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Engage the Patient’s Supporters to Customize and Coordinate Care

Learning Objectives

After completing this unit, you’ll be able to:

  • Describe how a patient site helps optimize care.
  • Describe the information on the patient timeline.
  • Explain how problems, goals, and tasks are related 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 that Leif is the right person to be Phyllis Cotton’s patient manager.

Leif relies on healthcare professionals, family members, and others to provide Phyllis with all-around care. This collaborative network is Phyllis’s care team. The Care Team has its own private site, which includes her supporters and everyone else working to make sure that she succeeds with her care plan.

The first thing April does is add records in Health Cloud for the site members Leif will work with.

Alt text: Phyllis Cotton’s Care plan displays the name, phone, email, role, and location (internal or external) of the people on her care team.

Phyllis’s primary physician, Arnold Baker, works for a physicians group, not the Bloomington Caregivers home care agency.


Add Arnold Baker to Phyllis’s Care Team:

  1. Select the App Launcher (App Launcher), enter Health, and then select Health Cloud Lightning Console.
  2. Go to the patient navigation and click Patients.
  3. In the Name column, click Phyllis Cotton.
  4. In her patient record, click the All Care Plans subtab.
  5. Click Open Care Plan to expand Phyllis Cotton’s Care Plan.
  6. Click Care Team.
  7. Click More Options next to Open Collaboration Tab.
  8. Click Add Care Team Member.
  9. In Person, enter Arnold Baker.
    Note: Before you create a new care team member, you must search by name to avoid creating a duplicate record.
  10. Click Search.
  11. Click External and then click Create External Member.
  12. Define a new external member:
  13. First Name: Arnold
  14. Last Name: Baker
  15. Click Save.
  16. For Care Team Role, select Primary Care Physician.
  17. Click Add.

Now let’s add Arnold Baker to the Care Plan.


Alt text: The Add a Care Team Member screen, showing the Internal tab with a Care Team Role list and an Add Member to Community option.


Then April adds Robert Cotton, Phyllis’s son, as another external member. Robert lives near Phyllis and checks in on her a few times a week. He makes dinner and packs up the leftovers for Phyllis’s lunch. He drives her to her doctor and therapist appointments. He often compares notes with the home health aide about Phyllis’s various conditions.

Leif and Robert 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 Phyllis’s care, or filter the events to see a targeted view. So it is easy for Leif to get a snapshot of Phyllis’s prescriptions from last month or look at appointments for the next 6 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.


Alt text: Phyllis Cotton’s Timeline shows events and tasks.


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, which you can track from the patient’s tab in the console. You can also manage the team of caregivers associated with a particular care plan.

Leif Hansen and Robert Cotton work together to set up a customized care plan that brings together all the actions required to keep Phyllis healthy. Phyllis’s care plan describes her health issues. It defines goals for getting Phyllis as healthy as she can be, and it assigns tasks for each member of her care team to help her reach those goals. To find out more, check out the Health Cloud Care Plans module.


Alt text: Phyllis and her son, Robert, enter a physician’s office.


Problems

Arnold Baker, Phyllis's primary care physician, has noted that Phyllis’s blood pressure runs high, which can lead to an increased risk of heart disease. Leif enters that as a problem in Phyllis’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. Baker recommends that Phyllis adopt a lower-sodium diet, so Leif creates a goal to reduce Phyllis’s sodium intake by 50%. Leif updates the status of each of Phyllis’s goals as new data comes in.

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


Tasks

From conversations with Phyllis and Robert, Leif knows Phyllis loves to have friends over for coffee and snacks. Leif creates a task, which he assigns to Phyllis’s son Robert. The task is to visit the grocery store and buy crackers, chips, and cookies in reduced-sodium versions to replace the ones in Phyllis’s kitchen. When Robert 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 Phyllis had arthritis and her goal was to keep or increase her range of motion, she could have a task to attend physical therapy sessions.

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

Once Leif has assigned the pillbox task to Robert, he reviews the situation by taking a look at Phyllis’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 discover more about care plans, see the Health Cloud Care Plans module.

To effectively manage his patients, Leif needs their information at his fingertips. The Patient Info and Patient Card selects 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 Phyllis's care team to work with.

Now everyone on the care team—Phyllis’s son, Robert; patient manager, Leif Hansen; primary care physician, Dr. Arnold Baker; and care coordinator, April Guthman—can contact any of the other members to assign tasks or get information. They can see Phyllis’s upcoming appointments at a glance, as well as her medications. Phyllis’s care team is all set to provide excellent, collaborative care!


Resources

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