pre- program
What teams are live?
The live teams are 1, 2, 3, 6, 7 & 10
When to add yourself to the Care Team?
After contacting members and members confirm the services
What timeframe are the program activities to be completed?
The CHW Program has activities required to be completed at 4 days, 30 days, 90 days, and 180 days from the program start date
The first CHW Program Engagement has the SDoH Follow Up script. What are the timeframes?
Due to be completed within 4 business days of the program start. Outreach will be attempted within this timeframe
Unsuccessful Outreach what are the number attempt?
3 outreach attempts will be completed using the CHW Program Engagement Activity.
When receiving a referral what is the first step you take?
Accepting the Referral closing/acknowledging
Where do you go to Schedule Program Activities?
To access program activities, go to the “Activity Record,” click “Required Activities”, then “Clinical Programs”, and then “Community Health Worker”
Member declines to participate in assessment - Members are not required to complete the assessment to receive support. How To document declination?
Outcome Type: Unsuccessful /Activity Outcome: Member/Caregiver Declined
Where to go to start the program?
In the “Member Info” tab, click “Programs
When a member is reached and consents what is the next step?
: to participate in the assessment, you can initiate running the script directly from the activity.
Select Outcome Type: Successful
Scroll to the bottom of the activity to find links to open and run the script.
Select “From similar questions in related scripts” to allow mapping of similar questions from the SDoH Annual script
What to do if you want to add yourself to the care team?
You will submit an admin request to be added to the member’s care team.
When you have been added to the member’s care team in GC, you will update the CHW Program to add your name as the “Assigned Care Manager”. This provides clarity to the care team regarding who is supporting the member.
When do you use the SDoH Outreach/Intervention activity?
All encounters/outreach (aside from the CHW Program Engagement activities) will be documented using the new “SDoH Outreach/Intervention” activity. This replaces the use of Outreach/Visit – Member, Caregiver, etc. There is no template to complete this activity, however, CHWs may use the existing CHW note template or a modified version, if they choose. For all, ensure documentation is member-driven, clear, and contains what occurred and what comes next.
When to open a program?
All members referred to a CHW will be enrolled in the GC CHW Program within 2 business days of receiving the referral.
When do you complete the loop closure?
To notify of initial referral outreach outcome – e.g., member not reached, referral/program closed; member reached, next steps
Outcome of assessments/scripts completed
Following update of care plan OGI(s)
As needed to communicate and coordinate care based on clinical judgement, Loop closure will be documented in an “Internal CC/CM Discussion” activity, assigned to the Sr. CC/CCM/CP (name in blue banner in GC).
What to do when closing/ending the program?
In “Programs,” locate the Community Health Worker program and click the pencil and paper icon to edit.
Update “Status” to “Closed” and select the appropriate “Status Description” based on the reason for ending as outlined in the table below:
List some of the providers you contact with to support your member?
care coordination, Care partner, GSSC, LTSC, BH, CCA Provider, outside provider that involved in member care.