Care Coordination and 360 Referrals (Proof of Concept)
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Care Coordination and 360 Referrals (Proof of Concept) - Local Development build (v0.1.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

Dynamic Care Planning (DCP)

360X is a conversation between two providers about one referral. When several providers care for the patient over time - a virtual ward, community nursing, the GP, a specialist - they need a shared care plan that each can read and update. IHE Dynamic Care Planning (DCP) defines this.

References

Actors and Transactions

DCP actor Description (PCC TF-1 X.1.1) In this guide
Care Plan Contributor Reads, creates and updates care plans held by a Care Plan Service; applies plan definitions Each provider's system: GP, virtual ward, community, specialist
Care Plan Service Manages care plans as a whole (versioned), and provides updates to subscribers Shared care record or care coordination platform
Care Team Contributor Reads, creates and updates the care team As Care Plan Contributor
Care Team Service Manages the care team and notifies subscribers As Care Plan Service
Care Plan Definition Service Holds plan definitions (order sets, protocols, pathways) Pathway or protocol library - Open
Transaction Purpose
Update Care Plan [PCC-37] Create or update a care plan
Retrieve Care Plan [PCC-38] Read a care plan
Subscribe to Care Plan Updates [PCC-39] Subscribe to changes (option)
Provide Care Plan [PCC-40] Notify subscribers of an updated care plan
Search for Care Plan [PCC-41] Find care plans for a patient
Update / Search / Retrieve / Subscribe / Provide Care Team [PCC-45] to [PCC-49] The same for the care team
Plan and Activity Definition [PCC-63] to [PCC-70] Manage and apply plan definitions

Contributors SHALL read the latest version, change only their own parts and write it back, handling a version conflict (usually by retrying) - FHIR transactional integrity.

How Referrals and Care Plans Fit Together

flowchart TB
    CP[CarePlan<br/>shared plan, Care Plan Service]
    CT[CareTeam]
    SR1[ServiceRequest<br/>referral to virtual ward]
    SR2[ServiceRequest<br/>referral to community nursing]
    T1[Task<br/>virtual ward workflow]
    T2[Task<br/>community workflow]
    DOC[Composition<br/>consultation note / discharge report]
    CP --> CT
    CP -- activity.reference --> SR1
    CP -- activity.reference --> SR2
    SR1 -- basedOn --> CP
    SR2 -- basedOn --> CP
    T1 -- focus --> SR1
    T2 -- focus --> SR2
    T1 -- output --> DOC
    DOC -. updates .-> CP
Concept 360X only With DCP
Who knows the plan Referral Initiator receives it in the outcome Every care team member reads the shared CarePlan
A new referral New Referral Request A CarePlan activity, carried out by a Referral Request (ServiceRequest.basedOn the CarePlan)
Progress Status messages to the initiator Task status, also visible to the care team; CarePlan activity.progress
Outcome Referral Outcome document Document, and the CarePlan updated
Continued care with no end of care Outcome is a care plan (PCC TF-1 X.4.2) The CarePlan is the outcome

DCP needs a Care Plan Service that every contributor can reach - a shared care record or platform with FHIR REST APIs. Contributors update the shared care plan held by that service; they do not write into each other's records. Clinical results and documents still travel by the general patterns (HL7 v2 ORU^R01, FHIR / CDA Documents). Where that does not exist, the care plan is sent in the documents (the HDR plan of care section) and 360X messaging carries the workflow. This is the step from Document Messaging to Conversational Workflow in the integration layers.

Task-based Workflow

The Referral Task is the FHIR form of the 360X status messages. With a shared FHIR server it can be used as a conversation:

Communication pattern How Example
Push messages (360X) Each status change is a message to the other party HL7 v2 OSU^O51, FHIR Message
Shared Task Initiator creates the Task; the recipient updates status / businessStatus; the initiator subscribes or polls eRS worklists, GOMS, HL7 AU eRequesting
Request more information Recipient sets businessStatus information-requested, with a Communication or Questionnaire eRS / BaRS return to referrer

See FHIR Workflow Management Communication Patterns options for creating and polling Task resources.

Use Cases

Use case Care plan
Virtual ward Monitoring, visits, escalation; contributors: virtual ward, community nursing, GP - see Virtual Wards
Long-term condition GP-led plan with specialist and allied health activities (DCP chronic conditions use case)
Pregnancy Maternity plan across GP, midwife and hospital (DCP pregnancy use case)
Newborn hearing screening Hearing plan of care updated by audiology (360X Use Case #2)
Cancer Treatment plan from the MDT - see Cancer Pathology Report - Cancer Pathway
Child protection Plan owned by the local authority; only its existence, dates and owner are shared, as a flag (CP-IS) - see Patient Flags