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OneCareVT.org OneCareVT.org
Care Navigator Implementation 2016
May 2016
Maura Crandall, RN, BSN, CCM
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Goals of Care Coordination Software
Goals of Care Coordination Software
Streamline communication among care team members and patients and caregiver
Shared care plans Coordination of tasks among multiple care team members Stratification of risk for patients Automation of workflows that support care of complex
patients Complimentary to an EMR (non duplicative)
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Care Coordination Software Features
Features and Capabilities Access to patients/families Secure messaging with patients, families, and other providers Claims data to see trends Ability to add assessments with reportable fields Patients and families can complete assessments Real-time updates as care team adds to the software Ribbon function Uploading of documents Addition of education materials Mobile app At this time only OneCare Vermont Attributed members
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Who Will Have Access?
I. Robert Wood Johnson Foundation Grant Participating Communities: Bennington, Berlin, Burlington, and ST. Albans! II. OneCare Vermont Connected Organizations:
OCV Participants: practices and hospital systems OCV Affiliates: HHAs, DAs, SNFs, OCV Collaborators: AAAs, SASH Pending: State of Vermont Agency of Human Services
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Access to Care Coordination Software in St. Albans
St. Albans Champlain Imaging Participant
St. Albans Clinical Colleagues, Inc. Participant
St. Albans Cold Hollow Family Practice, P.C. Participant
St. Albans Fairfax Associates in Medicine PLLC Participant
St. Albans Franklin County Surgical Associates PC Participant
St. Albans Mary Ann Yeatts-Peterson, MD, LLC Participant
St. Albans Michael J. Corrigan, MD PC Participant
St. Albans Northwestern Medical Center Participant
St. Albans Northwestern Occupational Health, LLC Participant
St. Albans Champlain Valley Area Health Education Center Collaborator
St. Albans Five Ninety Six Sheldon Road Operations LLC dba Saint Albans Healthcare and Rehabilitation Center Affiliate
St. Albans Franklin County Home Health Agency, Inc. Affiliate
St. Albans Franklin County Rehab Center, LLC Affiliate
St. Albans Northwestern Counseling and Support Services Affiliate
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CN Implementation 2016
April Set up CN software for OCV
May Gather Focus Group feedback
June Incorporate FG feedback into CN
June 30th CN early release to pilot communities
July Outreach & training site visits to pilot communities
July 29th 1st user group mtg
August 26 2nd user group mtg
September Expand CN to additional communities
November 18 5th user group mtg
December 16 6th user group mtg
September 30 3rd user group mtg
October Enhance patient engagement
October 28 4th user group mtg
December Network-wide engagement
We are here
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II. A. CN Demo Patient Dashboard- 1. Patient Details and Care Coordination Status
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II. A. CN Demo Patient Dashboard 2. About me, Communication, and ACO/Insurance Info.
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II. A. CN Demo Patient Dashboard 3. Care Team Members
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II. A. CN Demo Patient Dashboard 4. Key Utilization Metrics
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II. A. CN Demo Patient Dashboard 5. Health Conditions, Educational Material, Documents
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II. B. Shared Care Plan
1. Goals
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II. B. Shared Care Plan
2. Challenges/Barriers
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II. B. Shared Care Plan 3. Shared Care Plan Document
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II. C. Assessments 1. List of Assessments
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II. D. Care Coordinator Dashboard