Population Management Supporting Patient Care. Office of Information Technology
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1 Population Management Supporting Patient Care Office of Information Technology
2 Using icare as a Case Management Tool May 17, 2016 Theresa Tsosie-Robledo MS RN-C OIT Nurse Informatacist Kathy Ray, CNM Navajo Area Clinical Applications Coordinator
3 icare Population Management Provides an intuitive, integrated view into diverse patient data elements for populations as well as individuals Facilitates the proactive identification and management of populations Supports easy creation and customization of panels of patients Nationally deployed in May 2007 Iterative, phased development Active workgroup, change control board and Subject Matter Expert involvement
4 P C C How icare Fits in the RPMS World
5 Where Does icare Get its Information? Office of Information Technology Note: Not all packages are represented here. Focus is on icare dependencies.
6 icare Features and Highlights HIV Mgmt Patient List icare IPC CMET Women s Health Care Mgmt
7 icare and Value-Based Care One key requirement for transitioning to moving to valuebased care is Comprehensive Population Health. Strong population health management practices backed by the latest care guidelines are key to engaging patients to take an active role in their healthcare. The icare tool as a population health software encompasses value-base care.
8 Value-Based Care for Effective Case Management Focus on care management for high-risk patients as well as other segments of the population that could become high risk in the future. Automate as much of population health management as possible while emphasizing human contact for high-risk patients Embed care managers in practices wherever possible to create close relationships with patients. Don t try to manage population health with EHR alone, but use applications built for population health to help accomplish goals. Find ways to obtain timely information about admissions, discharges, and procedures Use registries to track patients health status and make sure they get the services they need.
9 Effective Nurse Case Management Scenarios Utilizing icare Riverside San Bernardino County Indian Health Inc. Diabetes Educator/Case Manager Diabetes/ Healthy Heart Program Wewoka Indian Health Center (OK Area). Nurse Performance Improvement Officer Whiteriver Service Unit (PHX Area). Nurse Clinical Care Coordinator Outpatient Clinic. Chinle Comprehensive Health Care Facility (Navajo Area). Specialty Clinic Nurse Case Manager. Santa Fe Service Unit (ABQ Area). Nurse Supervisor
10 icare Functionality icare is a reporting and case management tool for clinical decision support Panel definitions allow users to create custom patient lists based on users needs Definitions are applied to all patients in RPMS Lists are utilized to: Manage care for groups of patients Report on site measures Report on provider measures
11 icare - Community Alerts Splash Screen at first login of the day Related to Community of Residence Anonymous alerts are not patientspecific for all users Based on CDC Nationally Notifiable Diseases
12 icare - Opening View Easy display of user defined patient panels. Site level tabs provide facility level reporting. Share your panels with other users to help manage the workload.
13 icare - Panel Creation Quickly define the patients you are interested in. Numerous options to filter your search.
14 icare - Panel View/Patient List Quick look at your patients. Customize the view to suit your needs. Share your panels and custom layouts with others.
15 icare Diagnostic Tags Currently 13 Diagnostic tags available. Users are encouraged to help define additional tags to be implemented in future releases such as HepC, depression, and other chronic conditions.
16 Clinical Decision Support Reminder Views Users select Reminders display Aggregate View
17 Clinical Decision Support National Measure Views Users select Nat l Measure Display Aggregate View
18 icare Patient Record The Snapshot and Cover Sheet provide a wealth of information. Know more, with less effort. Links to detailed visit details.
19 CMET - Introduced in icare v2.1 Care Management Event Tracking (CMET) Provides ability to track certain pre-defined events Breast Cervical Colon Skeletal health Liver STI Workflow includes four steps Event (a mammogram, for example) Findings (Bi-Rad 3) Recommendations for Follow-up (repeat mammogram in six months) Patient Notification (documentation that the patient has been informed of the Findings and Recommendations).
20 HIV Management System (HMS) HIV/AIDS specific Care Management Windows are designed for the specific care of HIV patients
21 Diabetes Care Mgmt Group
22 Diabetes Layout Customization
23 DM Audit Care Mgmt Group
24 Training Resources Audio Recordings: Please copy and paste the following link into your browser to get to the new room. You will be prompted to register. Register and enter the new room! OIT RPMS Training site: Training materials: ftp://ftp.ihs.gov/pubs/rpms-training/icare/
25 Questions? Thank you!
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