CM workflow
PCN workflow
THE PCL---doom doom doooooooom
Charting
Who's that CM
(or RD or Manager)
(or RD or Manager)
Who's that PCN?
100
How long is a patient in the TCM window?
During inpatient stay + 14 days post discharge!
100
If you are chart reviewing for a patient who is INPATIENT, what reminder subtypes do you use?
TCM!!
Remember you only use TCM or referral during the "TCM WINDOW"
100
I am filtering my list to find the ED patients....what is wrong with my settings?
It is set to the complex care list and NOT Early Disease Management
100
How do you chart that you did a chart review?
YOU DON'T!!!! You longer have to do that!
100
I have a degree in culinary arts and worked as a chef before this role.
Dana Beals!!!!!
100
I am currently on vacation and will be assigned to the WCR team!
Lori Baker!
200
A patient DC from the hospital and needs outreached but you have attempted 2 x without success. What do you do?
CC provider on TCM dotphrase letting them know you were unsuccessful in reaching them.
Set reminder to call patient again the day after their 7 day follow-up .
200
If you are doing follow up calls with a patient and the patient shows some clinical concerns, what do you do?
Notify CM immediately.
200
What important step do I need to take before assigning a patient to our team?
A CHART REVIEW!!!
200
what subtype do you use to send a referral to Social Work or Dietitian?
Method: REFERRAL
200
I have delivered a baby at home.......that wasn't mine!!!
Lisa Gard!
200
I have watched a movie at Marco Andretti's house!!!
Aimee Dunn!!!
300
How many attempts do we make to reach a patient before closing as UTR?
3! Same for TCM process except the 3rd attempt is after their 7 day follow-up.
(use clinical judgement)
300
You are doing chart reviews on a patient who is inpatient and see that they are being discharged. What do you do?
Send reminder to the CM
Subtype: TCM initial outreach
Subject: TCM IA-Pt DC 5/7
300
A patient is on the PCL and I do a chart review. I notice the banner bar says PHSA:NO. What do I do?
Assign them anyway! We are to TRUST the PCL.
300
You are sending an introduction letter to a patient. You select patient letters. Which option do you pick to send the intro letter?
300
I have 3 children, 2 of which we adopted through Foster Care. :)
Monica Myers!!!
(Thank you for opening your home and hearts to children in need!)
300
I was on my High School golf team!
Denise Eckerty!
400
What tool do we use to determine what program a patient should go to next?
REFERRAL CRITERIA GUIDE!
400
You are doing a follow-up call with a patient and determine that patient needs a referral sent to a social worker. You send a referral to the social worker. What important next step do you take?
Send a reminder to the CM letting them know of the referral so that they can update the GOALS AND INTERVENTION!
400
What does the GOLD bar beside a patient's name on the PCL mean?
That a case has already been opened on that patient! (those names will fall off of the list within 12-36 hours)
400
What tool is available to use to determine what the appropriate communication event to use is?
Communication Event Crosswalk!!!
400
I was in the movie "Eight Men Out" and got to meet Charlie Sheen and John Cusack!
Jennie Soto!!!
400
Cold Sandwiches: Mayonnaise
Hot Sandwiches: Mustard
Teri-Lyn Morton!
500
How do you decide what patients you should keep versus sending to a PCN for follow-up?
Based on patient status/acuity
500
If a patient is in the TCM timeframe and you are calling the patient to remind them of their 7 day follow-up. (the call is successful)
Next reminder is to check pt's chart to see if they attended appointment.
Subtype: TCM follow-up
Subject: Chart review for 7 day follow-up
500
where does a patient go immediately after you click "assign patient?"
HINT: there are 2 locations
Onto your case list
they will show in the blue line right above "Potential cases"
500
If you are trying to chart a communication event and can't seem to find anything that fits. What do you do?
Just put it in your note!
"If it don't fit, QUIT!!!"
500
I can tear a phone book in half with my bare hands!
WILMA!!!!!!
500
I am the caregiver of my 86 year old Mother!
Wendy Lee!
600
Who opens the new case when referring to another program?
WE DO! The care manager opens new case and assigns to new care team!
600
You are chart reviewing a patient and they seem more appropriate for Complex Care. What do you do?
Consult with CM!
(the goal is to get resources to all patients and then send them off so likely all patients will be opened in EDM and them referred out)
600
You are chart reviewing a patient and feel they aren't appropriate for EDM and want to remove them from the PCL as "Does not meet priority guidelines" what important step MUST you take before doing that?
Check with Wilma!
You are only to use "Deceased" or "Deferred programs" as closure reasons otherwise!
600
When referring to another program, how do you send the warm handoff to the new team?
Cerner Message!
600
I have traveled to Ireland and Spain!
Anne O'Connor-Clark!
600
I have been involved in 4 emergency airplane landings!
Melissa Adams!