The Re-Assessment Timepoints IG describes a means to break up extended Post-Acute admissions into consumable blocks that can reflect the evolution of care over time for an encounter or episode of care.

On average, Post-Acute Admissions extend over much longer periods of time than encounters in the Acute and Ambulatory Care Settings, often spanning several months or even years. Over the course of these time periods, the patient condition and therefore the care provided is changing constantly. For example, in Home Health the goal is rehabilitation; Care Plans, Medications, and Orders all likely are changing throughout an admission that could last several months. Already in existence within post-acute care settings are periods of time structured by a variety of stakeholders, some more rigid than others, such as regulations and conditions of participation, payer and revenue cycle requirements, and provider specific processes and protocols. In settings like Home Health and Skilled Nursing Facilities (SNF), there are Medicare assessment instruments that providers must complete at specified intervals thatvary by care setting; the results of these assessments drive the Care Plan until a subsequent assessment. If a patient has a pain management Care Plan and their pain levels improve, then they may have their Opioid drug dosages reduced or eliminated. If a patient’s ambulation is improving, then the care team may focus interventions on more complex exercises. These periods of time, defined by many different drivers, have direct impact on how data is made available outside of an EMR. Without a structure in place to hold this information, a connecting application or patient would have to sift through months of information, rather than focusing on a given period or periods most relevant to the needs of the application, patient, or other entity.

The ClinicalImpression or ServiceRequest that initiated this timepoint

Re-Assessment Timepoints Encounter is a profile of the Encounter resource that allows longer-term post-acute admissions to be structured into smaller more consumable components, in line with the longer-term clinical care and progression of a patient.

This extension allows Re-Assessment Timepoint Encounters to be linked to the formal assessments that define the start and end of the timepoint. Each linked ClinicalImpression instance represents a completed assessment, such as an MDS 5-day or OASIS 120-day Follow-up. The instance will include links to the Observation instances that document the discrete results of the assessment.

Codes for the classification of patient timepoint. This is an extension of the ActEncounterCode value set

Codes describing various entity types for structuring timepoints.

Various service types of clinical assessment or instrument that a timepoint is centered on.

Codes for the current state of the re-assessment timepoint.

Defining codes for the classification of patient timepoint such as skilled nursing facility, home health, etc.

Defining codes for describing various entity types for structuring timepoints.

Defining codes for describing various service types of clinical assessment or instrument that a timepoint is centered on.

Clinical impression for assessment and impression at start of home health care

Clinical impression for assessment and impression after 60 days of home health care

Clinical impression for assessment and impression after 120 days of home health care

Clinical impression for assessment and impression prior to discharge from home health care

Sequelae of cerebral infarction diagnosis at HHA

HHA Encounter for Betsy Smith-Johnson, period 2021-04-07 to 2021-08-24

HHA-Stay OASIS Re-Assessment Timepoint with Type Payer, period 2020-02-10 to 2020-04-09

HHA-Stay OASIS Re-Assessment Timepoint with Type Payer, period 2020-04-10 to 2020-06-09

HHA-Stay OASIS Re-Assessment Timepoint with Type Payer, period 2020-06-10 to 2020-06-29

HHA-Stay Episode of Care for Betsy Smith-Johnson, period 2021-04-07 to 2021-08-24

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Patient Betsy Smith-Johnson

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Practitioner Daniel Granger

Practitioner Jacob Hartwell

Practitioner Jen Cadbury

Practitioner John Smith

Practitioner Lia Nguyen

Practitioner Luna Baskins Jones

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Practitioner Nora Ologist

Practitioner Scott Dumble

Practitioner Tamara Rodriguez

Organization Happy Skilled Nursing Facility

Organization Sky Harbor Home Health Services

Location Happy Skilled Nursing Facility

Location Sky Harbor Home Health Services

PractitionerRole - Cherise Langford as OT at Happy Nursing

PractitionerRole - John Smith as PCP

PractitionerRole - Daniel Granger as PT at Happy Nursing

PractitionerRole - Jen Cadbury as OT at Happy Nursing

PractitionerRole - Luna Baskins as PT at Sky Harbor HH

PractitionerRole - Scott Dumble as PT at Sky Harbor HH

PractitionerRole - Jacob Hartwell as Home Health RN at Sky Harbor HH

PractitionerRole - Lia Nguyen as RN at Happy Nursing

PractitionerRole - Tamara Rodriguez as Home Health RN at Sky Harbor HH

PractitionerRole - Maria Gonzalez as SLP at Happy Nursing

PractitionerRole - Nora Ologist as Neurologist

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Clinical impression for assessment and impression at admission to SNF

Clinical impression for assessment and impression at interim assessment at SNF

Clinical impression for assessment and impression at discharge from SNF

Cerebral infarction diagnosis at SNF

SNF Encounter for Betsy Smith-Johnson, period 2021-02-26 to 2021-04-07

SNF-Stay MDS Re-Assessment Timepoint with Type Payer, period 2020-01-01 to 2020-01-13

SNF-Stay MDS Re-Assessment Timepoint with Type Payer, period 2020-01-14 to 2020-02-10

SNF-Stay Episode of Care for Betsy Smith-Johnson, period 2021-02-26 to 2021-04-07

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