Chart Review
This is the place you would locate overdue well checks and vaccines.
What are the Care Gaps?
This rhyming phrase indicates starting a discussion based on the identified needs from referral and/or chart review.
What is "Lead with the Need" or "Recognize and Empathize"
This reason for case closure should only be used after collaborating with the intake team.
What is "ineligible"?
Asking questions in this format is recommended to elicit detailed responses.
What is open ended?
What is Care Coordinator?
This Epic function in the Storyboard is represented by a magnifying glass.
What is the chart search function?
The timeline for this specific type of outreach, especially helpful in building rapport and maintaining engagement, should be discussed at enrollment. For high risk patients, it should be scheduled.
What is face-to-face?
Before selecting the "No Needs Identified" reason for closure, this must be completed.
What is the initial HRA?
Using the MI tool of affirmation, revise this sentence: "You're doing great - keep it up!"
Affirmations are sincere compliments that focus on specific successes and efforts.
This is the deadline for completing and documenting the initial HRA.
What is 30 days?
You can check a patient's active roster by navigating to this part of the SnapShot.
What is Plan of Care?
If referred by a physician/clinic, this should be part of your enrollment script.
What is telling the family that physician/clinic referred them?
This reason for case closure should be used if the patient declines Care Coordination.
What is "Refused"?
This MI tool is used to close the loop in communication to ensure breakdowns don’t occur.
What is reflection or summary? (Will consider teachback)
Use this criteria to determine when to set the due date for the next outreach management task.
What is based on patient/family need?
When reviewing the chart, use this best practice for reviewing office notes.
What is look at the most recent last visit for each provider/specialty?
This topic, related to the termination of the relationship, should be discussed at the time of enrollment.
What is case closure?
These are two reasons for case closure that require Team Lead approval.
What are "Other" and "Unable to Contact"?
Use this MI tool to wrap-up the end of each outreach with family.
What is summary?
Complete an HRA review and SPOC on medium risk patients every ______ days.
What is 180?
Rather new access to this type of data is found in Epic (NCH) or in PowerBI (DCH).
What is the claims data?
This ultimate goal of all patients enrolled in Care Coordination should be discussed during initial interactions with the family.
What is self-management?
When transferring a case from WR to CR, this reason for case closure should be used.
What is "Sent to Care Program"?
These are 2 of the 4 levels of reflective listening.
What are repeating/rephrasing, paraphrasing, and reflection of listening?
These are the four ways patients are identified for Care Coordination.
What are data reporting (PICN), transitions of care, referral, and screening?