User Guide — Care Management Workflow

athenahealth Population Health

If a patient has or is at high risk of developing a disease or clinical issue that requires monitoring, you can use the Care Management Workflow to enroll the patient in a care management program. Care management programs help patients and their care teams set goals and take actions to prevent or manage a disease or chronic clinical issue and, in doing so, may improve clinical outcomes and prevent complications and costly medical care.

 

You can access care management program referrals on the following pages:

 

 

On the Main Menu, click Patients and select Care Management.

 

 

 

In the Schedule view, you can schedule and document care events.

 

 

 

In the Patients view, you can:

  • View patients assigned to you or to another care manager.
  • Identify patients for a care management program.
  • Edit or change the status of program referrals (including enrolling and un-enrolling patients in a program).
  • Reassign the program referral to a colleague.

 

 

In the Care Admin view, you can:

  • View care management statistics
  • View metrics about your team's to-do list

Note: You must have the Population Management: Care Manager: Admin permission to access this view.

 

 

 

 

 

On the Main Menu, enter the patient's name, patient ID, or member ID (insurance number) in the Search Bar. Under NETWORK PATIENTS, select the data type and then click the search icon. Matching patients are listed under the Patients tab. Click the patient name to expand the selection, and then click the patient name in large text to display the patient's Person Center. Click the Care Mgt tab.

 

 

On the Care Management tab of a patient's Person Center, you can:

  • Identify a patient for a care management program.
  • View the patient's care plan.
  • Complete assessments.
  • Review a patient's history in care management programs.

 

 

Events are activities related to a patient's care, both in and outside your organization. You can create and manage these events from the Care Manager and from the Person Center:

  • Communications (with patient, PCP, health professionals, other)
  • Appointments
  • Hospital stays
  • Skilled nursing facility stays
  • Patient consent
  • Reviews
  • General notes
  • Documentation
  • Creation of or modifications to the patient's care plan
  • Sending a care plan to the patient

On the event timeline of a patient's Person Center, you can:

  • View events related to a patient's care.
  • Schedule and document care events.

 

 

 

On the Main Menu, click Patients and select Patient Population.

 

On the Patient Population page, you can:

  • Filter the patient population for your organization.
  • View patients in a care program.
  • Identify a group of patients for a care program.

 

 

 

Your organization must use athenahealth Population Health, and you must have one of these roles to access care management referrals:

 

 

Assign this role to non-care managers, such as analysts, office staff, and PCPs, so that they can identify patients for care management programs.

 

This role provides limited access to care management referrals, meaning that you can:

 

 

Assign this role to non-care managers who may be part of a care team, such as PCPs and nurses, so that they can help monitor a patient's progress in care management programs.

 

Assigning this role allows you to:

  • Identify a patient for a care management program on the Care Management tab in the Person Center.
  • Identify multiple patients for the same care management program on the Patient Population page.
  • See a history of a patient's programs on the Care Management tab in the Person Center.
  • Review and update a patient's Care Plan.
  • Complete assessments.
  • View a patient's event timeline.
  • Schedule and document care events.

 

 

Assign this role to care managers.

 

This role provides full access to care management referrals, meaning that you can:

  • Identify, enroll, and unenroll a patient in a care management program on the Care Manager page or on the Care Management tab in the Person Center.
  • Identify and enroll multiple patients in the same care management program on the Patient Population page.
  • See a history of a patient's programs on the Care Management tab in the Person Center.
  • Create and update a patient's Care Plan.
  • Complete assessments.
  • Schedule and document care events.
  • View a patient's event timeline.
  • View metrics and all patients in a care management program.

 

 

 

 

Patients are referred by their plan, a practitioner, a member, a care giver, disease management, utilization management, or some other part of the healthcare system.

 

When someone in or outside your organization suggests that a patient may benefit from a care management program, you can use the 4-stage care management workflow to document and manage this process so that all members of a patient's care team can access the most up-to-date information, as well as a patient's history in care management programs.

 

 

 

 

Analysts can use these tools to identify patients who may be good candidates for a care management program:

  • Severity reports on the Report List page
  • Financial reports on the Report List page
  • Diagnoses on the Patient Population page and some reports on the Report List page, such as the ED Top Diagnosis, ED Frequent Utilization, and Readmit ED Detail reports
  • Patient lists from payers

Clinical providers, such as care managers, PCPs, and nurses, can also identify a patient to a care management program.

 

 

 

Care managers and patients decide together whether to enroll in a care management program. A care manager usually discusses program options with the identified patient and then enrolls the patient in a specific care management program.

 

 

 

Care managers and patients work together to create a Care Plan. The care plan sets goals (often for a specific focus problem), lists the actions needed to accomplish these goals, and identifies barriers that must be overcome.

 

To help identify focus problems and set goals, you can complete some initial assessments to identify relevant weaknesses and issues.

 

 

 

All members of a patient's care team, as well as the patients themselves, participate in monitoring the progress made toward meeting the Care Plan goals.

 

To monitor and track progress, the care team and patient:

  • Confirm that the focus problem still exists.
  • Complete actions to achieve goals.
  • Fill out assessments in the Care Plan to assess progress and as required by certain payer contracts.
  • Schedule and track care management activities and patient information in the Care Manager and the patient's Person Center.

Note: athenaWell is a patient-facing application that is closely integrated with the athenahealth Population Health Care Manager. athenaWell allows care managers to monitor their patient population in real time and with minimal effort. For more information, see the athenaWell page.

 

 

 

 

Automated care pathways create care plans and automatically add assessments and goals to the plan. If a care manager enrolls a patient in a program or adds a focus problem to the patient's care plan, the assessments and goals associated with the program or focus problem are automatically added to the patient's care plan.

 

For more information, see Automated Care Pathways.

 

 

 

 

 

You must be a care manager to complete this workflow.

 

  1. Display the Care Manager page: On the Main Menu, click Patients and select Care Management.
  2. Click the Patients tab.

    A list of all patients with an active care management program status appears.
  3. To filter the list, you can:
    • Click any column with an arrow and select an option to show only patients who meet your selected criteria.
    • Click any column without an arrow to reverse the sort order of the list.
    • Click MANAGE COLUMNS, choose the type of column to add, choose a column heading on the right, and then click Apply.

 

  1. Display your Population Health Inbox.
  2. Click No Future Scheduled.
    All enrolled patients assigned to you who do not have a future care event scheduled appear in this list.

 

 

 

 

 

You must be a care manager to complete this workflow.

  1. Display the Care Manager page: On the Main Menu, click Patients and select Care Management.
  2. Click Patients.

  3. Check the box next to the patient's name.
    Note: You can select more than one patient to refer.
  4. Click Add New Program Referral.
    If you want to refer all patients in the list to a care management program, click the down arrow to the right of Add New Program Referral and click Add Program Referral to All.
    The Add New Program Referral window appears.
  5. Complete the required and optional fields, noting the following:
    • Program — You cannot select a program that already has an active status (i.e., Identified, Pending, Scheduled, or Enrolled) for the patient.
    • Assigned To — The selected user is added to the patient's Care Team.
    • Focus problem(s) — Recommend focus problems for the patient.
      Note: You must display the Focus problem(s) list each time you add another focus problem. As you add focus problems, a tally of the selected focus problems appears in this field (e.g., "3 selected"), and the selected focus problems appear highlighted in blue in the list. You can click on a focus problem highlighted in blue to deselect it.
  6. Status — Select Identified.
    Note: You can select any status option, but if you do so, you may be skipping steps in the Care Management Workflow.
  7. Click Save.

 

 

  1. Display the patient's Person Center: On the Main Menu, enter the patient's name, patient ID, or member ID (insurance number) in the Search Bar. Under NETWORK PATIENTS, select the data type and then click the search icon. Matching patients are listed under the Patients tab. Click the patient name to expand the selection, and then click the patient name in large text to display the patient's Person Center.
  2. Click the Care Management tab.
  3. Next to Programs, click the plus icon .
    The Add New Program Referral window appears.
  4. Status — Select Referred.
  5. Fill in the other required and optional fields, noting the following:
    1. Program — You cannot select a program that already has an active status (i.e., Identified, Pending, Scheduled, or Enrolled) for the patient.
    2. Assigned To — The selected user is added to the patient's Care Team.
    3. Focus problem(s) — You must display the Focus problem(s) list each time you add another focus problem. As you add focus problems, a tally of the selected focus problems appears in this field (e.g., "3 selected"), and the selected focus problems appear highlighted in blue in the list. You can click on a focus problem highlighted in blue to deselect it.
  6. Click Save.

 

 

 

  1. Display the Patient Population page: On the Main Menu, click Patients and select Patient Population.
  2. Narrow the list of patients using the filter fields.
  3. Click Apply Filters.
  4. Select a group of patients:
    • To select individual patients, check the boxes next to their names.

    • To choose all patients (that is, all patients in the search results, even if your search results span multiple pages), leave all checkboxes blank.

  5. Click Add Program Referral.
    The Add New Program Referral window appears.
    Note: After you select a program, the number of eligible patients appears next to the number of patients that you selected for the program referral. A program referral is not created for ineligible patients (that is, patients who already have an active status in that care management program).

  6. Status — Select Identified.
  7. Complete the other required and optional fields, noting the following:
    • The program referral must have the same data for all patients.
    • Program — Patients who already have an active status (that is, Identified, Pending, Scheduled, or Enrolled) for a program appear as ineligible.
    • Assigned To — The selected user is added to the patient's Care Team.
    • Focus problem(s) — Recommend one or more focus problems.
      These focus problems do not appear on the patient's care plan because they are only the recommended focus problems.
      Note: You must display the Focus problem(s) list each time you add another focus problem. As you add focus problems, a tally of the selected focus problems appears in this field (for example, "3 selected"), and the selected focus problems appear highlighted in blue in the list. You can click a focus problem highlighted in blue to deselect it.
  8. Check the box for "I confirm that I want to create new program referrals for [#] patients."
  9. Click Save.

 

 

You must be a care manager to complete this workflow.

 

  1. Display the Care Manager page: On the Main Menu, click Patients and select Care Management.
  2. Click Patients.
  3. In the Actions column, click EDIT.
    The Edit Program Referral window appears.
  4. Status — Select Enrolled.
  5. Date updated — Enter the date of enrollment.
  6. Status note — Type any notes related to the status update.
  7. Click Save.

 

  1. Display the patient's Person Center: On the Main Menu, enter the patient's name, patient ID, or member ID (insurance number) in the Search Bar. Under NETWORK PATIENTS, select the data type and then click the search icon.
    Matching patients appear under the Patients tab.
  2. Click the patient name to expand the selection, and then click the patient name in large text to display the patient's Person Center.
  3. Click the Care Management tab.
  4. Under Programs, click the name of the care management program.
    The Edit Program Referral window appears.
  5. Status — Select Enrolled.
  6. Date updated — Enter the date of enrollment.
  7. Status note — Type any notes related to the status update.
  8. Click Save.

 

 

 

You must be a care manager to complete this workflow.

 

  1. Display the Care Manager page: On the Main Menu, click Patients and select Care Management.
  1. Click the Patients tab.
  2. In the Actions column, click EDIT.
    The Edit Program Referral window appears.
  3. Status — Select one of the Unenrolled statuses.
  4. Date updated — Enter the date of unenrollment.
  5. Status note — Type any notes related to the status update.
  6. Click Save.

 

  1. Display the patient's Person Center: On the Main Menu, enter the patient's name, patient ID, or member ID (insurance number) in the Search Bar. Under NETWORK PATIENTS, select the data type and then click the search icon. Matching patients are listed under the Patients tab. Click the patient name to expand the selection, and then click the patient name in large text to display the patient's Person Center.
  2. Click the Care Management tab.
  3. Under Programs, click the name of the care management program.
    The Edit Program Referral window appears.
  4. Status — Select Unenrolled.
  5. Date updated — Enter the date of unenrollment.
  6. Status note — Type any notes related to the status update.
  7. Click Save.

 

 

 

You must be a care manager to complete this workflow.

 

  1. Display the Care Manager page: On the Main Menu, click Patients and select Care Management.

  2. Click Patients.

  3. Under the Program column, click the name of the patient's program you want to edit.
  4. Edit the program information as needed.
  5. Click Save.

 

  1. Display the patient's Person Center: On the Main Menu, enter the patient's name, patient ID, or member ID (insurance number) in the Search Bar. Under NETWORK PATIENTS, select the data type and then click the search icon. Matching patients are listed under the Patients tab. Click the patient name to expand the selection, and then click the patient name in large text to display the patient's Person Center.
  2. Click the Care Management tab.
  3. Under Programs, click the name of the care management program.
    The Edit Program window appears.

  4. Edit the program information as needed.

  5. Click Save.

 

 

 

You must be a care manager to complete this workflow.

 

  1. Display the Care Manager page: On the Main Menu, click Patients and select Care Management.
  2. Click Patients.
  3. Under the Program column, click the name of the patient's program you want to edit.
    The Edit Program window appears.
  4. Status — Select a status from the list to change the patient's status in this program.
  5. Date updated — Enter the date associated with this status change.
  6. Status note — Type any notes related to the status update.
  7. Click Save.

 

  1. Display the patient's Person Center: On the Main Menu, enter the patient's name, patient ID, or member ID (insurance number) in the Search Bar. Under NETWORK PATIENTS, select the data type and then click the search icon. Matching patients are listed under the Patients tab. Click the patient name to expand the selection, and then click the patient name in large text to display the patient's Person Center.
  2. Click the Care Management tab.
  3. Under Programs, click the name of the care management program. The Edit Program window appears.
  4. Status — Select a status from the list to change the patient's status in this program.
  5. Date updated — Enter the date associated with this status change.
  6. Status note — Type any notes related to the status update.
  7. Click Save.

 

 

 

You must be a care manager to complete this workflow.

  1. Display the Care Manager page: On the Main Menu, click Patients and select Care Management.
  2. Click Care Admin.
    Metrics related to care management programs appear.
  3. In the "Patients waiting in each Onboarding Stage" area, you can see these metrics:
    • Enroll
    • First Encounter
    • Follow-up
  4. In the "Events To Do" area, you can see these metrics:
    • Overdue
    • No Future Event Scheduled
    • Incomplete
    • Scheduled
    • Completed
  5. Click any blue number to see a list of patients and more details.
    Tip: You can click a patient's name to access additional information on the patient's Person Center.

 

 

 

 

Add New Program Referral window
Program

Select a program from the list.
Note: You cannot select a program that already has an active status (that is, Identified, Pending, Scheduled, or Enrolled) for the patient.
Date referred

Today's date automatically appears in this field, but you can select a different date if needed.
Referred by

Select one of these options to indicate who referred the patient to the care management program.

Optional fields
Assigned to

Select which member of your organization will monitor the patient's progress in the care program.

Note: The selected user is added to the patient's Care Team.
Referral note

Enter a note to document any additional details about the patient's referral to this program.
Status

"Identified" automatically appears in this field when you add a new program.

Note: Although you can select a different status in this field when adding a new program referral, you will skip steps in the program enrollment process.
Date updated

Today's date automatically appears in this field, but you can select a different date if needed.
Status note

Type any notes related to the selected status.

 

 

 

Edit Program window
Program

The type of care management program being referred to the patient.

Date referred

Today's date automatically appears in this field, but you can select a different date if necessary.
Referred by

Select one of these options to indicate who referred the patient to the care management program.

Optional fields
Assigned to

Select which member of your organization will monitor the patient's progress in the care program.

Note: The selected user is added to the patient's Care Team.
Referral note

Enter a note to document any additional details about the patient's referral to this program.
Status

Select the status of the care management program for this patient.
Date updated

Today's date automatically appears in this field, but you can select a different date if needed.
Status note

Type any notes related to the selected status.

 

 

 

  • PCP — Select one or more PCPs.

    Note: You can choose groups of PCPs or individual PCPs.

  • Populations — Select one or more patient populations.

    Note: You can choose patient populations or subsets of each patient population.

  • Payors — Select one or more payors.

  • Quality — Select one or more measures.

    • You can expand each measure to select tests within a measure.
    • Below the Quality field, you can check any of these boxes:
      • Compliant
      • Noncompliant
      • Current Members
      • Plan only

  • Care — This area contains these fields:

    • Program — Select one or more care management programs.
    • Focus problems — Select one or more focus problems.
    • Severities — Select the severity: None, Low, Medium, High.

    Note: Below these fields, you can check any of these boxes:

    • People with open referrals
    • People with overdue activities

  • Care Teams — Select one or more care team administrators.

 

 

 

 

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