Nurses, PHARMACISTS & Social Workers PCMH 4: CARE MANAGEMENT AND SUPPORT ELEMENT A: IDENTIFYING PATIENTS FOR CARE MANAGEMENT Nurses, PHARMACISTS & Social Workers 16 Nurses and 3 Social Workers within RIPCPC have a presence in all 85 member offices 6 Pharmacists manage all Integra PCP offices Collectively there are responsible for the 100,000+ lives Integra manages
Daily outreach report using a workbench reporting tool PCMH 4: CARE MANAGEMENT AND SUPPORT ELEMENT A: IDENTIFYING PATIENTS FOR CARE MANAGEMENT Daily outreach report using a workbench reporting tool NCM/Pharmacist/ Social Worker begins day by running report Once a patient is reviewed, a Pt Outreach is opened. The Care Manage: My outreach today report is run daily. The Nurse Care Manager or Pharmacist will use the report to help organize her day. The NCM is able to work from this report without having to leave the window. This window also gives a snapshot of information about the patient which includes hyperlinks to other contacts with the patient. Your patient outreach can be started right from this report. All RIPCPC care managers add themselves to the care team, which drives reporting.
Patient outreach encounter PCMH 4: CARE MANAGEMENT AND SUPPORT ELEMENT A: IDENTIFYING PATIENTS FOR CARE MANAGEMENT Patient outreach encounter Call initiation section is completed and populates the patient’s care plan The top grouping of the table of contents is the call initiation where the episode can be created, linked or updated. The staff add themselves to the care team and if they know other member they should add them as well. Linking of encounter of episode Care team drives relationship to patient for reporting
Problem oriented charting PCMH 4: CARE MANAGEMENT AND SUPPORT ELEMENT A: IDENTIFYING PATIENTS FOR CARE MANAGEMENT Problem oriented charting Problem oriented charting is used for documentation. This allows the clinician to work with the patient and document as each problem is worked with the patient. This saves having to write narratives and relying on memory and cuts down on repetition.
Standardized note templates PCMH 4: CARE MANAGEMENT AND SUPPORT ELEMENT A: IDENTIFYING PATIENTS FOR CARE MANAGEMENT Standardized note templates Nurse Care Management Plan @FNAME@ is an @AGE@ @SEX@ contacted on @TODAYDATE@. Reason for Outreach @VISITINFOCC@ Current Medications reviewed with patient: @CMED@ Problem List Assessment and Plan: @PROBAPNOTES@ @GOALS@ Using a smart phrase allows the clinician to bring all the problem oriented documentation, the medication review and the goals into one cohesive and succinct note. This also allows reporting, because the staff all use this smart phrase to show a careplan has been created for the patient.
Pulling it all together PCMH 4: CARE MANAGEMENT AND SUPPORT ELEMENT A: IDENTIFYING PATIENTS FOR CARE MANAGEMENT Pulling it all together The last piece of the care management visit is to track the patient outreach. This will close the loop, to update the outreach report.
Pulling it all together PCMH 4: CARE MANAGEMENT AND SUPPORT ELEMENT A: IDENTIFYING PATIENTS FOR CARE MANAGEMENT Pulling it all together The last piece of the care management visit is to track the patient outreach. This will close the loop, to update the outreach report.
Pulling it all together PCMH 4: CARE MANAGEMENT AND SUPPORT ELEMENT A: IDENTIFYING PATIENTS FOR CARE MANAGEMENT Pulling it all together The last piece of the care management visit is to track the patient outreach. This will close the loop, to update the outreach report.