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Name
Address-- physical, facilities
Email
Cell phone
Phone 2
Emergency Contact
EC phone
DOB
MRN/ID
Link to family members?
SDOH:
Race | UDS Race Definition |
Ethnicity | UDS Ethnicity Definition |
Non-English | UDS Definition: Better served in language other than English |
PopStatus | UDS Definition: Special Population Status |
FPL | UDS Definition: Federal Poverty Level |
HealthInsStatus | Health Insurance Status |
HealthInsSource | Health Insurance Type |
Education | Educational attainment |
Transportation Access | Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living? |
Zip Code | |
Food Insecurity | |
Housing Insecurity | |
Access to Care | |
Social Isolation | |
Domestic Violence |
Pandemic Support Assessment
Bio Psycho -Social Assessment Measure
Bio - Medical
• Chronic
• Acute
• New
• COVID-19
Psycho -
• Existing MH
• Social Isolation & Coping
• New MH Needs
• Beyond Normal & Self harm (needing professional assistance)
Social -
• Groceries
• Transportation
• Access
• Financial
• Domestic Violence
○ Intimate Partner Safety
○ Child Abuse
Status:
No known risk, symptoms, testing or exposure-- have you ever tested positive, had illness consistent with COVID-19, been exposed to positive case or high risk person/location?
...
Nurse/Case Managers
Physicians/APRNs/PAs
Other care team members?
Community Health Workers?
Requirements:
PopHealth:
Filter patients by status, demographics, case manager, follow up action
Open/link to individual patient from dashboard
Generate reports
Stratify patients by risk
Case Management:
Facilitate shared decision-making
Document goals and progress towards goals
Allow inclusion of relevant clinical data-- vital signs, conditions, medications
Allow import of data from an inpatient encounter
Facilitate information about SDOH and barriers to health and identify enabling services
Provide CDS on the next management step-- assign follow up to an individual and a date/time
Stratify patients by risk and clinical progress (change in condition)-- modify CDS to those factors
General Requirements:
Robust testing and test patients
Connection to case reporting
Meets adequate patient matching requirements
Workflow:
Subcomponent 2: Risk Calculator for Existing Patients and Follow-Up Risk Reduction Tool (NACHC)
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