Reports on Epic
What report in EPIC helps you review your care team and track your metrics? and how often should it be run?
My Active Current Care Team Patients - Care Management View
It should be run on a daily basis.
What do you need to complete once a patient is assigned to you? and how much time (months or days) do you have to enroll this patient?
- Reach out to patient to introduce self as a care navigator as well as to explain Care management services.
- Document this encounter and add that patient gave verbal consent to enroll. Then, send this encounter and/or inform supervisor for enrollment (If patient does not want services, still document and send to supervisor for closure)
Care navigator have 30 days to enroll patient after this has been assigned. Patients should not be in outreach for more than 30 days.
What are the types of case closures? Please provide an example of each.
Voluntary - Patient agreed to close case as patient does not need ongoing care management services. Patient will be out of town for a long period of time. Patient will established all medical and social care somewhere else.
Graduation - Patient has met and completed all goals established in care plan. Patient does not present outstanding medical or social needs.
Involuntary - Patient refused to close case even though Patient does not present any outstanding needs. Patient has completed all goals and is ready for graduation but still wants to be part of the program.
How do you know when a patient had either an ED visit or a hospital admission/discharge? Then, what workflow do you complete as a follow up for your patient?
My Active Care Team Patients with an Emergency Department Visit or Hospital Visit Notification in the Past 7 Days
Complete TCM (Transitional Care Management) as a follow up.
How long is a verbal (Health Home) consent valid?
Only 60 days
"All attempts to obtain wet or electronic signatures must be documented in the case record, e.g. electronic, through mail, face to face, etc."
What are three ways you can provide a service for your assigned patients without working with them directly? Please provide examples for each way mentioned.
Different ways with Examples:
- Case conference with care team members (Supervisors, RN coordinator, Mental health clinicians or psychiatrists, PCP, Nurse manager or nursing team (Including MOAs) at each site, and others)
- Referral coordination (Schedule a specialist referral such us cardiology, physical therapy, ophthalmology, ENT, Neurology, and others. Also, schedule any cancer screenings)
- DME coordination (Use ParachuteHealth, AuntBertha, or any other DME supply store)
- Set up transportation (MAS, Access a ride, others)
- Applying to social support services (food stamps, MLTC, SSI/SSD, Supportive housing application)
- Assist with insurance application including renewals.
- Assist with home care applications
What dashboard in EPIC helps you review patients health maintenance?
Healthy Planet Quality Measures
How do you know if any of your patients do not have a signed consent on their chart (media section)
Running My Active Current Care Team Patients - Care Management View report. Then, look at the column named "Health Home Document Date" And, If this column is on blank/empty meaning there is not a date, it means signed consent is missing, Therefore, CN will follow up with patient to sign the consent (DOH 5055)
Patient Omar is overdue to review/update care plan and he mentions that one of his main focus in the program is to find a job. How do you create a goal for this need and how do you track this goal? Please mention step by step.
- Go to Care Plan tab on an open encounter.
- Click on "Problem List" section
- Add a new Problem by searching “Job”
- Double Click “Loss of Job” as a new problem
- Accept the new problem
- Click on “Loss of Job” > click “Add” under Related Goals
- Type “CM” into search bar
- Select “CM: Provide advocacy for specific need”
- Type in a SMART Goal that will help Hugo start looking for a new job
- Click “Modify Related Goals” and Accept new goal
This goal could be track by clicking on your SMART goal, click on "Assess", then select if Omar (or any of your patients) is "on track" or "not on track"