3. It is also a manual process for the SNF to retrieve the TOC. The SNF must log in to the portal, download the TOC, and import it into the EMR. SNFs are not consistently following this process because it represents additional steps outside of their normal workflows. 3. Referral “Accepted” at SNF via Ensocare by SNF Liaison; the LGH COC team logs into pt’s chart in Cerner; selects “Communicate.” Complete Complete 4. The LGH COC team hits “Send” to send Pt’s TOC as a PDF via Secure message to the SNF over Direct or the MassHIway. Complete Complete 5. SNF Liaison logs into Direct or MassHIway Inbox, selects “New Messages” that have “TOC” as PDF attachment and Downloads TOC PDF to pt’s most recent episode in PointClickCare EMR system. Complete Complete Use Case 4: Care Managers have immediate access to cross-setting care plans for SNF patients in athena Original workflow activity that will be impacted by implementing use case (original workflow activities may not align with process improvement activity line for line) Process improvement activity (Please list activities that must be implemented, or have been implemented, in order to achieve the objectives of this use case.) Anticipated Date of Completion Actual Date of Completion (To be added with submission of Milestone 3) Trading Partner/Collaborating Organization: Lowell General Hospital 1. athena was built to serve as the cloud-based care plan repository not only for SNF patients, but also for Circle Care patients and patients who are enrolled in one of the PHO's disease management programs. 1. The Clinical Care Team identifies pt for a Chronic Disease Management (CDM), Diabetes or SNF program and enters the pt into athena and enrolls them in appropriate programs. Complete Complete 2. There is significant overlap between these populations, so having a centrally located care plan that clinical staff can access and edit from anywhere at any time is critical. The care plan is a single living document, which avoids creating and 2. When new pts are transitioned to Collaborating SNFs, SNF NP conducts search in athena for new pt; if they are enrolled in programs, the SNF NP reads their history, prior admissions, etc.; SNF also makes updates to the Care Plan as needed. 4/30/17
circulating multiple inconsistent care plans for a patient. 3. Other documents, such as MOLSTs or Health Care Proxy forms, that are relevant for SNF patients will also be centrally located within athena. 3. When pt is d/c from SNF to home, the SW and CHW make a home visit to assess the patient, environment and needs and they meet with RN Manager to review patient goals, unmet needs and problems arising during SNF visit. 4/30/17 4. athena Care Manager contains an expanded, more comprehensive care plan, rather than 2-3 sentences. The care plans for SNF patients will be created and maintained by the PHO's SNF NP. 4. The SW and CHW build the athena Care Plan and maintain it from their meeting with the RN Manager. The plan is updated weekly or as goals are completed by patient or staff. 4/30/17 5. Any assigned care team members – SW, CHW, SNF NP - can view, add to and interact with care plan. This provides a more comprehensive patient centered care plan approach 4/30/17 Trading Partner/Collaborating Organization: D’Youville Senior Care 1. Please note that after careful review of the vision we had for this Use Case regarding SNFs becoming athena users, we have abandoned the aspect of this Use Case in which SNFs would have the ability to log on to athena to access the care plans and make edits as needed. N/A Trading Partner/Collaborating Organization: D’Youville Center for Advanced Therapy 1. Please note that after careful review of the vision we had for this Use Case regarding SNFs becoming athena users, we have abandoned the aspect of this Use Case in which SNFs would have the ability to log on to athena to access the care plans and make edits as needed. N/A