5.19 Resource EpisodeOfCare - Content

5.19.1 Scope and Usage

The EpisodeOfCare Resource contains information about an association of a Patient with a Healthcare Provider for a period of time under which related healthcare activities may occur.

In many cases, this represents a period of time where the Healthcare Provider has some level of responsibility for the care of the patient regarding a specific condition or problem, even if not currently participating in an encounter.

These resources are typically known in existing systems as:

• EpisodeOfCare: Case, Program, Problem, Episode
• Encounter: Visit, Contact

5.19.1.1 Multiple Organizations and Transfer of Care

Many organizations can be involved in an EpisodeOfCare, however each organization will have their own EpisodeOfCare which tracks their responsibility with the Patient.

When an Organization completes their involvement with the patient and transfers care to another Organization. This is often in the form of a referral to another Organization (or Organizations).

When an incoming referral is received a new EpisodeOfCare may be created for this organization. The initial step(s) in the intake workflow for the referral often involve some form of assessment(s), eligibility, capacity, care levels, which could take some time.
Once the intake process is completed and the patient is accepted, a CarePlan is often created.

5.19.2 Boundaries and Relationships

The primary difference between the EpisodeOfCare and the Encounter is that the Encounter records the details of an activity directly relating to the patient, while the EpisodeOfCare is the container that can link a series of Encounters together for problems/issues.
The Example scenarios below give some good examples as to when you might want to be using an EpisodeOfCare.

This difference is a similar difference between the EpisodeOfCare and a CarePlan. The EpisodeOfCare is a tracking resource, rather than a planning resource.
The EpisodeOfCare usually exists before the CarePlan. You don't need a CarePlan to use an EpisodeOfCare.

5.19.3 Background and Context

Systems collect a coherent group of activities (such as encounters) related to a patient's health condition or problem often referred to as a Care Episode. Information about an episode is often shared across systems, and in some cases organizational and disciplinary boundaries. An Episode Of Care contains details about the purpose of the care and can exist without any activities.
The minimal information that would be required in an episode of care would be a patient, organization and a reason for the ongoing association. Other reasons for creating an EpisodeOfCare could be for tracking the details required for government reporting or billing.

5.19.3.1 Expected Implementations

• Chronic Disease Management Systems
• Community Care Systems
  • Tracking progress of a specific condition
  • Tracking government funding
• Problem based General Practice systems
• Disability Support Systems
• Aged Care Systems (Community and Residential)

• Structure
• UML
• XML
• JSON
• All

Structure

Name	Flags	Card.	Type	Description & Constraints
EpisodeOfCare			DomainResource	An association of a Patient with an Organization and Healthcare Provider(s) for a period of time that the Organization assumes some level of responsibility
identifier		0..*	Identifier	Identifier(s) by which this EpisodeOfCare is known
status	?! Σ	1..1	code	planned | waitlist | active | onhold | finished | cancelled EpisodeOfCareStatus (Required)
statusHistory		0..*	Element	The status history for the EpisodeOfCare
status		1..1	code	planned | waitlist | active | onhold | finished | cancelled EpisodeOfCareStatus (Required)
period		1..1	Period	The period during this EpisodeOfCare that the specific status applied
type	Σ	0..*	CodeableConcept	Specific type of EpisodeOfCare
patient	Σ	1..1	Patient	The patient that this EpisodeOfCare applies to
managingOrganization	Σ	0..1	Organization	The organization that has assumed the specific responsibilities for the specified duration
period	Σ	0..1	Period	The interval during which the managing organization assumes the defined responsibility
condition		0..*	Condition	A list of conditions/problems/diagnoses that this episode of care is intended to be providing care for
referralRequest		0..*	ReferralRequest	Referral Request(s) that this EpisodeOfCare manages activities within
careManager		0..1	Practitioner	The practitioner that is the care manager/care co-ordinator for this patient
careTeam		0..*	Element	The list of practitioners that may be facilitating this episode of care for specific purposes
member		0..1	Practitioner | Organization	The practitioner (or Organization) within the team
role		0..*	CodeableConcept	The role that this team member is taking within this episode of care
period		0..1	Period	The period of time that this practitioner is performing some role within the episode of care

<EpisodeOfCare xmlns="http://hl7.org/fhir"> 
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier Identifier(s) by which this EpisodeOfCare is known --></identifier>
 <status value="[code]"/><!-- 1..1 planned | waitlist | active | onhold | finished | cancelled -->
 <statusHistory>  <!-- 0..* The status history for the EpisodeOfCare -->
  <status value="[code]"/><!-- 1..1 planned | waitlist | active | onhold | finished | cancelled -->
  <period><!-- 1..1 Period 
      The period during this EpisodeOfCare that the specific status applied --></period>
 </statusHistory>
 <type><!-- 0..* CodeableConcept Specific type of EpisodeOfCare --></type>
 <patient><!-- 1..1 Reference(Patient) The patient that this EpisodeOfCare applies to --></patient>
 <managingOrganization><!-- 0..1 Reference(Organization) 
     The organization that has assumed the specific responsibilities for the specified duration --></managingOrganization>
 <period><!-- 0..1 Period 
     The interval during which the managing organization assumes the defined responsibility --></period>
 <condition><!-- 0..* Reference(Condition) 
     A list of conditions/problems/diagnoses that this episode of care is intended to be providing care for --></condition>
 <referralRequest><!-- 0..* Reference(ReferralRequest) 
     Referral Request(s) that this EpisodeOfCare manages activities within --></referralRequest>
 <careManager><!-- 0..1 Reference(Practitioner) 
     The practitioner that is the care manager/care co-ordinator for this patient --></careManager>
 <careTeam>  <!-- 0..* The list of practitioners that may be facilitating this episode of care for specific purposes -->
  <member><!-- 0..1 Reference(Practitioner|Organization) 
      The practitioner (or Organization) within the team --></member>
  <role><!-- 0..* CodeableConcept 
      The role that this team member is taking within this episode of care --></role>
  <period><!-- 0..1 Period 
      The period of time that this practitioner is performing some role within the episode of care --></period>
 </careTeam>
</EpisodeOfCare>

{
  "resourceType" : "EpisodeOfCare",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // Identifier(s) by which this EpisodeOfCare is known
  "status" : "<code>", // R!  planned | waitlist | active | onhold | finished | cancelled
  "statusHistory" : [{ // The status history for the EpisodeOfCare
    "status" : "<code>", // R!  planned | waitlist | active | onhold | finished | cancelled
    "period" : { Period } // R!  
      The period during this EpisodeOfCare that the specific status applied
  }],
  "type" : [{ CodeableConcept }], // Specific type of EpisodeOfCare
  "patient" : { Reference(Patient) }, // R!  The patient that this EpisodeOfCare applies to
  "managingOrganization" : { Reference(Organization) }, // 
     The organization that has assumed the specific responsibilities for the specified duration
  "period" : { Period }, // 
     The interval during which the managing organization assumes the defined responsibility
  "condition" : [{ Reference(Condition) }], // 
     A list of conditions/problems/diagnoses that this episode of care is intended to be providing care for
  "referralRequest" : [{ Reference(ReferralRequest) }], // 
     Referral Request(s) that this EpisodeOfCare manages activities within
  "careManager" : { Reference(Practitioner) }, // 
     The practitioner that is the care manager/care co-ordinator for this patient
  "careTeam" : [{ // 
     The list of practitioners that may be facilitating this episode of care for specific purposes
    "member" : { Reference(Practitioner|Organization) }, // 
      The practitioner (or Organization) within the team
    "role" : [{ CodeableConcept }], // 
      The role that this team member is taking within this episode of care
    "period" : { Period } // 
      The period of time that this practitioner is performing some role within the episode of care
  }]
}

Structure

Name	Flags	Card.	Type	Description & Constraints
EpisodeOfCare			DomainResource	An association of a Patient with an Organization and Healthcare Provider(s) for a period of time that the Organization assumes some level of responsibility
identifier		0..*	Identifier	Identifier(s) by which this EpisodeOfCare is known
status	?! Σ	1..1	code	planned | waitlist | active | onhold | finished | cancelled EpisodeOfCareStatus (Required)
statusHistory		0..*	Element	The status history for the EpisodeOfCare
status		1..1	code	planned | waitlist | active | onhold | finished | cancelled EpisodeOfCareStatus (Required)
period		1..1	Period	The period during this EpisodeOfCare that the specific status applied
type	Σ	0..*	CodeableConcept	Specific type of EpisodeOfCare
patient	Σ	1..1	Patient	The patient that this EpisodeOfCare applies to
managingOrganization	Σ	0..1	Organization	The organization that has assumed the specific responsibilities for the specified duration
period	Σ	0..1	Period	The interval during which the managing organization assumes the defined responsibility
condition		0..*	Condition	A list of conditions/problems/diagnoses that this episode of care is intended to be providing care for
referralRequest		0..*	ReferralRequest	Referral Request(s) that this EpisodeOfCare manages activities within
careManager		0..1	Practitioner	The practitioner that is the care manager/care co-ordinator for this patient
careTeam		0..*	Element	The list of practitioners that may be facilitating this episode of care for specific purposes
member		0..1	Practitioner | Organization	The practitioner (or Organization) within the team
role		0..*	CodeableConcept	The role that this team member is taking within this episode of care
period		0..1	Period	The period of time that this practitioner is performing some role within the episode of care

UML Diagram

XML Template

<EpisodeOfCare xmlns="http://hl7.org/fhir"> 
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier Identifier(s) by which this EpisodeOfCare is known --></identifier>
 <status value="[code]"/><!-- 1..1 planned | waitlist | active | onhold | finished | cancelled -->
 <statusHistory>  <!-- 0..* The status history for the EpisodeOfCare -->
  <status value="[code]"/><!-- 1..1 planned | waitlist | active | onhold | finished | cancelled -->
  <period><!-- 1..1 Period 
      The period during this EpisodeOfCare that the specific status applied --></period>
 </statusHistory>
 <type><!-- 0..* CodeableConcept Specific type of EpisodeOfCare --></type>
 <patient><!-- 1..1 Reference(Patient) The patient that this EpisodeOfCare applies to --></patient>
 <managingOrganization><!-- 0..1 Reference(Organization) 
     The organization that has assumed the specific responsibilities for the specified duration --></managingOrganization>
 <period><!-- 0..1 Period 
     The interval during which the managing organization assumes the defined responsibility --></period>
 <condition><!-- 0..* Reference(Condition) 
     A list of conditions/problems/diagnoses that this episode of care is intended to be providing care for --></condition>
 <referralRequest><!-- 0..* Reference(ReferralRequest) 
     Referral Request(s) that this EpisodeOfCare manages activities within --></referralRequest>
 <careManager><!-- 0..1 Reference(Practitioner) 
     The practitioner that is the care manager/care co-ordinator for this patient --></careManager>
 <careTeam>  <!-- 0..* The list of practitioners that may be facilitating this episode of care for specific purposes -->
  <member><!-- 0..1 Reference(Practitioner|Organization) 
      The practitioner (or Organization) within the team --></member>
  <role><!-- 0..* CodeableConcept 
      The role that this team member is taking within this episode of care --></role>
  <period><!-- 0..1 Period 
      The period of time that this practitioner is performing some role within the episode of care --></period>
 </careTeam>
</EpisodeOfCare>

JSON Template

{
  "resourceType" : "EpisodeOfCare",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // Identifier(s) by which this EpisodeOfCare is known
  "status" : "<code>", // R!  planned | waitlist | active | onhold | finished | cancelled
  "statusHistory" : [{ // The status history for the EpisodeOfCare
    "status" : "<code>", // R!  planned | waitlist | active | onhold | finished | cancelled
    "period" : { Period } // R!  
      The period during this EpisodeOfCare that the specific status applied
  }],
  "type" : [{ CodeableConcept }], // Specific type of EpisodeOfCare
  "patient" : { Reference(Patient) }, // R!  The patient that this EpisodeOfCare applies to
  "managingOrganization" : { Reference(Organization) }, // 
     The organization that has assumed the specific responsibilities for the specified duration
  "period" : { Period }, // 
     The interval during which the managing organization assumes the defined responsibility
  "condition" : [{ Reference(Condition) }], // 
     A list of conditions/problems/diagnoses that this episode of care is intended to be providing care for
  "referralRequest" : [{ Reference(ReferralRequest) }], // 
     Referral Request(s) that this EpisodeOfCare manages activities within
  "careManager" : { Reference(Practitioner) }, // 
     The practitioner that is the care manager/care co-ordinator for this patient
  "careTeam" : [{ // 
     The list of practitioners that may be facilitating this episode of care for specific purposes
    "member" : { Reference(Practitioner|Organization) }, // 
      The practitioner (or Organization) within the team
    "role" : [{ CodeableConcept }], // 
      The role that this team member is taking within this episode of care
    "period" : { Period } // 
      The period of time that this practitioner is performing some role within the episode of care
  }]
}

5.19.5 Status Management

5.19.5.1 History and Period

When an Organization assumes responsibility for a patient, then the EpisodeOfCare is created and a start date entered to show when it has begun.
As the Organizations responsibility changes, as does the status of the EpisodeOfCare.
This is described via an example below for an example intake workflow.

5.19.5.2 Leave Handling

With long term care there is often a concept of the provision of care being suspended for various reasons. Many systems have extensive Leave Management/Tracking solutions which consider the complexities of this space, however this EpisodeOfCare resource is NOT intended to provide this level of tracking.
Extension(s) may be used on the status/status history to track the onhold reason which can facilitite the processing.

A more complete Leave Management solution may have to deal with:

• Leave Types
• Leave Entitlements
• Billing/Funding implications while on different types of leave

5.19.5.3 Example Intake Workflow

This example sequence demonstrates some status transitions and how other resources interact.
The context could be in a Community/Aged Care/Disability/Mental Health setting.

• ReferralRequest received
• intake clerk processes referral and decides that the first level eligibility has been met
  (e.g. Have capacity in the facility for the patient, the patient is covered by VA)
• EpisodeOfCare created with status of planned which is allocated as fulfilling the ReferralRequest
• Further assessment of needs is scheduled to be taken, a care manager is probably allocated at this point
• Assessment Practitioner sees the Patient and completes a series of relevant Questionnaires to rank the patient
• The assessments are reviewed and a formal CarePlan is created
• The EpisodeOfCare is updated to be marked as active, and the CareTeam is likely filled in
• The provision of care is then managed through the care plan, with all activities will also being linked to the EpisodeOfCare
• The patient is admitted to hospital for some procedures, EpisodeOfCare is marked as onhold
  Some of the services on the CarePlan (or scheduled appointments) would be reviewed to determine if they can be performed without the patient (e.g. Home Maintenance), or if they should be suspended while the patient is onhold.
• The patient returns from the hospital and the EpisodeOfCare is marked as active again (and services reviewed again)
• Patient wished to move to another area to be closer to family
• Organization creates an outgoing ReferralRequest to a new Organization to continue the care
• The EpisodeOfCare is closed

In some jurisdictions an Organization may be funded by a government body for the days that a patient is under their care. These are known as "active days". This does not mean that they are actively receiving a service (an encounter), but that the organization is responsible for managing their care.
This monthly reporting value can be easily extracted from the status history as described above.
The actual provision of services may also be funded separately, and this would be via the Encounters.

5.19.5.4 EpisodeOfCare Outcomes Review

An Organization may perform analytics on their Episodes Of Care to have an understanding of how their business is performing.
Observing that there was a 60/40 split of episodes being finished/cancelled is not very informative. The organization would prefer to know the reason why the episodes are completing so that they can plan their business effectively.
They’d be more interested in knowing whether it was due to services hitting their mandatory end date, client passing away, client transitioning to a higher level of services provided by them or to another provider etc.

Currently there are no attributes on this resource to provide this information. This would be very specific to each implementation and usage, so it would be recommended to use extensions to achieve this functionality.

5.19.6 Example Scenarios

A General Practitioner wants to review how well his patient is managing his diabetes over time from information within his clinic and also the regional community care organization's system(s).

The EpisodeOfCare enables the practitioner to easily separate the diabetes activities from the mental health problem's activities.

A Community Care organization wants to track all activities that occur with a patient relating to their disability to simplify the reporting to the government to receive funding to care for the patient