3. It is also a manual process for the SNF to 3. Referral “Accepted” at SNF via Ensocare by SNF Complete Complete retrieve the TOC. The SNF must log in to the Liaison; the LGH COC team logs into pt’s chart in Cerner; portal, download the TOC, and import it into the selects “Communicate.” EMR. SNFs are not consistently following this process because it represents additional steps outside of their normal workflows. 4. The LGH COC team hits “Send” to send Pt’s TOC as a Complete Complete PDF via Secure message to the SNF over Direct or the MassHIway. 5. SNF Liaison logs into Direct or MassHIway Inbox, Complete Complete selects “New Messages” that have “TOC” as PDF attachment and Downloads TOC PDF to pt’s most recent episode in PointClickCare EMR system. 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 Process improvement activity (Please list activities that Anticipated Actual Date of implementing use case (original workflow must be implemented, or have been implemented, in Date of Completion (To be activities may not align with process improvement order to achieve the objectives of this use case.) Completion added with activity line for line) submission of Milestone 3) Trading Partner/Collaborating Organization: Lowell General Hospital 1. athena was built to serve as the cloud-based 1. The Clinical Care Team identifies pt for a Chronic Complete Complete care plan repository not only for SNF patients, but Disease Management (CDM), Diabetes or SNF program also for Circle Care patients and patients who are and enters the pt into athena and enrolls them in enrolled in one of the PHO's disease management appropriate programs. programs. 2. There is significant overlap between these 2. When new pts are transitioned to Collaborating SNFs, 4/30/17 populations, so having a centrally located care SNF NP conducts search in athena for new pt; if they are plan that clinical staff can access and edit from enrolled in programs, the SNF NP reads their history, anywhere at any time is critical. The care plan is a prior admissions, etc.; SNF also makes updates to the single living document, which avoids creating and Care Plan as needed.
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