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Transitions of Care Legacy API

Transitions of Care addresses the level of care that is appropriate when a patient is transitioned from an acute care setting. It includes an algorithm that optimizes post-acute care utilization and mitigates readmission risk, which maximizes value to clinical staff.

Retrieve Transitions of Care Information

Example Request

require 'httparty'

HTTParty.post(
    'https://cernerdemo.programs.healtheintent.com/api/populations/0a9cc467-094c-403a-84d0-35604e1e418c/toc',
    headers: { 'Content-Type' => 'application/json', 'Authorization' => 'Auth Header' },
    body: {empi_ids: ['0655eafe-a71e-3b55-8258-2a51f43b14fc', '00e4fd48-efe7-301c-89bb-5f6d77312373']}.to_json
)
curl -H 'Authorization: <auth_header>' -H 'Content-Type: application/json' -X POST -d '{"empi_ids":["0655eafe-a71e-3b55-8258-2a51f43b14fc","00e4fd48-efe7-301c-89bb-5f6d77312373"]}' https://cernerdemo.programs.healtheintent.com/api/populations/0a9cc467-094c-403a-84d0-35604e1e418c/toc

Example Response

{
   "toc":[
      {
         "empi_id":"emp-id-1",
         "recommended_toc_location":"Home w/Home Health",
         "readmission_risk_reduction":"",
         "supporting_facts":[  
            {
               "name":"antibiotics",
               "type":"medications",
               "value":"yes"
            }
            {
               "name":"intravenous_medication",
               "type":"medications",
               "value":"yes"
            },
            {
               "name":"snf_admit_source",
               "type":"utility",
               "value":"no"
            },
            {
               "name":"toileting_ability_current",
               "type":"discharge_metrics",
               "value":"INTERPRETATION_OF_ABILITY_DEPENDENT_QUAL"
            },
            {
               "name":"toileting_ability_previous",
               "type":"discharge_metrics",
               "value":"INTERPRETATION_OF_ABILITY_ASSISTED_QUAL"
            },
            {
               "name":"walking_ability_current",
               "type":"discharge_metrics",
               "value":"INTERPRETATION_OF_ABILITY_DEPENDENT_QUAL"
            },
            {
               "name":"walking_ability_previous",
               "type":"discharge_metrics",
               "value":"INTERPRETATION_OF_ABILITY_ASSISTED_QUAL"
            }
         ]
      }
   ]
}

POST https://{tenant}.programs.healtheintent.com/api/populations/{population_id}/toc

Retrieves the transitions of care information for one or more patients.

Path Parameters

Parameter Description
population_id The HealtheIntent population ID.

Request Message Body

Name Type Description
empi_ids array: string A JSON array of the IDs of patients in the HealtheIntent population. A maximum of 100 IDs can be specified in a single request.

Responses

Status Type Description
200 Transition Of Care Information A collection of transitions of care details and supporting facts.
400 string Bad Request
401 string Unauthorized
403 string Forbidden
404 string Not Found

Transition of Care Information

Name Type Description
empi_id string The ID of the person in the HealtheIntent population.
recommended_toc_location string The location recommended for transition or discharge of the patient.
readmission_risk_reduction string The percentage of the amount of risk changed if the patient is discharged to the recommended location. Note: This field is deprecated.
supporting_facts array An array of the supporting facts for the transition of care information.

TOC Supporting Fact

The supporting_facts array contains the fields below. See the TOC Supporting Facts List section for more information about the possible supporting facts.

Name Type Description
name string The name of the supporting fact.
value string The value of the supporting fact.
type string The type or category of the supporting fact.

TOC Supporting Facts List

The following table provides details about each supporting fact for transitions of care:

Name Description Possible Values Example Object
antibiotics The antibiotic medications or ingredients that were started after the start of the encounter. yes, no {"name": "antibiotics","type": "medications","value": "yes"}
intravenous_medication The intravenous medications that were started after the start of the encounter. yes, no {"name": "intravenous_medications","type": "medications","value": "yes"}
toileting_ability_current Indicates a clinical finding of toileting ability after the start of the encounter, for example, INTERPRETATION_OF_ABILITY_DEPENDENT_QUAL or INTERPRETATION_OF_ABILITY_ASSISTED_QUAL. {"name": "toileting_ability_current","type": "discharge_metrics","value": "INTERPRETATION_OF_ABILITY_ASSISTED_QUAL "}
toileting_ability_previous Indicates a clinical finding of toileting ability before the start of the encounter but in the past year, for example, INTERPRETATION_OF_ABILITY_DEPENDENT_QUAL or INTERPRETATION_OF_ABILITY_ASSISTED_QUAL. {"name": "toileting_ability_previous","type": "discharge_metrics","value": "INTERPRETATION_OF_ABILITY_ASSISTED_QUAL "}
walk_ability_current Indicates a clinical finding of walking ability after the start of the encounter, for example, INTERPRETATION_OF_ABILITY_DEPENDENT_QUAL or INTERPRETATION_OF_ABILITY_ASSISTED_QUAL. {"name": "walk_ability_current","type": "discharge_metrics","value": "INTERPRETATION_OF_ABILITY_ASSISTED_QUAL "}
walk_ability_previous Indicates a clinical finding of walking ability before the start of the encounter but in the past year, for example, INTERPRETATION_OF_ABILITY_DEPENDENT_QUAL or INTERPRETATION_OF_ABILITY_ASSISTED_QUAL. {"name": "walk_ability_previous","type": "discharge_metrics","value": "INTERPRETATION_OF_ABILITY_ASSISTED_QUAL "}
snf_admit_source The qualifying encounter with an admittance source of TRANSFER_FROM_SNF. yes, no {"name": "snf_admit_source","type": "utility","value": "yes"}