Pick the Workflow
This workflow is used when the member was already mailed the ICP.
What is Workflow 1, ICP Already Mailed?
In Workflow 1, outreach may be needed when this cannot clearly demonstrate ICP implementation.
What is evidence of connection to care or claims evidence in member profile? (After date on ICP letter)
This type of structured note is used when the member is reached for Conduct ICT or Review ICP
What is the DSNP CC Structured Note?
In Workflow 2, every applicable PGI must be moved from this location before submitting the care plan.
What is Care Plan Builder?
A Care Plan Implementation task should be created when support, monitoring, or evidence is still needed. It should be due no later than this timeframe.
What is within 6 months?
This workflow is used when the HRA is complete and PGIs are waiting in Care Plan Builder.
What is Workflow 2, HRA Completed, ICP Not Mailed?
In Workflow 2, at least one outreach attempt should be made within this timeframe.
What is within 60 days?
This template is used when outreach remains unsuccessful in Workflow 1
What is the DSNP CC Conduct ICT Unsuccessful Outreach template
Newly added PGIs should not be closed on this day.
What is the same day they are added to the care plan?
Before outreach, Care Coordinators should review the Member Profile, care gaps, alerts, and this type of evidence.
What is evidence of connection to care?
This workflow is used when the member did not respond to the HRA and the Non Responder protocol is loaded.
What is Workflow 3, Non Responder Outreach?
In Workflow 3, the main outreach goal is to complete this with the member.
What is the Initial or Annual HRA?
In Workflow 3, this phrase should be used in the Care Plan Implementation task description box when the member is not reached
What is "Unsuccessful Non-Responder"?
After moving PGIs from builder, this must be submitted so the ICP can be mailed.
What is the care plan?
Evidence of ICP implementation may include PCP follow up, specialist follow up, claims, medication activity, or this.
What are closed care gaps?
This is the first thing a Care Coordinator should identify before starting outreach
What is select the correct workflow?
When the member is reached in Workflow 2, the Care Coordinator should review triggered PGIs, discuss care gaps, and identify this member centered item.
What is the member’s personal health goal?
Documentation should include dates, diagnoses when available, member input, barriers, CMT interventions provider follow up, and these.
What are next steps?
This template should be used 1 to 2 weeks later when closing supported PGIs.
What is the PGI Closure Note template?
If additional clinical support is needed beyond the coordinator role, the Care Coordinator should do this.
What is escalate to the PCP or Specialist or Care Manager or Nutritionist or the Pharmacy team or the Relationship Coordinator team, etc.?
These three items help determine the correct workflow: ICP status, HRA status, and whether PGIs are in this location.
What is Care Plan Builder?
In Workflow 1, member contact alone is not enough to close PGAs unless this is also documented.
What is supporting/claims evidence?
In Workflow 2, when the member is not reached, the task description should include this phrase with the HRA date.
What is "HRA (date) pending review"
PGAs and PGIs should only be closed when this clearly supports the closure.
What is evidence?
Before closing PGAs or PGIs, the Care Coordinator should connect the evidence (PCP/specialist follow-up, claims, closed care gaps, medication activity) to the specific PGA/PGI, barrier, or this.
What is diagnosis?