CM workflow changes
How does a CM decide if they should complete a chart review on a patient who is currently inpatient or send it to the PCN?
Use clinical judgment! (based on acuity)
What subtype should be used when setting the Reminder to check to see if patient attended their 7 day follow-up?
Subtype: TCM follow-up
Subject: Confirm 7 day follow up
(set for day after appointment was scheduled)
What tool do we use to identify where a patient should go at the end of our program? AND where is this found?
Referral Criteria Guide
It's at the end of all workflows as well as posted in TEAMS
Method: Aunt Bertha
Contact Type: Vendor
Outcome: What ever resource category you are getting for the patient (food, transportation etc)
what important item should you add to the end of each free text note you enter?
Your signature dot phrase!
What modality is used to send warm hand off to new CM if referring to another program?
Cerner Message
How often should you review a chart on a patient?
Depends on current patient status. Discuss daily with CM.
What resource is available to know how to appropriately chart a communication event?
Communication Event Crosswalk!
(Located in workflow and in TEAMS)
Where do you chart that a chart review was completed?
YOU DON'T!!! Charting this action is no longer needed!
PRAPARE TOOL!
What is the difference in the number of attempts between TCM UTR and Standard UTR processes?
Nothing! Both are 3 attempts to reach patient.
If you are chart reviewing for a patient who is inpatient, what reminder subtype should be utilized?
TCM and referral subtype should be the only reminder subtypes used during TCM timeframe. (inpatient and 14 calendar days post DC)
If a patient is admitted to an outside hospital, where do you look to find their records/notes?
HealtheRecord, Outside Records, or Careweb
In the comment section of patient's goal/intervention
What reminder subtype do you use for CM and PCN follow-up calls? (pt is not in TCM timeframe)
CM priority 1,2,3
Based off of Patient Progression Guide (see hyperlink within workflow)
Instead CM is now entering a free text note.
It is now embedded in the CERNER menu
You workflow document!!!!
Located in TEAMS
What do you do if you can't find a Communication Event that matches your action?
You chart it in your free text note and not in the Communication Event!
"If it don't fit-quit" (don't force it)
What does the SMART in SMART goals stand for?
Specific
Measurable
Action-oriented
Realistic
Time Specific
YOU ARE!
You will manually open new case, assign to new team, and send a reminder. (don't forget to send warm handoff via Cerner message)
How do you get find the patient ED utilization list?
Sort Complex Care PCL by "last ED utilization"
What new, amazing tool can you use as a checklist to assess if all appropriate charting has been completed on a patient?
CHEAT SHEETS!!!!
Located in TEAMS!!!
Subtype: Referral
Method: Care Coordinator
(search name)
Outcome: AMB Social Worker
What reminder subtype should be used when sending a referral to your Social Worker?
Subtype : REFERRAL
(this will help them be able to filter their list)