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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