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  1. Care Coordination
    1. Create Care Coordination Use Case Workflow
      1. Acute Patient Admission 
        1. Patient Name
          1. Mrs. Patricia (Pat) Chess
          2. 42-year-old full time office assistant, was involved in a road accident 
        2. Patient Condition
          1. Post MVA
            1. Pat is admitted to ER, treated and transferred to OR (see primary story)
            2. Diagnostic abdominal, peripheral, and chest and spinal X-rays and CT, showed a closed undisplaced comminuted fracture left mid shaft femur, fracture left ribs 6-7 with spleen and liver contusions. No fracture vertebrae detected.
            3. Post Surgical open reduction and internal fixation of her femoral fracture and exploratory laparotomy for abdominal injuries. 
              1. No abdominal injuries, successful treatment of femoral fracture. 
              2. Pain treatment and management- (CQF) Opioid Guidelines
            4. Post OR and Successful Recovery Pat is transferred to ICU
              1. Post Op monitoring and treatment for pulmonary embolism.
              2. When stable pat is transferred to Medical Surgical Floor. 
            5. Medical surgical unit prepares Pat for transfer to extended on site rehabilitation.
          2. History
            1. Smoking history: average 10 cpd/17 years
            2. Hypercholesterolaemia: diagnosed in 2009
            3. Hypertension: diagnosed in 2010
            4. Ischaemic heart disease in 2015
            5. She was diagnosed with Type 2 DM in early 2019 and is still working with her diabetes management team to control her blood sugar levels and manage her body weight
            6. No daily exercise, BMI 34
        3. Discharge Planning 
          1. Discharge Orders 
            1. Referral Transfer Request to Inpatient Rehabilitation until patient is prepared to return to home.
            2. Surgical Wound Care
            3. Pain management, post surgical and fractured ribs - (CQF) Opioid Guidelines
              1. Opioid prescription based on CDC guidelines
            4. Respiratory Treatments and incentive spirometer exercises. 
      2. Emma to do: Payer Case Management and Disease Management
        1. Upon awareness that Pat has been admitted to the hospital due to an MVA followed by surgical interventions, Pat's Health plan enrolls her in the health plan case management/disease management program to support adherence to care, avoid preventable complications, support the patient in making informed care decisions (that minimize financial impacts), and increase the patient’s/caregiver's understanding of and ability to self-manage care.  
      3. Rehab Admission 
        1. Dynamic Care Planning 
          1. Care Planning Condition/Concerns
            1. Physical
              1. Surgical Wound Care
              2. Pain management, post surgical and fractured ribs
              3. Diabetes Management 
              4. Strength training 
              5. Walking, with assistance as needed 
              6. ADL (Activities of Daily Living) Assessment and Training
              7. Respiratory incentive spirometer 
            2. SDoH (Social Determinants of Health)
              1. Long term smoker - Potential for respiratory compromise r/t history of smoking and mobility. 
              2. Diabetes management / appropriate diet and reduced mobility 
              3. Physical Strength and Coordination - No daily exercise - potential weakened state & potential for fall 
              4. Mental State - Pat is  depressed over her inability to return immediately home and unknown duration of he stay 
          2. Discharge to home planning (Orders)
            1. Discharge Orders
              1. Visiting Nurse Assessment
              2. Physical Therapy Sessions 
              3. Pain management, post surgical and fractured ribs - (CQF) Opioid Guidelines
                1. Opioid prescription based on CDC guidelines
              4. Follow up visit with Orthopedist Specialist 
      4. Discharge To Home (ToDo: Emma update Home Health Case Management/Care Coordination)
        1. Dynamic Home Care Planning
          1. Visiting Nurse Assessment
            1. ADL assessment/mobility
            2. Smoking cessation options.
            3. Respiratory Exercises 
            4. Diabetes Management
            5. Pain management, post surgical and fractured ribs - (CQF) Opioid Guidelines
              1. Opioid prescription based on CDC guidelines
          2. Physical Therapy Sessions 
            1. Strength Training 
            2. Coordination Exercises 
            3. ADL assessment and gap recommendations
            4. Monitor pain during exercises
    2. Care Team management 
      1. Condition-Focused, Event-focused Care Team

      2. Acute Care Team Transactions 
        1. On admission to ED the provider providing care assigned to the patient (Dr. Medy) is auto assigned to CT (Care Team)
        2. When patient is transferred to Surgery the Trauma Surgeon (Dr. Burke) assigned to the patient is auto assigned to CT
        3. When Patient is transferred/admitted to unit post recovery the attending (Dr. Shackleton)  for the care area is auto assigned to CT
          1. Dr. Shackleton is auto assigned as care team lead by institution policy 
        4. When Dr. Shackleton writes physical Therapy order Physical therapist (Mr. Roberts) is assigned to the CT by his manager based on patient load and expertise. 
        5. When Patient is transferred/admitted to unit post recovery a primary nurse (Ms Curry) is assigned to the CT by her manager and agreement by Ms. Curry.
        6. When Dr. Shackleton writes discharge planning order Care Coordinator (Ms Hopper) is assigned by department manager based on availability 
        7. When patient arrives/admitted to unit Nutritional assessment is standard assessment and Mr Krum is assigned by Nutrition Department manager. 
        8. Patient is default added to care team. 
        9. Patient names sister Ms. Chess - Rollings as her support caregiver the team lead adds sister to care team 
        10. When Patient discharged after prescribed interval designed to provide support post transfer the Acute Care team is inactivated 

      3. Emma - Payer Disease Management/Case Management Team Transactions
        1. The disease/case management screening program of the payer’s population health management system identifies Pat as a candidate for proactive care management, triggered by his ED physician assessment/diagnosis and the patient’s admission to the inpatient setting. 

        2. Upon admission, the hospital's care coordinator/discharge planner is made aware of the patient't candidacy for enrollment in the payer's care management program. The hospital care coordinator is also provided a single point of contact for all needed services from the payer. 
        3. When Pat is able, the payer Care Manager has a telephone discussion with Pat and gets her agreement to enroll in the health plan’s Trauma Care Management Program.
        4. The health plan's trauma care management program care plan interventions include: 
          1. Informing of and providing the patient access to needed services including pre-authorizations.
          2. Providing educational information related to disease/care processes.
          3. Assisting the patient with care coordination between care providers.
      4. Rehabilitation Care Team Transactions 
        1. Rehabilitation Care Team auto adds the rehabilitation provider assigned to cover the newly admitted patient. 
        2. The Trauma Surgeon (Dr. Burke) is auto added to the care team based on system rules to provide transition of care support. 
        3. The Trauma Surgeon (Dr. Burke) is auto inactivated after prescribed time interval.
        4. When Dr. Burke writes referral order for consulting orthopedic specialist and referred to practice accepts referral and assigns a provider (Dr. Todd) is assigned to the care team.
          1. The patient begins to complain of deep stabbing pain in affected area  after start of physical therapy 
        5. When Dr. Burke writes an order for specific physical therapy Physical Therapist (Mr. Ridge) as assigned by department manager based on availability and expertise. 
        6. When patient is admitted to Rehabilitation facility Nursing assigns staff (Ms. Bloomaker) based on availability and care team is updated
        7. When patient is admitted to Rehabilitation facility, by policy, Discharge Planner (Ms Parks) is added to care team by department manager after review of available staff. 
        8. When patient is admitted to Rehabilitation facility, by policy, Nutritionist (Ms Kobe) is added to care team by department manager after review of available staff
        9. Patient is default added to care team. 
        10. Patient names sister Ms. Chess - Rollings as her support caregiver the team lead adds sister to care team 
        11. When Patient discharged after prescribed interval designed to provide support post discharge the Rehabilitation care team is inactivated 
      5. ToDo:Emma -  Home Health Care Team Transactions
      6. Out Patient Community Care Team Transactions 
        1. When discharged to community team /home PCP (Dr. Hare) is added to Community Team as provider by default since in the longitudinal care team.
        2. Patient is default added to care team. 
        3. When Patient discharged after prescribed interval designed to provide support post transfer the Acute Care team is inactivated 
        4. When Dr. Hare orders continuing community care which includes Physical Rehabilitation, Visiting Nursing a care coordinator (Mr Holbert) is added to the care team from the practice staff, by practice policy Mr. Holbert becomes the Care team Lead. 
        5. When Mr. Holbert reaches out to Care Giver Community Services and the patient to coordinate, a services coordinator (Ms Night) is assigned to the care team and Patient names sister Ms. Chess - Rollings as her support caregiver and Mr. Holbert adds sister to care team. 
          1. Alternatively the family support person could have been automatically carried through to each team as she is present in the longitudinal care team. 
        6. Ms Night coordinates Visiting Nurse and Physical therapy with patient and her sister. As she Does this Visiting Nurse (Mr. Smyth) and Physical Therapist (Mr Ridge) are assigned to the care team by Ms Night. 
        7. When Mr Smyth completes his first visit he reports concern over patients nutritional status. This report is received by Mr Holbert who discusses with Dr Hare who then writes a nutritional consult referral, at this point a nutritionist (Ms Colby) in the practice is assigned to the Care team. 
          1. Ms Colby visits the patient and provides a consultation report which is used by Dr Hare to provide additional nutritional training which Ms Colby carries out. At the completion of this training and satisfactory comprehension by the patient her engagement is complete and she is inactivated from the care team. 
        8. Mr Holbert receives a complaint by the Patient's sister that they found the visiting nurse to be disrespectful and do not want them to came back.  Mr. Holbert reviews with Ms Night and the visiting nurse assignment is changed, Mr. Holbert inactivates Mr. Smyth and adds visiting nurse Ms Doe to the care team. Mr. Smyth's assignment history can still be viewed if inactive team members areAs Physical Therapy progresses the patient responds well and Dr. Hare decides to end the therapy by placing an order. At which point the therapist is inactivated from the care team. 
        9. When the patient later visits Dr. Hare he reviews the visiting nurses documentation and reviews the updates from therapy and discusses stopping the visits and therapy with the patient .  The decision is made to stop both and Dr. Hare writes an order to stop.  Mr. Holbert Contacts the community coordinator and cancels both. Mr. Holbert inactivates both the therapist and visiting nurse from the care team. 
        10. Mr. Holbert contacts the Community services coordiantor and closes the engagement, he then inactivates the post discharge community care team. 

      7. Longitudinal Care Planning 

                     Longitudinal Care Team, Long term cross incident and condition care planning and oversight 

        Member NameRoleRelationship to PatClinical WorkflowExpected Outcomes Associated Encounter (Episode of Care) Steps (Manual workflow) FHIR Resource NeededComments
        Mrs. Patricia (Pat) ChessPatient


        inpatient encounter; Acute Rehab encounter; Home care encounters; Ambulatory Care encounters


        William Hare MD

        Primary Care Provider

        Care Team Lead

        Longitudinal Care Plan ProviderLongitudinal CP Team Lead
        Home care encounters; Ambulatory Care encounters

        CarePlan

        CareTeam

        Reference CareTeam from CarePlan
        Inpatient Care Team
                     Care Team engaged during Pat's post MVA admission and following surgery until discharged. 
        Member NameRole Relationship to Patient CommentsClinical WorkflowExpected Outcomes Associated Encounter (Episode of Care) Steps (Manual workflow) FHIR Resource NeededComments
        Dr Ernie Medy MD

        ER Physician

        Initial treating providerAdded to team as initial provider in ED 
        ED encounter


        William Burke MD

        Surgeon

        Care Team Lead

        Acute/Trauma Surgeon

        Added to team as surgeon on duty when Patricia was admitted. 

        Initial Care team lead, lead then transferred to Attending 

        In some workflows, this surgeon continues to follow the patient throughout inpatient stay, acute rehab, and outpatient - Emma provide complete example

        In some workflow, this is a service - surgical services where the surgeon is a member of the surgical team providing the surgical service. 


        inpatient encounter; Acute Rehab encounter; Home care encounters; Ambulatory Care encounters. Note that encounters are independent of each other. For example,  patient may get PT as part of her rehab (PT encounters) that might not be part of the PCP encounters. 
        See gForge 23029 careTeam.encounter need (0..*)
        Ernie Shackleton MD

        Attending post surgical care

        Care Team Lead 

        In patient Medical Coverage

        Added to team as primary provider covering area patient transferred to post procedure/ICU 

        Picked up care team lead after patent transfer 

        Record of provider at time of discharge - Who needs this info?

        Realistic workflow. What do you need, depending on place /role in workflow. 

        How would you do this in FHIR

        Template- who would you query, is it a pull/push. The technical data flow paralleling the physical workflow. 

        inpatient encounter; Acute Rehab encounter; Home care encounters; Ambulatory Care encounters


        Eric Roberts MPTPhysical Therapy In Patient Physical Therapist Added to team by provider order




        Miriam Curry RNNursingInpatient Nursing Added to team related to patient assignment 




        Tricia Hopper LCSW

        Discharge Planner / Care Coordinator


        Acute Social Services 

        The Care Coordinator is the facilitator/steward who is responsible for reviewing and reconciling
        proposed modifications to the care plan

        Added to team as part of Discharge Planning Order






        Reginald KrumNutritionistIn patient nutrition assessment, dietary recommendations Added to team as standard post op & Diabetic protocol 




        Karen Chess - Rollings Caregiver Sister
        inpatient encounter; Acute Rehab encounter; Home care encounters; Ambulatory Care encounters



        Bobby KnightCaregiverSon
        inpatient encounter; Acute Rehab encounter; Home care encounters; Ambulatory Care encounters



        Mrs. Patricia (Pat) ChessPatient

        inpatient encounter; Acute Rehab encounter; Home care encounters; Ambulatory Care encounters



        Payer Care Coordination Team
        Health plan case management/disease management program to support adherence to care, avoid preventable complications, support the patient in making informed care decisions (that minimize financial impacts), and increase the patient’s/caregiver's understanding of and ability to self-manage care.  





        Mrs. Patricia (Pat) ChessPatientRelationship to PatientClinical WorkflowExpected OutcomesAssociated EncounterSteps FHIR ResourceComments
        Pamela Care-Manager, RN, CCMHealth Plan CM/DM NurseCare coordinator - to support effective care coordination from a payer prospective. Added to team to assist and inform care providers and patient of available services and resources to promote care.  inpatient encounter; Acute Rehab encounter; Home care encounters; Ambulatory Care encounters



        Rehabilitation Care Team

                 Care Team engaged during Pat's transfer to and during on site rehabilitation stay 

        Member NameRole Relationship to PatientClinical WorkflowExpected OutcomesAssociated EncounterStepsFHIR ResourceComments
        William Burke MD, F.A.C.O.S.SurgeonConsulting Surgeon Specialist

        The original Trauma Surgeon is anticipated to follow for a short time, at which point the CP Team role becomes inactive 






        Bill Warfel MDRehab Medical Support Rehabilitation Medical TeamAdded to care team by admission from pool and current case load 




        Albert Todd MD

        Orthopedic Specialist

        Consulting Orthopedic Specialist Added to care team as referral consultant when patient continues to complain of deep stabbing pain on movement. 




        Kyle Ridge MPT

        Physical Therapy

        Care Team Lead

        Rehab TherapistAdded to care team as available staff and provider order 




        Bertha Bloomaker  RNNursingRehab Nursing StaffAdded to care team as available staff and policy. 




        Evan Parks RN

        Discharge Planner / Care Coordinator


        Rehab Social Services The Care Coordinator is the facilitator/steward who is responsible for reviewing and reconciling
        proposed modifications to the care plan





        Clementine KobeNutritionistRehab Nutrition assessment/supportAdded to Care Team as protocol and lighter patient load at the time. 




        Karen Chess - Rollings Care Giver Sister





        Bobby KnightCare GiverSon





        Mrs. Patricia (Pat) Chess

        Patient








        Outpatient /Community Care Team

               Care Team engaged on Pat's discharge to home 

        Member NameRoleRelationship to Patient Clinical WorkflowExpected OutcomesAssociated EncounterSteps FHIR ResourceComments
        William Hare MDPCPPrimary ProviderAs PCP default care team member




        Kyle Ridge MPTPhysical TherapyVisiting TherapistAdded to care team per order for follow up care 




        Peter Smyth RNNursing Visiting Nurse

        Added to care team per order for follow up care nursing support. Selected as available by agency. 

        Removed from care team based on patient preference for female nurse 






        Jan Doe RNNursing Visiting Nurse Added to care team as replacement for Peter Smyth RN




        Wayne Holbert 

        Care Coordinator

        Care Team Lead 

        Assigned Care Coordinator 

        The Care Coordinator is the facilitator/steward who is responsible for reviewing and reconciling
        proposed modifications to the care plan

        Added to care team per order for follow up care 






        Olive ColbyNutritionistOut Patient Dietitian Added  to care team based on nutrition referral r/t nursing assessment documentation 




        Karen Chess - Rollings CaregiverSister





        Bobby Knight Caregiver Son





        Gail NightCommunity Services
        Added to Care Team by referral from PCP




        Mrs. Patricia (Pat) ChessPatient







      8. Care Team Discussion Points

        1. The Care Team configuration (pattern) is not rigid. The Care Team adapts to the context, environment, and the patients needs. 
          1. Examples
            1. The Care Team Leader may not be consistently held by the same role 
            2. The Patient could be the team lead or partnered with another, this depends on the capability of the patient. 
            3. Care Teams may be Longitudinal, or Condition based, or event based, or all of the above. The longitudinal care team could exist with each condition or event care team existing within the longitudinal frame work. 
          2. Care Team Section / C-CDA
          3. Dynamic Care Planning chronic condition (an Example) 
            View file
            nameDynamicCarePlanningFlow_chronicCondition.pdf
            height250
          4. Care Team Management chronic condition (an Example) 
            View file
            nameDynamicCareTeamManagement_chronicCondition_Flow (1).pdf
            height250
          5. Longitudinal Care Team 



            2019.06.18 - PC CoF meeting Notes - Hand off concentration during Friday CoF

            Care team members transitioning on and off teams depending on changing patient condition. Relapse may require an earlier team member returning to active participation. How does the resource handle retrospective / Current / and prospective future/plan . E.g. Planned surgery in future (known location/planning) versus more emergent e.g. "Pin fell out".  Focus on workflow - specific to care team (how do CP and CT tie together?)  Need transition scenarios and the related data elements.  Need Nutritionist added to care plan Rehab/home, maybe acute. (Weight, loss, non compliant, slow wound healing). 

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