The Typical Day of a Care Coordinator using Integrated Care Management

At a high level, here’s how Integrated Care Management plays a part in your typical day.

• You start your day and notice that Charles Green has been recently diagnosed with hypertension but he hasn’t taken any medication. So, you create a care gap for him.
• You realize the need for a care plan to manage his hypertension and close his care gap. You discuss this with Charles so that he knows the plan.
• In Health Cloud, you go to Charles’ person account page to start creating his care plan. Alternatively, you can go to an appropriate case or clinical service request record page to access the care plan interface.
• You create the care plan using a related assessment Charles has completed, his care gap, or a care plan template for hypertension.
• You navigate to the care plan’s case record and add members to the case team.
• You reassign intervention tasks to the appropriate case team members.
• Now that Charles has a care plan for his hypertension and he’s taking the recommended treatment and medication, you can close his care gap.

Now let’s see how you can perform these tasks with Integrated Care Management.

1. Evaluate a Measure to Create a Care Gap
   Evaluate a clinical measure and identify gaps in patient care.
2. Create a Care Plan from Care Gaps
   Create a care plan for a patient using open care gaps. If the care gaps are associated with problem definitions, you can also add goals and interventions to the care plan.
3. Complete an Assessment to Use with Integrated Care Management
   Use Discovery Framework-based internal assessments configured in Salesforce, MCG assessments, and suggested assessments to gather health-related information from your patients or members. After you’ve collected that information, you can use it to create care plans.
4. Create an Enhanced Care Plan from Assessments
   Create care plans from completed assessments using an OmniScript flow. When you use this work flow, Integrated Care Management gives you recommendations for what problems, goals, and interventions you should add in the care plan.
5. Create an Enhanced Care Plan Using Care Plan Templates
   Create care plans from care plan templates using an OmniScript flow. When you use this work flow, Integrated Care Management gives you recommendations for what problems, goals, and interventions you should add in the care plan based on the selected templates.
6. Add Conditions to an Existing Care Plan
   You can add more conditions to an existing care plan from the care plan user interface on the patient account, case, or clinical service request record page.
7. Add Social Determinants to an Existing Care Plan
   You can add more social determinants to an existing care plan from the care plan interface on the patient account, case, or clinical service request record page.
8. Add Goals to an Existing Care Plan
   You can add more conditions to an existing care plan from the care plan interface on the patient account, case, or clinical service request record page.
9. Add Interventions to an Existing Care Plan
   You can add interventions to an existing care plan by creating Task records. If you’re adding interventions for problems or goals that already have action plans, you can create action plan tasks. If you’re adding interventions for problems or goals that don’t have action plans or are created manually, you have to create standard tasks.
10. Add Care Team Members
    A patient or member’s care team is responsible for executing the interventions assigned in their care plan. You can assign a care team to a care plan by going to its Case record and adding case team members there.
11. Delegate Interventions to Care Team Members
    When you manually add interventions to care plans, you also specify who’s responsible for those interventions. However, the interventions created by the Integrated Care Management work flow are automatically assigned to you. You can delegate those interventions to care team members from the Action Plans page.
12. Mark an Intervention as Complete
    After you complete an intervention that’s assigned to you, you have to mark it as complete in the system. To make this change, you go to the care plan, problem, or goal page that the intervention is added to and select the intervention in the activity pane.
13. Update Care Plans
    Update existing care plans by adding new problems, goals, and interventions using Discovery Framework-based internal assessments, MCG assessments, and predefined care plan templates. You can maintain a single, comprehensive care plan for a patient, instead of creating a new care plan every time you want to update the components. This makes it easier to manage patient care.
14. Track MCG Assessment History
    Access every instance of an MCG assessment from a single place using the Assessment History component.