Consolidated Patient Information Across Sectors
The patient profile consolidates patient data into several pages:
- Risk Profile
- Acute Care Summary
- Acute Care Details
- Community Support Services (CSS)
- Addictions & Mental Health (AMH)
- Home & Community Care (HCC)
- Coordinated Care Plan (CCP)
On each page, you will see the patient header which contains some identifying information as well as a grouping of badges that indicate certain statuses. These statuses include:
- In Hospital: will be blue if the patient is currently visiting an acute care facility
- Complex: will be blue if the patient is considered ‘complex’, or grey otherwise
- CCP: will be blue if an electronic Coordinated Care Plan exists within SHIIP for this patient
- Home Care: will be blue if the patient is currently receiving Home & Community Care services
- CSS: will be blue if the patient is currently receiving services from their community.
- AMH: will be blue if the patient is currently receiving services from an Addictions & Mental Health agency.
- LTC App: will be blue if the patient has an active Long Term Care Application
- EOL Care: will be blue if the patient is currently receiving end of life (palliative) care
- HARP: colour will vary depending on the patient’s HARP-30D risk score
- LACE: colour will vary depending on the patient’s LACE risk score
- MAPLe: colour will vary depending on the patient’s MAPLe risk score
- AUA: colour will vary depending on the patient’s AUA risk score
- CSI: colour will vary depending on the patient’s CSI risk score
The Patient Summary contains basic demographic information as well as a list of the patient’s complex conditions.
- Date of birth
- Primary care provider name and CPSO number
- Home address
- Phone number
- Last active date
- A list of the patient’s complex conditions
- Condition name
- First diagnosis date
- Source of diagnosis
SHIIP’s data integrations provide users with several risk and assessment scores. Some of these scores are determined by SHIIP (HARP / LACE) and calculated based on a variety of factors. The scores available are below:
- Hospital Admission Risk Prediction (HARP) helps identify patients at risk of future hospitalization.
- The LACE Index identifies patients at risk of readmission or death within 30 days of discharge.
- The Assessment Urgency Algorithm (AUA) is a tool used to determine if a patient will require special geriatric services, home care, or hospital admission.
- Caregiver Stress Index (CSI) is a tool that can be used to identify families with potential care-giving burdens.
- The Method for Assigning Priority Levels (MAPLe) is a tool used to prioritize patients needed community-based or facility-based services.
- Resource Intensity Weights (RIW) represent the relative health care resources used by a patient.
- Social Determinants of Health (SDOH) are used to determine the patient’s social and material deprivation.
More information on SHIIP’s risk and assessment scores can be found here.
Acute Care Summary
The Acute Care Summary provides an overview of a patient’s acute care activity. It is split into four sections with the following information:
Acute Inpatient Activity
- Date of last inpatient admission
- Date of last inpatient discharge
- Last hospital visited as an inpatient
- Last discharge disposition as an inpatient
- Total number of inpatient admissions within the last 30 days and year
- Total number of inpatient readmissions within the last month
Emergency Department Activity
- Date of last emergency department visit
- Last hospital where the patient visited the emergency department
- Last discharge disposition after visiting an emergency department
- Total visits to an emergency department within the last 30 days and year
- Total repeat visits to an emergency department within the last 30 days
- Date of last day procedure
- Last hospital visited for day procedure
- Last procedure received
- Last discharge status from a day procedure
- Date of last procedure
- Last hospital visited as an outpatient
- Last procedure received as an outpatient
- Last discharge status as an outpatient
Acute Care Details
The Acute Care Details page provides detailed information about all acute care activity for a patient. Filters are available to drill-down specific activity, such as; date range, hospital visited, and CTAS score (for emergency department visits only). Details are split into the following sections:
- All activity
- Emergency department activity
- Acute inpatient activity
- Outpatient clinic activity
- Day procedure activity
In each of these sections, detailed information is displayed. It includes:
- Admission and discharge date
- Length of stay
- Hospital / clinic visited
- Chief complaint
- Discharge diagnoses
- Discharge disposition
- Procedures received
- Arrival method
- Patient location
Home Care (HCC)
The Home Care page contains information for Home & Community Care services utilized by the patient. It contains five sections:
- Referral Details: contains information pertaining to a patient’s Home & Community Care referrals
- Service Details: contains information pertaining to a patient’s Home & Community Care services
- Medical Equipment and Supplies: contains a list of the medical equipment and supplies used for Home & Community Care services involving a patient.
- Safety Details: contains a list of safety issues involving a patient’s behaviour, living situation, environment, etc.
- Assessment Information: contains a list of assessment files for a patient
Community Support Services (CSS)
The Community Support Services page contains information for community services utilized by the patient. It contains three sections:
- The patient’s core CSS services
- Site and service name
- Start and end date
- Most recently planned event
- The patient’s CSS events
- Site and service name
- Event type and description
- Event date and duration
- The patient’s CSS case notes
- Site and service name
- Case note date
- Case note content
Addictions & Mental Health (AMH)
The Addictions & Mental Health page displays information about a patient’s AMH activity. It lists all AMH events submitted to SHIIP and contains the following information:
- Program name and current status (active, inactive)
- Presenting issues
- Eligibility date screening, results, and results date
- Discharge date and disposition
- Involved support workers
- Referral date, type, and source
- Discontinued date and reason
- Outgoing referral type, program, and organization
Coordinated Care Plan
SHIIP supports a web-based Coordinated Care Plan in alignment with the Health Links initiative. More information can be found here.
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