Effective management of a patient population (e.g., Care Management) uses a set of evidence-based, integrated clinical care activities that are tailored to the individual patient and that ensure each patient has his or her own coordinated plan of care and services. To achieve this, care managers need an integrated system that allows them to assess patients in a repeatable, consistent way to drive the most effective health and quality of life outcomes.
In general, embodiments of the present invention provide methods, apparatus, systems, computing devices, computing entities, and/or the like for a plan of care.
In accordance with one aspect, a method for a plan of care is provided. In one embodiment, the method comprises (1) providing an interactive assessment for a patient, the interactive assessment comprising a plurality of sections, each section comprising a plurality of questions to which responses can be provided; (2) receiving a response to at least one of the plurality of questions; (3) determining whether a workflow is associated with the response to the at least one of the plurality of questions; and (4) after determining that a workflow is associated with the response to the at least one of the plurality of questions, providing the workflow for a plan of care for the patient, the workflow comprising one or more goals and one or more interventions.
In accordance with another aspect, a computer program product for a plan of care is provided. The computer program product may comprise at least one computer-readable storage medium having computer-readable program code portions stored therein, the computer-readable program code portions comprising executable portions configured to (1) provide an interactive assessment for a patient, the interactive assessment comprising a plurality of sections, each section comprising a plurality of questions to which responses can be provided; (2) receive a response to at least one of the plurality of questions; (3) determine whether a workflow is associated with the response to the at least one of the plurality of questions; and (4) after determining that a workflow is associated with the response to the at least one of the plurality of questions, provide the workflow for a plan of care for the patient, the workflow comprising one or more goals and one or more interventions.
In accordance with yet another aspect, an apparatus comprising at least one processor and at least one memory including computer program code is provided. In one embodiment, the at least one memory and the computer program code may be configured to, with the processor, cause the apparatus to (1) provide an interactive assessment for a patient, the interactive assessment comprising a plurality of sections, each section comprising a plurality of questions to which responses can be provided; (2) receive a response to at least one of the plurality of questions; (3) determine whether a workflow is associated with the response to the at least one of the plurality of questions; and (4) after determining that a workflow is associated with the response to the at least one of the plurality of questions, provide the workflow for a plan of care for the patient, the workflow comprising one or more goals and one or more interventions.
Having thus described the invention in general terms, reference will now be made to the accompanying drawings, which are not necessarily drawn to scale, and wherein:
Various embodiments of the present invention now will be described more fully hereinafter with reference to the accompanying drawings, in which some, but not all embodiments of the inventions are shown. Indeed, these inventions may be embodied in many different forms and should not be construed as limited to the embodiments set forth herein; rather, these embodiments are provided so that this disclosure will satisfy applicable legal requirements. The term “or” is used herein in both the alternative and conjunctive sense, unless otherwise indicated. The terms “illustrative” and “exemplary” are used to be examples with no indication of quality level. Like numbers refer to like elements throughout.
Embodiments of the present invention may be implemented in various ways, including as computer program products that comprise articles of manufacture. A computer program product may include a non-transitory computer-readable storage medium storing applications, programs, program modules, scripts, source code, program code, object code, byte code, compiled code, interpreted code, machine code, executable instructions, and/or the like (also referred to herein as executable instructions, instructions for execution, computer program products, program code, and/or similar terms used herein interchangeably). Such non-transitory computer-readable storage media include all computer-readable media (including volatile and non-volatile media).
In one embodiment, a non-volatile computer-readable storage medium may include a floppy disk, flexible disk, hard disk, solid-state storage (SSS) (e.g., a solid state drive (SSD), solid state card (SSC), solid state module (SSM), enterprise flash drive, magnetic tape, or any other non-transitory magnetic medium, and/or the like. A non-volatile computer-readable storage medium may also include a punch card, paper tape, optical mark sheet (or any other physical medium with patterns of holes or other optically recognizable indicia), compact disc read only memory (CD-ROM), compact disc-rewritable (CD-RW), digital versatile disc (DVD), Blu-ray disc (BD), any other non-transitory optical medium, and/or the like. Such a non-volatile computer-readable storage medium may also include read-only memory (ROM), programmable read-only memory (PROM), erasable programmable read-only memory (EPROM), electrically erasable programmable read-only memory (EEPROM), flash memory (e.g., Serial, NAND, NOR, and/or the like), multimedia memory cards (MMC), secure digital (SD) memory cards, SmartMedia cards, CompactFlash (CF) cards, Memory Sticks, and/or the like. Further, a non-volatile computer-readable storage medium may also include conductive-bridging random access memory (CBRAM), phase-change random access memory (PRAM), ferroelectric random-access memory (FeRAM), non-volatile random-access memory (NVRAM), magnetoresistive random-access memory (MRAM), resistive random-access memory (RRAM), Silicon-Oxide-Nitride-Oxide-Silicon memory (SONOS), floating junction gate random access memory (FJG RAM), Millipede memory, racetrack memory, and/or the like.
In one embodiment, a volatile computer-readable storage medium may include random access memory (RAM), dynamic random access memory (DRAM), static random access memory (SRAM), fast page mode dynamic random access memory (FPM DRAM), extended data-out dynamic random access memory (EDO DRAM), synchronous dynamic random access memory (SDRAM), double data rate synchronous dynamic random access memory (DDR SDRAM), double data rate type two synchronous dynamic random access memory (DDR2 SDRAM), double data rate type three synchronous dynamic random access memory (DDR3 SDRAM), Rambus dynamic random access memory (RDRAM), Twin Transistor RAM (TTRAM), Thyristor RAM (T-RAM), Zero-capacitor (Z-RAM), Rambus in-line memory module (RIMM), dual in-line memory module (DIMM), single in-line memory module (SIMM), video random access memory (VRAM), cache memory (including various levels), flash memory, register memory, and/or the like. It will be appreciated that where embodiments are described to use a computer-readable storage medium, other types of computer-readable storage media may be substituted for or used in addition to the computer-readable storage media described above.
As should be appreciated, various embodiments of the present invention may also be implemented as methods, apparatus, systems, computing devices, computing entities, and/or the like. As such, embodiments of the present invention may take the form of an apparatus, system, computing device, computing entity, and/or the like executing instructions stored on a computer-readable storage medium to perform certain steps or operations. Thus, embodiments of the present invention may also take the form of an entirely hardware embodiment, an entirely computer program product embodiment, and/or an embodiment that comprises combination of computer program products and hardware performing certain steps or operations.
Embodiments of the present invention are described below with reference to block diagrams and flowchart illustrations. Thus, it should be understood that each block of the block diagrams and flowchart illustrations may be implemented in the form of a computer program product, an entirely hardware embodiment, a combination of hardware and computer program products, and/or apparatus, systems, computing devices, computing entities, and/or the like carrying out instructions, operations, steps, and similar words used interchangeably (e.g., the executable instructions, instructions for execution, program code, and/or the like) on a computer-readable storage medium for execution. For example, retrieval, loading, and execution of code may be performed sequentially such that one instruction is retrieved, loaded, and executed at a time. In some exemplary embodiments, retrieval, loading, and/or execution may be performed in parallel such that multiple instructions are retrieved, loaded, and/or executed together. Thus, such embodiments can produce specifically-configured machines performing the steps or operations specified in the block diagrams and flowchart illustrations. Accordingly, the block diagrams and flowchart illustrations support various combinations of embodiments for performing the specified instructions, operations, or steps.
As indicated, in one embodiment, the management computing entity 100 may also include one or more communications interfaces 220 for communicating with various computing entities, such as by communicating data, content, information, and/or similar terms used herein interchangeably that can be transmitted, received, operated on, processed, displayed, stored, and/or the like. For instance, the management computing entity 100 may communicate with care manager computing entities 110 and provide functionalities of a plan of care platform.
As shown in
In one embodiment, the management computing entity 100 may further include or be in communication with non-volatile media (also referred to as non-volatile storage, memory, memory storage, memory circuitry and/or similar terms used herein interchangeably). In one embodiment, the non-volatile storage or memory may include one or more non-volatile storage or memory media 210, including but not limited to hard disks, ROM, PROM, EPROM, EEPROM, flash memory, MMCs, SD memory cards, Memory Sticks, CBRAM, PRAM, FeRAM, NVRAM, MRAM, RRAM, SONOS, FJG RAM, Millipede memory, racetrack memory, and/or the like. As will be recognized, the non-volatile storage or memory media may store databases, database instances, database management computing entities, data, applications, programs, program modules, scripts, source code, object code, byte code, compiled code, interpreted code, machine code, executable instructions, and/or the like. Such code may include of a plan of care platform. The terms database, database instance, database management computing entity, and/or similar terms used herein interchangeably may refer to a structured collection of records or data that is stored in a computer-readable storage medium, such as via a relational database, hierarchical database, and/or network database.
In one embodiment, the management computing entity 100 may further include or be in communication with volatile media (also referred to as volatile storage, memory, memory storage, memory circuitry and/or similar terms used herein interchangeably). In one embodiment, the volatile storage or memory may also include one or more volatile storage or memory media 215, including but not limited to RAM, DRAM, SRAM, FPM DRAM, EDO DRAM, SDRAM, DDR SDRAM, DDR2 SDRAM, DDR3 SDRAM, RDRAM, TTRAM, T-RAM, Z-RAM, RIMM, DIMM, SIMM, VRAM, cache memory, register memory, and/or the like. As will be recognized, the volatile storage or memory media may be used to store at least portions of the databases, database instances, database management computing entities, data, applications, programs, program modules, scripts, source code, object code, byte code, compiled code, interpreted code, machine code, executable instructions, and/or the like being executed by, for example, the processing element 205. Thus, the databases, database instances, database management computing entities, data, applications, programs, program modules, scripts, source code, object code, byte code, compiled code, interpreted code, machine code, executable instructions, and/or the like may be used to control certain aspects of the operation of the management computing entity 100 with the assistance of the processing element 205 and operating system, such as the of plan of care platform.
As indicated, in one embodiment, the management computing entity 100 may also include one or more communications interfaces 220 for communicating with various computing entities, such as by communicating data, content, information, and/or similar terms used herein interchangeably that can be transmitted, received, operated on, processed, displayed, stored, and/or the like.
Such communication may be executed using a wired data transmission protocol, such as fiber distributed data interface (FDDI), digital subscriber line (DSL), Ethernet, asynchronous transfer mode (ATM), frame relay, data over cable service interface specification (DOCSIS), or any other wired transmission protocol. Similarly, the management computing entity 100 may be configured to communicate via wireless external communication networks using any of a variety of protocols, such as general packet radio service (GPRS), Universal Mobile Telecommunications System (UMTS), Code Division Multiple Access 2000 (CDMA2000), CDMA2000 1X (1xRTT), Wideband Code Division Multiple Access (WCDMA), Time Division-Synchronous Code Division Multiple Access (TD-SCDMA), Long Term Evolution (LTE), Evolved Universal Terrestrial Radio Access Network (E-UTRAN), Evolution-Data Optimized (EVDO), High Speed Packet Access (HSPA), High-Speed Downlink Packet Access (HSDPA), IEEE 802.11 (Wi-Fi), 802.16 (WiMAX), ultra wideband (UWB), infrared (IR) protocols, near field communication (NFC) protocols, Bluetooth™ protocols, wireless universal serial bus (USB) protocols, and/or any other wireless protocol.
Although not shown, the management computing entity 100 may include or be in communication with one or more input elements, such as a keyboard input, a mouse input, a touch screen/display input, motion input, movement input, audio input, pointing device input, joystick input, keypad input, and/or the like. The management computing entity 100 may also include or be in communication with one or more output elements (not shown), such as audio output, video output, screen/display output, motion output, movement output, and/or the like.
As will be appreciated, one or more of the management computing entity's 100 components may be located remotely from other management computing entity 100 components, such as in a distributed system. Furthermore, one or more of the components may be combined and additional components performing functions described herein may be included in the management computing entity 100. Thus, the management computing entity 100 can be adapted to accommodate a variety of needs and circumstances. As will be recognized, these architectures and descriptions are provided for exemplary purposes only and are not limiting to the various embodiments.
A care manager may be a case manager, a care manager, a health manager, a health liaison, a care associate, pharmacist, medical management representative, a care coordinator, and/or the like associated with or involved in the health care of a patient. A care manager may operate a care manager computing entity 110 that includes one or more components that are functionally similar to those of the management computing entity 100.
The signals provided to and received from the transmitter 304 and the receiver 306, respectively, may include signaling information in accordance with air interface standards of applicable wireless systems. In this regard, the care manager computing entity 110 may be capable of operating with one or more air interface standards, communication protocols, modulation types, and access types. More particularly, the care manager computing entity 110 may operate in accordance with any of a number of wireless communication standards and protocols, such as those described above with regard to the management computing entity 100. In a particular embodiment, the care manager computing entity 110 may operate in accordance with multiple wireless communication standards and protocols, such as UMTS, CDMA2000, 1xRTT, WCDMA, TD-SCDMA, LTE, E-UTRAN, EVDO, HSPA, HSDPA, Wi-Fi, WiMAX, UWB, IR, NFC, Bluetooth™, USB, and/or the like. Similarly, the care manager computing entity 110 may operate in accordance with multiple wired communication standards and protocols, such as those described above with regard to the management computing entity 100 via a network interface 320.
Via these communication standards and protocols, the care manager computing entity 110 can communicate with various other entities using concepts such as Unstructured Supplementary Service Data (USSD), Short Message Service (SMS), Multimedia Messaging Service (MMS), Dual-Tone Multi-Frequency Signaling (DTMF), and/or Subscriber Identity Module Dialer (SIM dialer). The care manager computing entity 110 can also download changes, add-ons, and updates, for instance, to its firmware, software (e.g., including executable instructions, applications, program modules), and operating system.
According to one embodiment, the care manager computing entity 110 may include a location determining aspect, device, module, functionality, and/or similar words used herein interchangeably. For example, the care manager computing entity 110 may include outdoor positioning aspects, such as a location module adapted to acquire, for example, latitude, longitude, altitude, geocode, course, direction, heading, speed, universal time (UTC), date, and/or various other information/data. In one embodiment, the location module can acquire data, sometimes known as ephemeris data, by identifying the number of satellites in view and the relative positions of those satellites. The satellites may be a variety of different satellites, including Low Earth Orbit (LEO) satellite systems, Department of Defense (DOD) satellite systems, the European Union Galileo positioning systems, the Chinese Compass navigation systems, Indian Regional Navigational satellite systems, and/or the like. Alternatively, the location information will be determined by triangulating the care manager computing entity's 110 position in connection with a variety of other systems, including cellular towers, Wi-Fi access points, and/or the like. Similarly, the care manager computing entity 110 may include indoor positioning aspects, such as a location module adapted to acquire, for example, latitude, longitude, altitude, geocode, course, direction, heading, speed, time, date, and/or various other information/data. Some of the indoor systems may use various position or location technologies including RFID tags, indoor beacons or transmitters, Wi-Fi access points, cellular towers, nearby computing devices (e.g., smartphones, laptops) and/or the like. For instance, such technologies may include the iBeacons, Gimbal proximity beacons, Bluetooth Low Energy (BLE) transmitters, Near Field Communication (NFC) transmitters, and/or the like. These indoor positioning aspects can be used in a variety of settings to determine the location of someone or something to within inches or centimeters.
The care manager computing entity 110 may also comprise a user interface (that can include a display 316 coupled to a processing element 308) and/or a user input interface (coupled to a processing element 308). For example, the user interface may be a care manager application, browser, care manager interface, and/or similar words used herein interchangeably executing on and/or accessible via the care manager computing entity 110 to interact with and/or cause display of information from the management computing entity 100, including the plan of care platform. The care manager input interface can comprise any of a number of devices allowing the care manager computing entity 110 to receive data, such as a keypad 318 (hard or soft), a touch display, voice/speech or motion interfaces, or other input device. In embodiments including a keypad 318, the keypad 318 can include (or cause display of) the conventional numeric (0-9) and related keys (#, *), and other keys used for operating the care manager computing entity 110 and may include a full set of alphabetic keys or set of keys that may be activated to provide a full set of alphanumeric keys. In addition to providing input, the care manager input interface can be used, for example, to activate or deactivate certain functions, such as screen savers and/or sleep modes.
The care manager computing entity 110 can also include volatile storage or memory 322 and/or non-volatile storage or memory 324, which can be embedded and/or may be removable. For example, the non-volatile memory may be ROM, PROM, EPROM, EEPROM, flash memory, MMCs, SD memory cards, Memory Sticks, CBRAM, PRAM, FeRAM, NVRAM, MRAM, RRAM, SONOS, FJG RAM, Millipede memory, racetrack memory, and/or the like. The volatile memory may be RAM, DRAM, SRAM, FPM DRAM, EDO DRAM, SDRAM, DDR SDRAM, DDR2 SDRAM, DDR3 SDRAM, RDRAM, TTRAM, T-RAM, Z-RAM, RIMM, DIMM, SIMM, VRAM, cache memory, register memory, and/or the like. The volatile and non-volatile storage or memory can store databases, database instances, database management computing entities, data, applications, programs, program modules, scripts, source code, object code, byte code, compiled code, interpreted code, machine code, executable instructions, and/or the like to implement the functions of the care manager computing entity 110. As indicated, this may include a care manager application that is resident on the entity or accessible through a browser or other care manager interface for communicating with the plan of care platform of the management computing entity 100 and/or various other computing entities.
In another embodiment, the care manager computing entity 110 may include one or more components or functionality that are the same or similar to those of the management computing entity 100, as described in greater detail above. As will be recognized, these architectures and descriptions are provided for exemplary purposes only and are not limiting to the various embodiments.
In one embodiment, a patient may operate a patient computing entity 115 that includes one or more components that are functionally similar to those of the management computing entity 100 and/or the care manager computing entity 110. Although the term patient is used, others terms may be used herein interchangeably, including health plan member, user, and/or the like. For example, in one embodiment, each patient computing entity 115 may include one or more processing elements (e.g., CPLDs, microprocessors, multi-core processors, coprocessing entities, ASIPs, microcontrollers, and/or controllers), one or more display device/input devices (e.g., including user interfaces), volatile and non-volatile storage or memory, and/or one or more communications interfaces. For example, the user interface may be a patient application, browser, patient interface, and/or similar words used herein interchangeably executing on and/or accessible via the patient computing entity 115 to interact with and/or cause display of information from the management computing entity 100, including the plan of care platform. This may also enable the patient computing entity 115 to communicate with various other computing entities, such as care manager computing entities 110, and/or various other computing entities. As will be recognized, these architectures and descriptions are provided for exemplary purposes only and are not limiting to the various embodiments.
Reference will now be made to
Embodiments of the present invention relate to creating/generating and managing one or more plans of care of a patient. A plan of care may comprise or indicate (a) services a patient needs, (b) problems the patient is facing, (c) goals for overcoming the problems or achieving desired health-related results, (d) tasks for completing the goals, (e) tasks or schedules for following up with or monitoring the patient, (f) who should assist the patient in obtaining the needed services or achieving the desired goals, (g) what equipment is needed for the patient, and/or the like. In one embodiment, the process may begin once a need for care management services is identified for a particular patient. After identifying a particular need for a patient, a care manager can intake information for the patient, screen the patient, and enroll the patient in any appropriate programs. A care manager (e.g., operating a care manager computing entity 110) can then assess the patient on an individual basis using one or more assessments. As will be described in greater detail below, an assessment may include one or more topics/sections, with each topic/section comprising one or more questions (oftentimes conditional) pertaining to the enrolled program and/or needs of the patient. For a given assessment, the responses to questions may trigger/initiate authoring, creating/generating, linking, establishing, assigning, and/or similar words used herein interchangeably one or more recommended problem, goal, and intervention (PGI) workflows onto a plan of care for a patient. It is a workflow in the sense that a PGI workflow includes one or more problems, one or more goals for overcoming or addressing the problem, and one or more interventions for achieving the goals that can be used to create tasks for the care manager and/or patient. The term workflow may be used to refer to any part of the PGI workflow (collectively or individually): one or more problems, one or more goals, one or more interventions, and/or combinations thereof. Then, the care manager can manage the patient's plan of care (e.g., comprising one or more PGI workflows) and engage the patient in one or more self-management action plans (SMAPs).
In one embodiment, the management computing entity 100 (executing the plan of care platform) may store or otherwise have access to patient information/data for patients, which may comprise electronic medical records (EMRs). The patient information/data may comprise a patient's biographic information, such as name, birthdate, age, social security number, addresses, phone numbers, email addresses, and/or the like. The patient information/data may also comprise a patient's weight, height, medical record number, patient or member number, allergies, symptoms, medical conditions, and/or the like. The patient information/data may also comprise one or more plans of care (including PGI workflows). The patient information/data may also comprise information/data regarding the patient's surgeries, claims, medical providers, schedules, treatments, care pathways, care programs, medical history, insurance information, payment information, family history, and/or the like. By way of example,
In one embodiment, through the care manager application, browser, or care manager interface executing on a care manager computing entity 110, a care manager can create/generate, manage, update, modify, and similar words used herein interchangeably a plan of care (including PGI workflows) for a patient. The plan of care (including PGI workflows) can be stored in association with the patient information/data.
As previously indicated, a care manager may be a case manager, a care manager, a health manager, a health liaison, a care associate, a care coordinator, a medical provider, pharmacist, medical management representative, and/or the like associated with or involved in the health care of a patient. Each of these different types of care managers may have (a) different access rights, (b) different abilities to perform assessments, (c) different abilities to assign tasks to other care managers or patients, (d) different abilities to modify assessments, topics/sections, questions, PGI workflows, plans of care, (e) different abilities to access or manage plans of care, (f) access to or be provided with different assessments or sets of assessments, and/or the like. Given the potentially different rights, privileges, and abilities, the management computing entity 100 may store care manager profiles that correspond respectively to different care managers. A care manager profile may include the care manager's attributes, such as (a) username to access the management computing entity 100, (b) password to access the management computing entity 100, (c) employee identification number, (d) name, (e) email addresses, (f) SMS addresses, (g) phone numbers, (h) residential address, (i) primary skill, (j) work/job class, (k) seniority date, (l) birthday, (m) languages spoken, (n) certifications or licenses, (o) schedule preferences, (p) role, and/or the like.
In one embodiment, care managers have corresponding profiles for accessing, using, and/or interacting with the plan of care platform of the management computing entity 100. As noted, the different care manager profiles may be associated with (a) different access rights, (b) different abilities to perform assessments, (c) different abilities to assign tasks to other care managers or patients, (d) different abilities to modify assessments, topics/sections, questions, PGI workflows, plans of care, (e) different abilities to access or manage plans of care, (f) access to or be provided with different assessments or sets of assessments, and/or the like. Moreover, a care manager profile can be used by a care manager (e.g., operating a care manager computing entity 110) (a) to view his or her assigned tasks, (b) to view tasks assigned to other care managers, (c) to track, monitor, and/or record information/data about patients, and/or the like. The types of profiles and their corresponding access and rights may vary and be customized to suit a variety of needs and circumstances.
In one embodiment, with the appropriate credentials, a care manager (e.g., operating a care manager computing entity 110) can access the plan of care platform executing on the management computing entity 100 to create, access, modify, and/or manage various plans of care.
As will be recognized, each topic/section can comprise one or more hierarchical questions with conditional logic. As shown in
In one embodiment, the questions may be specific to the topic/section with which they are associated. As with each topic/section, each unique question may be associated with a unique topic/section identifier (e.g., a unique character string). For instance,
In one embodiment, if a predefined assessment is modified or a new assessment is created/generated, the modified or new assessment can be saved in the content library as a predefined assessment that can be reused. The content library may comprise any number of assessments, topics/sections, and/or questions. Thus, similar to topics/sections and/or questions, each unique assessment may have a unique name and/or be associated with a unique assessment identifier (e.g., a unique character string, such as A11RE4). As with the above, a care manager (e.g., operating a care manager computing entity 110) or other user with appropriate credentials can create/generate one or more assessments to be provided by adding one or more topics/sections to an assessment template.
Continuing with the previous example,
In one embodiment, there may be questions that require responses before a topic/section is considered complete (in addition to optional questions). Moreover, there may be topics/sections or portions thereof that require responses for an assessment to be considered complete (in addition to optional topics/sections). To ensure the completeness of a question, topic/section, and/or assessment, the management computing entity 110 can impose validation logic in a variety of circumstances. For example, before allowing a user (e.g., care manager) to move to a different topic/section, the management computing entity 110 can execute validation logic on the corresponding questions for the current topic/section to ensure that the topic/section as completed as desired. Similarly, the management computing entity 110 can also execute the validation logic when an assessment is saved, closed, exited, and/or the like (see
In operation, a care manager (e.g., operating a care manager computing entity 110) can access, create/generate, and/or modify one or more assessments for a patient. The management computing entity 110 can execute/provide the corresponding assessment (Block 405 of
In one embodiment, for a given assessment or topic/section, the responses to questions can be configured to trigger/initiate authoring, creating/generating, linking, establishing, or assigning one or more PGI workflows onto a plan of care for a patient (Block 410 of
Continuing with the above example, based on the responses received from the SNU Follow-Up Assessment, the management computing entity 100 triggered/initiated several PGI workflows to be displayed by the care manager computing entity 110. In one embodiment, in addition to causing display of the PGI workflows, the management computing entity 100 can author the PGI workflows in a recommended state onto a patient's plan of care and store the same in association with the corresponding patient's information/data. As shown in
Continuing with the above example, the Care Coordination problem of the PGI workflow—comprises one goal, which can be accepted or rejected: Coordinate appropriate behavioral health services. This goal comprises eleven interventions, which can be accepted or rejected. The Clinical Issues problem of the PGI workflow comprises two goals, which can be accepted or rejected: Achieve adequate nutritional intake via alternative route and achieve medication optimization and adherence. These two goals comprise 19 interventions, which can be accepted or rejected. The Knowledge Deficit problem of the PGI workflow comprises two goals, which can be accepted or rejected: identify and adhere to diet in support of priority goals and independent self-management of condition. These two goals comprise three interventions, which can be accepted or rejected. And the Risk for Admission problem of the PGI workflow comprises two goals, which can be accepted or rejected: prevent hospitalization and prevent re-admission. These two goals comprise four interventions, which can be accepted or rejected. As shown in these figures, exemplary interventions (e.g., one or more tasks to help accomplish the one or more objectives) may be: (1) educate in enteral feedings via G-tube or PEG, (2) educate in importance of regular eating patterns, (3) educate in low fat, low cholesterol diet, and/or the like. As will be recognized, a variety of other approaches and techniques can be used to adapt to various needs and circumstances.
As with the PGI workflow, if the care manager (e.g., operating a care manager computing entity 110) rejects a goal or intervention of an accepted PGI workflow, the management computing entity 100 may require the care manager to input the reason for the rejection—see
In one embodiment, as indicated, a care manager (e.g., operating a care manager computing entity 110) may be requested or required to input the detailed information/data for each PGI workflow, goal, and/or intervention (see
In one embodiment, the management computing entity 100 executing/providing the plan of care platform can also provide the care manager (e.g., operating the care manager computing entity 110) with the ability to initiate other workflows and processes, such as selecting or defining whether the goals and/or interventions become tasks (e.g., automatically creating/generating a task when an intervention is marked for follow-up), whether and how to notify the appropriate parties assigned the goals and/or interventions, when to follow up regarding the goals and/or interventions, whether to create/generate SMAPs for patients, and/or the like (Block 415 of
In one embodiment, a care manager (e.g., operating a care manager computing entity 110) can track or schedule interactions with a patient (
In one embodiment, a care manager (e.g., operating a care manager computing entity 110) can create/generate one or more SMAPs (self-management action plans) to better engage the patient in his or her care (
In one embodiment, the management computing entity 100 can also provide various reporting capabilities associated with assessments, topics/sections, questions, PGI workflows, and/or the like (Block 425 of
Many modifications and other embodiments of the inventions set forth herein will come to mind to one skilled in the art to which these inventions pertain having the benefit of the teachings presented in the foregoing descriptions and the associated drawings. Therefore, it is to be understood that the inventions are not to be limited to the specific embodiments disclosed and that modifications and other embodiments are intended to be included within the scope of the appended claims. Although specific terms are employed herein, they are used in a generic and descriptive sense only and not for purposes of limitation.