circulating multiple inconsistent care plans for a patient. 3. Other documents, such as MOLSTs or Health 3. When pt is d/c from SNF to home, the SW and CHW 4/30/17 Care Proxy forms, that are relevant for SNF make a home visit to assess the patient, environment patients will also be centrally located within and needs and they meet with RN Manager to review athena. patient goals, unmet needs and problems arising during SNF visit. 4. athena Care Manager contains an expanded, 4. The SW and CHW build the athena Care Plan and 4/30/17 more comprehensive care plan, rather than 2-3 maintain it from their meeting with the RN Manager. sentences. The care plans for SNF patients will be The plan is updated weekly or as goals are completed by created and maintained by the PHO's SNF NP. patient or staff. 5. Any assigned care team members – SW, CHW, SNF NP 4/30/17 - can view, add to and interact with care plan. This provides a more comprehensive patient centered care plan approach Trading Partner/Collaborating Organization: D’Youville Senior Care 1. Please note that after careful review of the N/A 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. Trading Partner/Collaborating Organization: D’Youville Center for Advanced Therapy 1. Please note that after careful review of the N/A 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.
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