Improving the transition to home healthcare by rethinking the purpose and structure of the CMS 485: first steps.

Transition points are the weak links in communication between providers. As an example, the discharge home often is a hurried "handoff" from inpatient physician to home care agency, whose visiting nurse admits the patient for a period of observation, medication management, rehabilitation, and teaching. The primary means of communication between physician and home health agency is the CMS 485, a form that contains the orders and that physicians frequently sign well after patients begin receiving services. This paper describes the first phase of a project that restructured and automated the CMS 485 using an existing electronic health record. The principles guiding the restructuring are described along with early reaction to and revision of the form to address operational issues. The paper also discusses evaluation plans and a web-based system of communication that will be developed in the second phase of the project.