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v4.0 - Feb21
McLeod River PCN - Positive RIFS Screen PathwayC
linic
MO
AC
linic
Phy
sici
anP
CN
Wel
lnes
s S
uppo
rt P
rogr
amC
omm
unity
Age
ncy
StartPositive Screen?
MOA enters screening
results in EMREnd
Yes
MOA Documents Results and Completes
further assessment
Physician reviews results & assesses
needs
+ive Screen for Trans.?
MOA Assesses Transportation Social support available and
needs
MOA Refers to Appropriate Community Service and
provides patient
resources (Help Seeker /
Key Ring)
Transportation Community Serivce: 1. Dial-a Bus2. Transit Discount3. Volunteer Driver Program4. Patty's Helping Hands
MOA Document
Referrals and Follow-up plan
in EMR
Additional Transit
Supports Required?
MOA provides patient resources (Help Seeker /Key
Ring), makes referral to
Wellness Support Program at PCN and documents in
EMR
End
Yes
Yes
NoYes
No
Physician Completes Visit with Patient
Emergency Referral
Required?No
YesEmergency
access to Rx Funding?
Physician initiates
emergency referral
pathway to Alberta
Supports
Yes
Alberta Supports puts patient at the "front of the line"
upon arrival, addresses
emergency need and sends patient
back to clinic
Physician provides Rx
and counsels patient
Patient triaged and assessed
for needs
No
Physician initiates
emergency referral to PCN
Wellness Support Program
Patient Seen on an urgent
basis
Physician Completes Visit with Patient
Financial Support
Required?Yes
Income Tax completed?
Community Tax Supports:1. Community Volunteer Tax Program2. PCN Tax Clinic3. Whitecourt Community Connections Day4. Edmonton Firm Volunteer Program (TBD)
No
YesRefer to Alberta
Supports
Alberta Supports inclucing:1. Income Support2. Assured Income for the Severely Handicapped (AISH)3. Alberta Adult Health Benefits4. Family Support for Children with Disabilities (FSCD)
No
Referral made to Community
Agencies
Other Supports
Required?
Ongoing monitoring of
patients referrals and
needs
Ongoing monitoring of referrals and patient needs
Yes
Counselling, referrals and follow-up plan documented in
Clinic EMR
Other community agencies including: 1. Alberta Supports2. Financial Planning3. Transportation supports4. Housing supports5. Food Bank & Meal support4. Recreation programs5. Volunteer Opportunities6. Other support
No
No
No
Clinic Process for Emergency Referral for Prescription Financial Support
v2.0 - 14Apr20
Legend
Start
MOA reviews scheduled
patients daily to identify patients
in target population eligible for screening
Patient Declines Screen?
MOA rooms patient and offers SDoH
Screen
YES
MOA documents decline in
EMR
Patient completes
screenNO
Physician greets
patient and reviews Screen
Positive Screen?
Physician assesses
patient
MOA enters screening results in
EMR
NO
YES
Patient
MOA
Physician
End
Patient is seen for physician
visit
Patient identifed with
OUD?
YesPhysician
offers patient OAT
Patient agrees
to offer ofcare?
No
MOA documents screening results if
appropriate
MOA makes referral to Community
Transportation Resources and/or PCN
Wellness Support Program as appropriate and documents in EMR
End
Yes
Patient requires
financial support for Rx?
Yes
Physician calls Alberta Supports with emergency
referral and sends patientsto Alberta
Supports
Alberta Supports
Upon arrival patient is put to the
front of the line
Addresses emergency
needs and sent patient back to
clinic
Physician provides Rx
and counsels patient
No
Clinic Process for Positive Social Determinants of Health (SDoH) Screen - Transportation
v4.0 - 16Mar20
Legend
Start
MOA reviews scheduled
patients daily to identify patients
in target population eligible for screening
End
Patient Declines Screen?
MOA rooms patient and offers SDoH
Screen
YES
MOA documents decline in
EMR
Patient completes
screenNO
Physician greets
patient and reviews Screen
Positive Screen?
Physician completes their visit
with patient
MOA enters screening results in
EMR
NO
YES
MOA enters screening results in
EMR
+ive Screen for
Transportation?
NO
MOA makes Referral to Wellness Support Program at PCN and documents in EMR including follow-up
YES
Additional Transportation
supports required
MOA assesses Transportation social support available and
needs
MOA refers to appropriate Community Services including : 1. Dial-a-Bus2. Transit Discount3. Volunteer Driver Program4. Patty's Helping Hands
MOA Documents Referrals in
EMR & Documents
Follow-up Plan
No
YESPatient
MOA
Physician
End
Patient refuses referral and follow-up?
Yes
MOA documents
refusal
No
Screening Process
Patients are identified in EMR: See EMR PDSA1 Sort by Dr and Postal Code Select patients ID Select RIFS ScreenerDocument outcome with EMRpatient flags
Patient Declined Screening Document status
Patient Screened Positive Document outcome
Patient Screened Negative: Document outcome
Patient offered: RIFS Resource Sheet T/C from RIFS CIL
Patient requests RIFS CIL
Independent access of resources
Patient identifies unmet need or
access challenges
Self-Management: No further
intervention
Contacts clinic for referral to CIL
YESNO
Referral is generated by MOA and faxedto St. Albert and Sturgeon PCN
RIFS CIL reviews chart or referral information:: Demographics Health history Identified riskes
RIFS CIL receives task or referral
RIFS CIL contacts patient to discuss resources
Patient is able to self-manage accessing
resources
RIFS CIL assessment of patient presenting concerns and intervention plan using a SDoH framework and promotion of self-management (HCM)
Self-Management: No further
intervention
YES
RIFS CIL schedules assessment with patient
RIFS CIL supports patient’s access of resources: Documentation in
EMR(s)
RIFS CIL schedules assessment with patient
(TC or F2F)
NO
RIFS CIL Work Referral, Assessment and Intervention
DRAFT 2020/05/25
Refer to other PCN team members if patient need is identified (centralized
or decentralized)
1. Patient is roomed by MOA2. Patient completes financialtrain screener while waiting forMD3. MD reviews screener, discusses same with patient and alerts MOA if patientscreened positive
St. Albert and Sturgeon PCN Process Map
Patient Screened Positive Document
outcome
Patient offered: RIFS Resource
Sheet T/C from RIFS
CIL
Patient requests RIFS CIL
Independent access of resources
Patient identifies unmet need or
access challenges
Self-Management: No further
intervention
Contacts clinic for referral to CIL
YES NO
Referral is generated by MOA Faxes patient contact
information and screener
CIL reviews chart or referral information:: Demographics Health history Identified riskes
CIL receives referral
CIL contacts patient to discuss resources
Patient is able to self-manage accessing
resources
CIL assessment of patient presenting concerns aligned with SDoH, intervention and promotion of self-management (HCM)
Self-Management: No further
intervention
YES
CIL supports patient’s access of resources: Documentation in
EMR(s) Follow-up as needed Report to Physician
CIL schedules assessment with patient
(TC or F2F)
RIFS Patient Flow Screening, Assessment and Intervention and Linkages
Design Day 2020/03/17
CIL refers to other PCN team members if patient
need is identified (centralized or decentralized)
NO
RIFS Screening to Resources and Referral Process: Associate Medical Clinic
Daily MOA reviews scheduled appointments in EMR for Sturgeon County Postal Codes: Patient is verified on check
in as eligible for screening
Patient declined screening EMR documentation
Patient is roomed Offered screener
Patient Screened Positive 1 or more ”yes”
responses
Patient Screened Negative: 4 “no” responses
Patient offered: RIFS Resource Sheet Referral to PCN CIF
Patient requests PCN CIF referral
Independent access of resources
Patient identifies unmet need or access challenges
Self-Management: No further intervention
Contacts clinic for referral to PCN SW
Referral is generated by MOA: PCN referral form
FAXed
PCN processes referral in PCN EMR: CIL receives referral
Patient completes screener while waiting
for Dr. M
Physicians review screener Informs MOA of
positive
MOA documents results in EMR
YES
NO
Revised 2020-03-09
LEGEND
Clinic MOA
Patient
Primary Care Physician
PCN CIL (Central)
Data Entry Points
Increase to 3 physicians offering
screening
Increase screening simplified when
same MOA
Able to access to EMR information
Challenges in connecting with
patients – change to provider
Resources Referral Process: Associate Medical Clinic
Patient Screened Positive 1 or more ”yes”
responses
Patient Screened Negative: 4 “no” responses
Patient offered: RIFS Resource Sheet Referral to PCN CIF
Patient requests PCN CIF referral
Independent access of resources
Patient identifies unmet need or access challenges
Self-Management: No further intervention
Contacts clinic for referral to PCN SW
Referral is generated by MOA: PCN referral form
FAXed
PCN processes referral in PCN EMR: CIL receives referral
Physicians review screener Informs MOA of
positive
MOA documents results in EMR
YES
NO
Revised 2020-03-13
LEGEND
Clinic MOA
Patient
Primary Care Physician
PCN CIL (Central)
Updated: RIFS Screening to Resources and Referral Process: Morinville Family Medical Clinic
Daily MOA checks for patient appointments flagged for Sturgeon County Postal Codes: Patient 20-60 verified on
check in as eligible for screening
Patient declined screening EMR documentation
Patient is offered screener at reception
Patient Screened Positive 1 or more ”yes”
responses
Patient Screened Negative: 4 “no” responses
MOA offers: RIFS Resource Sheet Responds to
questions
Independent access of resources
Patient identifies unmet need or access
challenges
Self-Management: No further intervention
Patient contacts clinic for referral to CIL
MOA: EMR entry for PCN
SW referral EMR Worklist to CIL
PCN CIL completes EMR review and contacts patient for further assessment and interventions
Patient: completes screener
in waiting room Returns completed
screener to reception
Reception scans screener into EMR and documents results in
the EMR
MOA rooms patient; alerted to screener
result by EMR
Dr is alerted to positive screener by EMR Reviews screener
and discusses with patient
Offers referral to CIL
YES
NO
Revised: 2020-03-09
Clinic MOA
Patient
Primary Care Physician
PCN CIL (PCN Central)
Data Entry Points
LEGEND
Referrals to SW were held within
the EMR.Failure related to getting access to
clinic EMR
Ongoing expectation and
support for MOA to invest time in
screening
Limited PhysiciansInvolved (50%)
related to extended leave
Engage PCN Mental Health
Nurse to fax referrals
Greets patient and verifies demographics
and attachment
Waits in waiting room
Pt seen
Books appt
VIKINGCURRENT Clinic Flow Map - Visit to PCN clinician
EMR: MedAccess
28 August 2019
Confirmation call
MOA
Patient
PCN Clinician
EMR Documentation
Leaves clinic
Arrives at clinic
Arrives at clinic
Greets patient and verifies
demographics and
attachment
Waits in waiting room
Roomspatient
Waits in exam room
Pt seen
MOA does weight, height and BP
ASaP screening highlighted
Annual Complete Appt
VIKINGCURRENT Clinic Flow Map - Visit to physician
EMR: MedAccess
28 August 2019Annual Complete Appt
ASaP screening maneuvers completed
Referred to PCN clinician as needed
MOA
Panel manager
Patient
Physician
EMR Documentation
Book appt
Leavesclinic
Arrives at clinic
Waits in waiting room
Rooms patient
Waits in exam room
Pt seen
Highlights that RIFS SCREENING needs to be completed
VIKINGPROPOSED RIFS Clinic Flow Map
EMR: MEDACCESS
28 August 2019
MOA
Panel manager
Patient
Physician
Book appt
Leaves clinic
Greets patient & verifies
demographics & attachment
Positive screen
Negative screen
Provide community support summary
NO
YES
Book appointment
with PCN Nurse
Pt confirms ability to
self-manage accessing resources
Completes RIFS
SCREENING
EMR Documentation
Arrives at clinic
Waits in waiting room
Rooms patient
Waits in exam room –
SCREENING TOOL ON
CHAIR
Physician discusses screening
results
Notes on daysheetthat RIFS
SCREENING needs to be completed
VIKINGACTUAL RIFS Clinic Flow Map
EMR: MEDACCESS
24 February 2021
MOA
Panel manager
Patient
Clinician
Book appt
Greets patient & verifies
demographics & attachment
Positive screen
Negative screen
Task sent to PCN Nurse
Completes RIFS
SCREENING
EMR Documentation
PCN staff discussesscreening
results
PCN Nurse discusses
community agencies
Positive screen
Negative screen
Leaves clinic
Referral sent to
community agencies
Information sent back to
clinician from community
Arrives at clinic
Greets patient and verifies
demographics and
attachment
Waits in waiting room
Rooms patient
Waits in exam room
Pt seen
Complete weight, height and BPHighlights maneuvers
needed to be completed
VERMILIONCURRENT Clinic Flow Map - Visit to physician
EMR: ACCURO
28 August 2019ASaP screening
Referred to PCN clinician as needed
ASaP screening maneuvers completed
ASaP screening
MOA
Panel manager
Patient
Physician
Book appt
Leaves clinic
EMR Documentation
Leaves clinic
Waits in waiting room
Greets patient & verifies
demographics & attachment
Does weight, height and BP
Reach out
Books appt
VERMILIONCURRENT Clinic Flow Map - Visit to PCN Clinician
EMR: ACCURO
28 August 2019
PaCT
PaCT
Review by physician
PaCT
Confirmation call
MOA
Panel manager
Patient
PCN Clinician
Arrives at clinic
Leaves clinic
Pt seen
EMR Documentation
Arrives at clinic
Waits in waiting room
Rooms patient
Waits in exam room
Pt seen
Highlights that RIFS SCREENING needs to be completed
VERMILIONPROPOSED RIFS Clinic Flow Map
EMR: ACCURO
28 August 2019
MOA
Panel manager
Patient
Physician
Book appt
Leaves clinic
Greets patient & verifies
demographics & attachment
Positive screen
Negative screen
Provide community support summary
NO
YES
Book appointment
with PCN Nurse
Pt confirms ability to
self-manage accessing resources
Completes RIFS
SCREENING
EMR Documentation
Arrives at clinic
Waits in waiting room
Rooms patient –provides
RIFS screener
Waits in exam room
Physician discusses screening
results
Highlights that RIFS SCREENING needs to be completed
VERMILIONACTUAL RIFS Clinic Flow Map
EMR: ACCURO
24 February 2021
MOA
Panel manager
Patient
Clinician
Book appt
Greets patient & verifies
demographics & attachment
Positive screen
Negative screen
Task sent to PCN Nurse
Completes RIFS
SCREENING
EMR Documentation
PCN staff discussesscreening
results
PCN Nurse discusses
community agencies
Positive screen
Negative screen
Leaves clinic
