDate Actual date/time when the patient was READY for discharge. MUST be provided if status='ready'. If this date/time is not recorded separately, then the system time when updating the status to 'ready' should be used.

Example

Example of the MedicallySafeForDischarge Extension is should below:

"hospitalization": {
    "extension":  [
        {
            "extension":  [
                {
                    "url": "status",
                    "valueCode": "ready"
                },
                {
                    "url": "predictedDate",
                    "valueDateTime": "2024-09-30T09:00:00Z"
                },
                {
                    "url": "actualDate",
                    "valueDateTime": "2024-01-03T10:20:00Z"
                }
            ],
            "url": "https://fhir.yhcr.nhs.uk/StructureDefinition/Extension-Interweave-MedicallySafeForDischarge"
        }
    ]
},

         </div>

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"
            }
        }
    ]
}

D2A Assessment

The D2A Assessment is completed using a form template on Nervecentre. Once finished/submitted, it will be converted to a PDF document for sharing.

A FHIR DocumentReference will need to be searchable with the following attributes (Note: where the Data Provider is using a REST Adaptor, the DocumentReference and accompanying Binary will be created on demand)

Attribute Cardinality Type Details
meta.profile 2..2 url Fixed:
https://fhir.yhcr.nhs.uk/StructureDefinition/Interweave-DocumentReference
https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-DocumentReference-1
id 1..1 string Unique id for updates and referencing
status 1..1 code Fixed: current
docStatus 1..1 code Fixed: final
type.coding 1..1 code Fixed:
"system": "https://fhir.nottscr.nhs.uk/CodeSystem/D2A-ArtifactCode-1",
"code": "d2a-assessmentFull",
"display": "Discharge 2 Assess (D2A) Assessment"
subject 1..1 Reference Reference to the relevant Patient FHIR Resource
context 0..1 Reference Reference to the relevant Encounter FHIR Resource.
MUST be provided if technically possible
indexed 1..1 DateTime When the document was added
content.attachement.contentType 1..1 code Fixed: "application/pdf
content.attachement.url 1..1 reference Reference to the Binary resource that represents the PDF
content.attachement.size 0..1 integer Number of bytes of content (if url provided)
content.attachement.creation 0..1 dateTime Date attachment was first created

Example

Example of a D2A Assessment Form:

{
    "resourceType": "DocumentReference",
    "id": "D2A-Assessment-Form-Example",
    "meta": {
        "profile":  [
            "https://fhir.yhcr.nhs.uk/StructureDefinition/Interweave-DocumentReference",
            "https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-DocumentReference-1"
        ]
    },
    "status": "current",
    "docStatus": "final",
    "type": {
        "coding":  [
            {
                "system": "https://fhir.nottscr.nhs.uk/CodeSystem/D2A-ArtifactCode-1",
                "code": "d2a-assessmentFull",
                "display": "Discharge 2 Assess (D2A) Assessment"
            }
        ]
    },
    "subject": {
        "reference": "Patient/9999999999"
    },
    "context": {
        "encounter": {
            "reference": "Encounter/acute-inpatient-encounter"
        }
    },
    "indexed": "2024-04-01T09:37:00Z",
    "content":  [
        {
            "attachment": {
                "contentType": "application/pdf",
                "url": "Binary/21f51e78-a46d-402c-aa22-dd43e0fec530",
                "size": 158892,
                "creation": "2024-04-01T09:37:00Z"
            }
        }
    ]
}

D2A Parent Task

The Parent Task builds on the CarePlan and details the high level tasks/activities that need to be undertaken to facilitate a safe and timely discharge and which organisation is responsible for them. The Parent Task will usually be agreed as part of the Triage process in the ToC Hub and recorded in the D2A section of the Notts Care Record (NCR).

Note: as the Parent Task will be created/mastered by the NCR, hence the details below are provided for Data Consumers, e.g. those organisations that wish to automatically create workflow in their line of business systems, when a new Parent task is created for which their Organization is the Owner.

The NCR Project Team can advise on how organisations can create a subscription to Parent Task for their Organization. On receipt of a subscription notification, Data Consumers may also need to fetch the referenced Patient, Encounter Resources etc. to be able to populate all the required fields in the Line of Business System (LoBS)

The D2A parent Task 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-Task-1
id 1..1 string Unique id for updates and referencing
basedOn 1..1 Reference Reference to the CarePlan created by the Hospital to model the D2A Discharge Plan
status 1..1 code 'requested' when the task is created
'cancelled' if the task is cancelled
Note: all other statuses will be derived from the assoicated D2A Child Task
intent 1..1 code Fixed: plan
code.coding 1..1 code Fixed:
"system": "https://fhir.nottscr.nhs.uk/CodeSystem/D2A-ArtifactCode-1",
"code": "d2a-parentTask",
"display": "D2A Parent Task"
description 1..1 string description of what is required
for 1..1 Reference Reference to the relevant Patient FHIR Resource
context 1..1 Reference Reference to the relevant Encounter FHIR Resource
executionPeriod.start 1..1 DateTime When the D2A Parent Task was added in the NCR
executionPeriod.end 0..1 DateTime When the D2A Parent Task was cancelled in the NCR
(Note: period.end will be derived from the aassoicated D2A Child Task when one exists and parent has not been cancelled)
authoredOn 1..1 DateTime When the task was created .., this will be the same as executionPeriod.start
lastModified 1..1 DateTime When the task was last updated
owner 1..1 Reference Reference to Organization that is responsible for the task
output:reasonForAbandonedDischarge 0..1 code/string details of why the task was cancelled / discharge abandoned

Example

Example of a D2A Trigger Task :

{
    "resourceType": "Task",
    "meta": {
        "profile":  [
            "https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-Task-1"
        ],
        "tag":  [
            {
                "code": "D2A"
            }
        ]
    },
    "id": "D2A-Parent-Task-Example",
    "basedOn": {
        "reference": "CarePlan/RX1.acute-care-plan"
    },
    "status": "cancelled",
    "intent": "plan",
    "code": {
        "coding":  [
            {
                "system": "https://fhir.nottscr.nhs.uk/CodeSystem/D2A-ArtifactCode-1",
                "code": "d2a-parentTask",
                "display": "D2A Parent Task"
            }
        ]
    },
    "description": "Arrange Reablement package for patient",
    "for": {
        "reference": "Patient/9999999999"
    },
    "context": {
        "reference": "Encounter/acute-inpatient-encounter"
    },
    "executionPeriod": {
        "start": "2024-03-14T17:43:21+00:00",
        "end": "2024-03-26T09:50:00+00:00"
    },
    "authoredOn": "2024-03-14T17:43:21+00:00",
    "lastModified": "2024-03-26T09:50:00+00:00",
    "owner": {
        "reference": "Organization/511"
    },
    "output":  [
        {
            "type": {
                "coding":  [
                    {
                        "system": "https://fhir.nottscr.nhs.uk/CodeSystem/D2A-ArtifactCode-1",
                        "code": "reasonForAbandonedDischarge"
                    }
                ]
            },
            "valueCodeableConcept": {
                "text": "Reason for Abandoned Discharge would only really be entered when the parent task had been cancelled, but shown here for illustrative purpose.  Only CodeableConcept text shown, but codings could be used in the future"
            }
        }
    ]
}

D2A Child Task

The Child Task is a composite part of the Parent Task, and is used to record progress and outcome of the parent.

Each Organization can choose to maintain task progress (i.e. D2A Child Tasks) either manually in the Notts Care Record Portal, or automatically via their Line of Business Systems. Whilst the latter will generally be preferable, it will require development / support from ICT Integration teams, which is why the manual option may be required in the short to medium term.

Hospital Trusts who wish to view progress of ToC Hub activities in their LoBS (e.g. Nervecentre), can subscribe to D2A Child Tasks to receive updates when they are created/changed in order to automatically update their local systems.

The D2A Child Task 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-Task-1
id 1..1 string Unique id for updates and referencing
parOf 1..1 Reference Reference to the D2A Parent Task that the Child Task is part of
status 1..1 code 'in-progress' when the task is created
'completed' when the task is complete
'rejected' if the LoBS suggests the Task is no longer appropriate. Note: Where the Child Task is rejected by the LoBS, the D2A Parent Task will need to be Cancelled in the NCR with the reason.
intent 1..1 code Fixed: plan
code.coding 1..1 code Fixed:
"system": "https://fhir.nottscr.nhs.uk/CodeSystem/D2A-ArtifactCode-1",
"code": "d2a-childTask",
"display": "D2A Child Task"
executionPeriod.start n/a DateTime The period start will be derived from the parent task
executionPeriod.end 0..1 DateTime When the D2A Parent Task was completed or rejected
authoredOn 1..1 DateTime When the task was created in the relevant system
lastModified 1..1 DateTime When the task was last updated in the relevant system
note 0..1 Annotation Comments made about the task
output:plannedDischargeDate 0..1 DateTime Discharge Date that the child task owner organisation is working to. This will be used by the Hospitals to update the Hub Planned Discharge Date field on Nervecentre
output:plannedServiceStartDateTime 0..1 DateTime Date the service that has been arranges is due to commence. This will be used by the Hospitals to update the Hub Planned Service Start Date field on Nervecentre
output:serviceProvider 0..1 Code/String Details of which service / provider has been arranges for the Patient. This will be used to update the Hub Provider and Community Service Provider fields in Nervecentre depending on whether the task owner is a Social Care or Community Health Organization
output:bridgingSupport 0..1 Code/String Details of any bridging support arranged, i.e. for when the Planned Discharge Date is before the Panned Service Start Date. This will be used by the Hospitals to update the Uncommissioned Bridging Support field on Nervecentre
output:idealService 0..1 Code/String Used by owner Organization to record when the ideal services would have been, when an alternate service was arranged instead (e.g. due of lack of capacity)

Example

Example of a D2A Child Task:

{
    "resourceType": "Task",
    "meta": {
        "profile":  [
            "https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-Task-1"
        ],
        "tag":  [
            {
                "code": "D2A"
            }
        ]
    },
    "id": "D2A-Child-Task-Example",
    "partOf": {
        "reference": "Task/NCR.D2A-Parent-Task-Example"
    },
    "status": "completed",
    "intent": "plan",
    "code": {
        "coding":  [
            {
                "system": "https://fhir.nottscr.nhs.uk/CodeSystem/D2A-ArtifactCode-1",
                "code": "d2a-childTask",
                "display": "D2A Child Task"
            }
        ]
    },
    "for": {
        "reference": "Patient/9999999999"
    },
    "executionPeriod": {
        "end": "2023-12-18T13:03:21+00:00"
    },
    "authoredOn": "2023-12-14T17:53:18+00:00",
    "note":  [
        {
            "authorString": "Name of author",
            "time": "2023-12-15T10:33:17+00:00",
            "text": "Note 1 on child task ... Notes added by LoBS, might not reference a practioner"
        },
        {
            "authorString": "Name of author",
            "time": "2023-12-15T10:33:17+00:00",
            "text": "Note 2 on child task ..."
        }
    ],
    "output":  [
        {
            "type": {
                "coding":  [
                    {
                        "system": "https://fhir.yhcr.nhs.uk/CodeSystem/D2A-OutputType-1",
                        "code": "plannedDischargeDate"
                    }
                ]
            },
            "valueDateTime": "2023-12-18"
        },
        {
            "type": {
                "coding":  [
                    {
                        "system": "https://fhir.yhcr.nhs.uk/CodeSystem/D2A-OutputType-1",
                        "code": "plannedServiceStartDateTime"
                    }
                ]
            },
            "valueDateTime": "2023-12-19T14:00:00+00:00"
        },
        {
            "type": {
                "coding":  [
                    {
                        "system": "https://fhir.yhcr.nhs.uk/CodeSystem/D2A-OutputType-1",
                        "code": "serviceProvider"
                    }
                ]
            },
            "valueCodeableConcept": {
                "text": "HomeFirst Service"
            }
        },
        {
            "type": {
                "coding":  [
                    {
                        "system": "https://fhir.yhcr.nhs.uk/CodeSystem/D2A-OutputType-1",
                        "code": "bridgingSupport"
                    }
                ]
            },
            "valueCodeableConcept": {
                "text": "Family to provide BridgingSupport on 18th Dec"
            }
        },
        {
            "type": {
                "coding":  [
                    {
                        "system": "https://fhir.yhcr.nhs.uk/CodeSystem/D2A-OutputType-1",
                        "code": "idealService"
                    }
                ]
            },
            "valueCodeableConcept": {
                "text": "START Reablement ... not required in UI"
            }
        }
    ]
}