HEALTHCARE SYSTEMS CONNECTORS
Care Transitions & Discharge
7 of 9Support coordinated care transitions across the healthcare continuum with admission/discharge information, care plans, prescriptions, follow-up tasks and Mediloop CareFlow orchestration.
CareFlowHL7 v2FHIR R4 / R4BCDA / C-CDADischarge SummaryCarePlanTaskMedicationRequestAppointmentIHE XDSDSP / DMPEHDS (future)
End-to-End Care Transition Flow
1
Pre-Admission
Referral or scheduled admission
2
Admission
Patient enters hospital via ADT
3
Hospital Stay
Inpatient care, orders, results and procedures
4
Discharge Planning
Prepare summary, care plan and follow-up
5
Discharge
Send documents, prescriptions and notifications
6
Post-Discharge
GP, nurse, pharmacy, home care and patient
A coordinated discharge process ensures every involved professional receives the right information and follow-up responsibilities at the right time.
Key Use Cases
Admission notification
Notify Mediloop and involved care teams when a patient is admitted.
Discharge summary exchange
Receive and process CDA/C-CDA or FHIR discharge documentation.
Community care plan
Share CarePlan and tasks with GP, nurse, physio and home-care teams.
Medication reconciliation
Validate discharge medications and route prescriptions to pharmacy.
Follow-up appointments
Schedule GP/specialist/rehab follow-up before or after discharge.
Notifications & tasks
Coordinate accountable actions across professionals and patient.
Admission Care Package
Patient identity and demographics
Medical history, allergies and active treatments
Recent labs and imaging
Referral / reason for admission
Known diagnoses and risk factors
Referrer and involved healthcare professionals
Home-care aides / community providers
Existing care pathway and consent context
Discharge Package & CareFlow
| Component | FHIR / document representation | Downstream action |
|---|---|---|
| Discharge summary | Composition / DocumentReference / CDA-C-CDA | Update longitudinal record and share with care team |
| Care plan | CarePlan | Community nursing / GP / allied-health coordination |
| Tasks | Task | Assign follow-up responsibilities |
| Medications / prescriptions | MedicationRequest + medication reconciliation | Send to default pharmacy / patient workflows |
| Follow-up | Appointment / ServiceRequest | Book GP, specialist, rehab or monitoring |
| Encounter closure | Encounter | Close admission and update status |
Notifications & Tasks
Notify patient, GP, pharmacy and other involved professionals
Create explicit owner/due date/status for each transition task
Escalate overdue or failed handoffs
Avoid duplicate notifications through idempotent transition events
Capture acknowledgement and completion evidence
Keep post-discharge monitoring separate from one-time discharge tasks
Developer Integration Surface
How to read this section
FHIR resources and HL7/IHE operations are standards-based integration surfaces. Mediloop REST routes shown here are documentation contracts and must remain marked planned until the corresponding backend route is implemented and production-approved.
| Surface | Operation / resource | Use | Status |
|---|---|---|---|
| FHIR | Encounter / CarePlan / Task / MedicationRequest / Appointment / ServiceRequest / DocumentReference | Build admission/discharge packages and coordinated follow-up | FHIR surface |
| HL7 / CDA | ADT discharge events + CDA/C-CDA documents | Integrate existing hospital discharge workflows | Protocol / document |
| CareFlow API / SDK | Transition package orchestration, participants, tasks and status | Mediloop-native care-transition coordination | Planned / product contract |
| Events | admission.started / discharge.planned / discharge.completed / task.overdue | Notify downstream systems and professionals | Planned contract |
National & Cross-Border Exchange
Luxembourg DSP / national exchange through country-specific adapters
France DMP / Mon espace santé through country-specific onboarding
IHE document-sharing profiles where applicable
MyHealth@EU / EEHRxF capabilities must remain marked future/planned until implemented and certified
Respect national sovereignty, consent/legal basis and data-residency requirements
Best Practices
Start discharge planning before the discharge event itself
Make responsibility and acknowledgement explicit
Reconcile medication list at the transition boundary
Ensure patient-accessible instructions are understandable and current
Track failures and uncompleted handoffs
Audit every recipient, document and action in the transition package