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Engage the Patient’s Community to Customize and Coordinate Care

Learning Objectives

After completing this unit, you’ll be able to:
  • Describe how a patient community helps optimize care.
  • Describe what information is on the patient timeline.
  • Explain how problems, goals, and tasks work together in Health Cloud.

Create a Care Team

Leif Hansen is a case manager for Bloomington Caregivers. He’s got a strong background in supporting patients with memory issues, and he’s passionate about his elderly patients’ quality of life. April Guthman, the Bloomington Caregivers care coordinator, decides Leif is the right person to work as Elena Nieto’s patient manager.

Leif will rely on healthcare professionals, family members, and others to provide Elena with all-around care. This collaborative network is Elena’s care team. It’s her own private community, and it includes everyone working to make sure that she succeeds with her care plan.

The first thing April does is add records in Health Cloud for the community members Leif will work with. She clicks Add a Care Team Member. Elena’s primary care doctor, Foua Khang, works for a physicians group and not directly for the Bloomington Caregivers home care agency. So April clicks Create External Member. She enters Dr. Khang’s name and email address, selects her role, then clicks Add member to community. Done!

Patient manager Leif Hansen works closely with Raul Nieto, Elena's caregiver.

Then April adds Raul Nieto, Elena’s son, as another external member. Raul lives near Elena and checks in on her a few times a week. He makes dinner and packs up the leftovers for Elena’s lunch. He drives her to her doctor and therapist appointments. He often compares notes with the home health aide about Elena’s various conditions. Leif and Raul are going to be working closely together.

Leif can now click a care team member’s profile picture in the care team view to send them a Chatter message, assign them a task, or update their contact info.

View a Patient’s Timeline

Every patient record in Health Cloud has a timeline view of the patient’s healthcare events and activities in chronological order. Leif can select any time scale and see all the important details of Elena’s care, or filter the events to see a targeted view. So it’s no problem for Leif to get a snapshot of Elena’s prescriptions from last month or look at appointments for the next six weeks.

Leif can filter the timeline to show events such as messages from medical practitioners, forms sent to the patient, diagnosed conditions, medical procedures, and other electronic health records. He uses the slider to select the amount of time he wants to look at.

Elena's care team can use her timeline to keep up on her health history.

Plan for Improved Health

A care plan gives the healthcare team a history of the patient and the progress or challenges related to the patient’s health. A care plan can have any number of problems, goals, and tasks that you can track from the patient’s tab in the console. You can also manage the team of caregivers that are associated with this particular care plan.

Leif Hansen and Raul Nieto work together to set up a customized care plan that brings together all the actions required for keeping Elena healthy. Elena’s care plan describes her health issues. It defines objectives for getting Elena as healthy as she can be, and it assigns tasks for each member of her care team to help reach those objectives.

Elena's doctor and Elena's son Raul collaborate to map out Elena's care plan.

Problems

Foua Khang, Elena’s primary care doctor, has noted that Elena’s blood pressure runs high, which can lead to an increased risk of heart disease. Leif enters that as a problem in Elena’s care plan.

A problem can be a specific diagnosis, or it can be a general issue, such as when a patient needs assistance with daily activities in the home.

Goals

Dr. Khang has recommended that Elena adopt a lower-sodium diet, so Leif creates a goal to reduce Elena’s sodium intake by 50%. Leif updates the status of each of Elena’s goals as new data comes in.

A problem can involve several goals. For example, if Elena had arthritis, she could have the goals to keep daily pain levels under 4/10 and to keep or increase her range of motion.

Tasks

From conversations with Elena and Raul, Leif knows Elena loves to have friends over for coffee and snacks. Leif creates a task, which he assigns to Elena’s son Raul. The task is to visit the grocery store and buy crackers, chips, and cookies in reduced-sodium versions to replace the ones in Elena’s kitchen. When Raul reports that the shopping trip is done, Leif updates the percent complete in the associated goal.

Tasks are actions toward the goals to mitigate the associated problem. So if Elena had arthritis and her goal was to keep or increase range of motion, she could have a task to attend physical therapy sessions.

Leif also knows that some days Elena has trouble remembering which medications to take when. He describes the situation in a problem, then he sets a goal to get Elena consistently taking the right pills at the right times. Next Leif calls Raul to talk it over. Together they come up with a task: Raul agrees to go to the pharmacy and buy a programmable electronic pill box with multiple compartments that can be configured to open the right compartment at a specified time.

Once Leif has assigned the pillbox task to Raul, he reviews the situation by taking a look at Elena’s timeline view. He can see upcoming events up to a year out. He hovers his cursor over the pillbox purchase task and makes sure the address of the pharmacy is right.

To effectively manage his patients, Leif needs their information at his fingertips. The Patient Card extracts the most important information from a patient’s medical records, such as conditions, medications, and contact information, and displays it all in one place for Elena’s care team to work with.

Now everyone on the care team—Elena’s son Raul, patient manager Leif Hansen, Dr. Foua Khang, and care coordinator April Guthman—can contact any of the other members to assign tasks or get information. They can see Elena’s upcoming appointments at a glance, as well as her medications and dietary recommendations. Elena’s care team is all set to provide excellent, collaborative care!

Resources

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