Page Comparison

...

• Name

• Address-- physical, facilities

• Email

• Cell phone

• Phone 2

• Emergency Contact

• EC phone

• DOB

• MRN/ID

• Link to family members?

SDOH:

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

  • https://ehrintelligence.com/news/2-short-term-patient-matching-solutions-to-mitigate-covid-19

Workflow:

Subcomponent 2: Risk Calculator for Existing Patients and Follow-Up Risk Reduction Tool (NACHC)

...

• Link to the use case 2 for home care as an outcome

• SDOH typical stakeholders supporting social and community needs are currently overburdened or not operating at normal capacity (Hassanah)https://www.ajmc.com/newsroom/how-can-employers-address-social-determinants-of-health-exacerbated-by-covid19

• https://www.cdc.gov/coronavirus/2019-ncov/covid-data/investigations-discovery/assessing-risk-factors.html

Subcomponent 15: Case Management of COVID-19 cases, individuals under suspicion and those at risk

Define high risk clinical conditions- use CDC conditions

• Targeting patients via text, email and patient portal-- education about symptoms and exposure, risk reduction activity

• PopHealth program to enroll high risk individuals-- symptom checking, asking about needs and safety, recommendations-- text-based pilot at Alliance-- see screen shot

• Consider creation of “high risk for COVID-19” data element?

• Consider also high risk via essential worker or healthcare worker status

  Image Added

Individuals under suspicion -

• Present in clinic, via phone, via virtual visit, referrals (formal or informal) from inpatient/ED, testing center, other providers, referral from health department or organization notifying patient of exposure (workplace, etc)

• Record initial evaluation: exposures and symptoms

• If presenting to healthcare provider --> immediate evaluation and plan

• If presenting to clinic with symptoms → schedule evaluation and provide quarantine recommendation

• If notified of exposure → refer to testing and provide quarantine recommendation

• If referred from healthcare facility → follow up recommendations and schedule evaluation?

• Testing plan

• Contact tracking

Components of the Clinical Evaluation:

• Health conditions of risk

• Needs at home/in community

  • Medication/health supplies

  • Food

  • Housing

  • Safety

• Symptoms

• Ability to quarantine

Statuses in workflow: