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The CMS Data Element Library (DEL) is a centralized repository that provides standardized definitions and mappings for data elements used in post-acute care (PAC) assessments, such as the Minimum Data Set (MDS), the Outcome and Assessment Information Set (OASIS), and the Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI). By offering consistent terminology and interoperability standards, the DEL can significantly inform and improve transitions of care, particularly for patients moving between care settings. Below is an explanation of how the DEL contributes to transitions of care, supported by references:
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### Standardized Data for Continuity of Care ###
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The DEL ensures that PAC providers use standardized data elements, which are mapped to health IT standards such as Logical Observation Identifiers Names and Codes (LOINC) and SNOMED CT. This standardization allows for seamless communication and data exchange between different care settings, reducing the risk of errors or omissions during transitions of care.
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Supporting Reference: CMS emphasizes that the DEL supports interoperability by aligning data elements with standards required for electronic health records (EHRs) under the 21st Century Cures Act. This alignment ensures that data can be shared across systems without loss of meaning or accuracy. (Centers for Medicare & Medicaid Services, 2023)
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### Improved Care Coordination ###
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The DEL facilitates the sharing of critical patient information, such as functional status, cognitive abilities, and social determinants of health, which are essential for care planning during transitions. For example, when a patient is discharged from a skilled nursing facility to home health care, the receiving provider can access standardized data to tailor interventions to the patient’s needs.
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Supporting Reference: Research shows that standardized data improves care coordination by enabling providers to quickly understand a patient’s clinical status and history, reducing the likelihood of adverse events during transitions. (Kripalani et al., 2007, JAMA)
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### Compliance with Interoperability Mandates ###
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The DEL supports compliance with federal interoperability mandates, such as the CMS Interoperability and Patient Access Final Rule. By using DEL data elements, providers can ensure that patient information is shared in a format that meets regulatory requirements, promoting smoother transitions of care.
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Supporting Reference: CMS states that the DEL is a key resource for aligning PAC data with interoperability requirements, ensuring that providers can meet regulatory standards while improving patient outcomes. (CMS, 2023)
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### Facilitating Patient-Centered Care ###
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The DEL includes data elements that capture patient preferences, goals, and outcomes, which are critical for delivering patient-centered care during transitions. For example, understanding a patient’s mobility goals or pain management preferences can help ensure that care plans are aligned with their needs as they move between settings.
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Supporting Reference: Studies highlight the importance of incorporating patient preferences into care transitions to improve satisfaction and outcomes. Standardized data elements, like those in the DEL, make this integration feasible. (Coleman, 2003, Annals of Internal Medicine)
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### Reducing Readmissions and Adverse Events ###
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By providing accurate and comprehensive data during transitions, the DEL helps reduce hospital readmissions and adverse events. Standardized data ensures that critical information, such as medication reconciliation and discharge instructions, is consistently communicated to the next care provider.
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Supporting Reference: Evidence suggests that poor communication during transitions is a leading cause of readmissions and adverse events. The use of standardized data, like that in the DEL, mitigates these risks. (Jencks et al., 2009, New England Journal of Medicine)
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### In Summary ###
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The CMS Data Element Library is a powerful tool for improving transitions of care by promoting standardized, interoperable, and patient-centered data exchange. Its alignment with health IT standards and regulatory requirements ensures that providers can deliver high-quality care while reducing risks associated with care transitions.
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The PACIO Community divided into several sub-groups, each representing a different medical discipline, to produce a minimum set of data elements that can support each discipline and provide comprehensive transitions of care information to a new facility receiving a patient. The different groups included:
Data elements from additional disciplines will be added as time and availability permits. If you are interested in participating in this analysis, please contact us at [info (at) pacioproject.org](mailto:info@pacioproject.org).
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### Transitions of Care Data Elements ###
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The following table is the result of that analysis:
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### References ###
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* Centers for Medicare & Medicaid Services (CMS). (2023). Data Element Library Overview. Retrieved from https://www.cms.gov
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* Kripalani, S., et al. (2007). "Deficits in Communication and Information Transfer Between Hospital-Based and Primary Care Physicians." JAMA, 297(8), 831-841.
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* Coleman, E. A. (2003). "Falling Through the Cracks: Challenges and Opportunities for Improving Transitional Care." Annals of Internal Medicine, 141(7), 533-536.
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* Jencks, S. F., et al. (2009). "Rehospitalizations Among Patients in Medicare Fee-for-Service Program." New England Journal of Medicine, 360(14), 1418-1428.
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This section provides additional guidance on the relationship between the associated profiles and the structure of the interoperable transitions of care document.
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### TOC Document Structure
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### Purpose of Defining Transitions of Care Data Elements
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Post-acute care transitions of care are critical for ensuring continuity, safety, and quality of care as patients move from one healthcare setting to another, such as from a hospital to a skilled nursing facility, home health care, or rehabilitation center. Effective transitions reduce the risk of adverse events, rehospitalizations, and gaps in care. Below are the important aspects of post-acute care transitions:
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#### Comprehensive Discharge Planning ####
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Discharge planning is essential to ensure that patients leave the acute care setting with a clear plan for managing their health. This includes medication reconciliation, follow-up appointments, and instructions for self-care.
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* Evidence: A systematic review by Hansen et al. (2011) found that comprehensive discharge planning and follow-up interventions significantly reduced hospital readmissions. (Hansen LO, Young RS, Hinami K, Leung A, Williams MV. Ann Intern Med. 2011;155(8):520-528.)
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#### Effective Communication Between Providers ####
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Clear communication between healthcare providers across settings (e.g., hospital to skilled nursing facility) is critical to avoid information gaps that can lead to errors or delays in care.
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* Evidence: Kripalani et al. (2007) emphasized that communication failures during transitions are a major contributor to adverse events. Structured communication tools, such as discharge summaries and standardized handoff protocols, improve outcomes. (Kripalani S, Jackson AT, Schnipper JL, Coleman EA. JAMA. 2007;297(8):831-841.)
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#### Medication Reconciliation ####
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Ensuring accurate medication lists and reconciling changes made during hospitalization is vital to prevent medication errors, which are common during transitions.
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* Evidence: A study by Coleman et al. (2005) highlighted that medication discrepancies during transitions are associated with adverse drug events. Implementing medication reconciliation processes reduces these risks. (Coleman EA, Smith JD, Raha D, Min SJ. Arch Intern Med. 2005;165(16):1842-1847.)
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#### Patient and Caregiver Education ####
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Patients and their caregivers must understand the care plan, including medications, follow-up care, warning signs, and how to access resources. Education empowers patients to manage their health effectively.
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* Evidence: Research by Naylor et al. (1999) demonstrated that patient-centered education and support during transitions improve outcomes and reduce rehospitalizations. (Naylor MD, Brooten D, Campbell R, et al. JAMA. 1999;281(7):613-620.)
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#### Follow-Up Care Coordination ####
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Timely follow-up appointments with primary care providers or specialists are crucial to monitor progress, address complications, and reinforce the care plan.
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* Evidence: The Care Transitions Intervention (CTI) model developed by Coleman et al. (2006) showed that structured follow-up care significantly reduced 30-day readmissions. (Coleman EA, Parry C, Chalmers S, Min SJ. Arch Intern Med. 2006;166(17):1822-1828.)
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#### Use of Transitional Care Models ####
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Evidence-based transitional care models, such as the Transitional Care Model (TCM) or Project RED (Re-Engineered Discharge), provide structured approaches to improving care transitions.
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* Evidence: The Transitional Care Model (TCM), developed by Naylor et al., has been shown to improve outcomes for older adults with complex care needs during transitions. (Naylor MD, Aiken LH, Kurtzman ET, et al. Health Aff (Millwood). 2011;30(4):746-754.)
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#### Addressing Social Determinants of Health ####
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Social determinants such as transportation, housing, and access to food can impact a patient’s ability to adhere to the care plan. Identifying and addressing these factors is essential.
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* Evidence: Studies have shown that addressing social determinants improves patient outcomes and reduces readmissions. For example, Berkowitz et al. (2018) found that interventions targeting food insecurity reduced healthcare utilization. (Berkowitz SA, Hulberg AC, Standish S, et al. Health Aff (Millwood). 2018;37(3):393-400.)
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#### Use of Technology and Telehealth ####
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Technology, such as electronic health records (EHRs) and telehealth, facilitates communication and monitoring during transitions, especially for patients in remote or underserved areas.
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* Evidence: A study by Lin et al. (2020) found that telehealth interventions during care transitions improved patient satisfaction and reduced hospital readmissions. (Lin MH, Yuan WL, Huang TC, et al. J Med Internet Res. 2020;22(10):e19099.)
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#### Monitoring and Quality Improvement ####
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Ongoing evaluation of transition processes, including patient outcomes and satisfaction, allows healthcare organizations to identify gaps and implement improvements.
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* Evidence: The National Transitions of Care Coalition (NTCC) emphasizes the importance of monitoring key metrics, such as readmission rates and patient satisfaction, to improve care transitions. (NTCC. Improving Transitions of Care: Findings and Considerations of the "Vision of the National Transitions of Care Coalition." 2008.)
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Effective post-acute care transitions require a multidisciplinary approach that emphasizes communication, patient education, medication safety, follow-up care, and addressing social determinants. Evidence-based models and interventions, such as the Transitional Care Model and Care Transitions Intervention, have demonstrated their ability to improve outcomes and reduce rehospitalizations.
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By focusing on these key aspects, healthcare providers can ensure smoother transitions, better patient outcomes, and reduced healthcare costs.
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