Care Management Application provides a guided process to help you define components needed for care plans and programs. The dashboard in the Business Analyst portal allows a system administrator or a business analyst access to instances of configured rules such as goals, tasks, and alerts for the management of chronic conditions and wellness and preventative programs. Each rule type has its own template for creating and maintaining these instances. At run time, when these rules are called in the context of a patient’s care plan, a work object is created.

 These reusable components let you create and maintain care plans to manage programs based on the needs and designs suited to your business.

You must plan for and create the instances of the following rule types suited to your business needs:

Program category

Specifies the name of the clinical category in which the program is being managed, such as Care Management, Disease Management, and Health and Wellness.

Program 

Specifies the name of the clinical condition or chronic disease program that is being managed such as Diabetes, Asthma, Smoking Cessation, Post-Discharge or Re-Admission Prevention, Falls Risk, and High-Risk Maternity. The programs are categorized as Disease Management, Case Management, or Health and Wellness programs.

Care plan

Specifies the name of the clinical condition or chronic disease program that is being managed such as Diabetes, Asthma, Smoking Cessation, Post-Discharge or Re-Admission Prevention, Falls Risk, and High-Risk Maternity. The programs are categorized as Disease Management, Case Management, or Health and Wellness programs.

Task

Defines the automated and manual user actions such as scheduled phone calls, scheduled risk assessments, sending fulfillment, sending correspondence (emails and letters), and interventions.

Goal

Defines an objective to be met by the patient within a given time frame, for example, achieve HbA1c levels <7.

Alert

Defines the automated queries against claims and authorizations data sources used for monitoring changes, that is, the presence or absence of clinical events.

Problem

Defines issues associated with the patient that need to be addressed.

Fulfillment

Refers to documents, brochures, or educational materials sent to a patient or a patient's Primary Care Physician (PCP). Selecting this rule allows you to attach these files to the associated program and program category.

Barrier

Defines situations that prevent a patient from completing a goal.

For additional information, refer to the Diabetes example, below.

To create the components, refer to Create the Care Management components.

Program example with two care plans and many components

A program can contain multiple care plans which in turn, are made up of a combination of other components such as alerts, tasks, and goals. An alert can spawn tasks and goals if the condition specified in the alert is met, but tasks and goals can also be part of the care plan without being embedded in an alert.

This graphic shows a combination of components (rule instances) such as alerts, tasks, and goals that can be combined to manage a program. For additional information, refer to the Diabetes example below.

Diabetes program example with three care plans

The following example shows that a Diabetes Program is managed with three care plans.

Initial Risk Assessment Care Plan

This type of care plan is typically used to schedule an initial risk assessment task.

Low Risk DM Care Plan

This example shows the types of alerts, goals, and tasks that can be set up to manage a low-risk diabetic.

High Risk DM Care Plan

This example shows the types of alerts, goals, and tasks that can be set up to manage a high-risk diabetic with more active management.