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Inputs into the PopHealth/Case Management system:

  1. Phone or in person screening by the clinic

  2. Patient comes in with symptoms

  3. Hospital or external facility referral

  4. Referred by health department as exposed to a positive patient

  5. Telehealth visit or virtual message from patient

  6. Routine surveillance

  7. Anonymous notification from an exposure notification system

  8. Referred as possibly exposed due to physical proximity to a positive patient?

Data Needed to Determine Status:

Symptoms: * research screening scoring-- speak to UPenn, ED/Inpatient team, consider how to deal with changing symptoms over time

  • COVID-19 symptoms + (with scoring or severity?)

    • Fever

    • Cough

    • SOB

    • Other symptoms?

  • No known symptoms

  • Symptoms have resolved

Exposure:

  • High risk settings (use the phone screening criteria to start)

  • Known positive contact

  • Anonymous exposure notification

  • No known high risk settings or positive contacts

Diagnostic Testing Performed:

  • Test specimen

  • Test date

  • Test product

  • Test location

  • Test result

    • Test pending

    • Test negative

    • Test positive

    • Inconclusive test

History of Positive Diagnostic Test?

Antibody Testing:

History of Positive Antibody Test?

Patient Identifiers and Contact Information:

  • Name

  • Address-- physical, facilities

  •  

Status:

  • Patient needs evaluation from a medical professional

  • Need for testing

  • Patient tested positive

 

Issues for Follow Up:

  • Deduplication-- failure to identify same patient across encounters

  • Need for accurate contact information

 

  1. Order and complete testing- order sets, CDS to suggest testing, instructions and referrals for tested patients, quarantine instructions - 2

  2. Follow up test results and referrals – receipt of test results internal or external, other required follow up - 3

  3. Case Reporting and Contact Tracing - eCR, paper reporting, contact identification, contact follow up - 2

  4. Risk Calculation or Stratification - tools to evaluate risk and respond to high risk patients, need for social and medical services to keep patients healthy in quarantine - 2

  5. Update Case Status--> Initiate Outpatient Case Monitoring of Positive or Probable Cases in Quarantine - 4

  6. Inpatient/Outpatient handoffs - coordinate with ED/Inpatient group -

  7. Convalescence - follow up testing, clinical research and plasma donation, identification of presumed low risk for future clinical activities - 1

Great Public Health Medical Center has arranged to start testing patients and employees for SARS-CoV-2 to assist with the public health crisis. They have had many patients who were suspected for COVID-19 and several who tested positive and either quarantined at home or were hospitalized and released. Two patients have died in the hospital so far. They are attempting to begin tracking both the patients who call in with suspected symptoms or exposures, testing those, and following up both on test results done on site and on those resulted from the public health department. They will perform contact tracing via phone as well and contact their own patients who a patient identifies as a contact if appropriate and send this data to the health department for both locations and individuals who are deemed at risk. The Medical Center needs a dashboard that allows them to assign follow up actions to the care team and schedule these as well as a method to follow up on pending tests.

Great Public Health Medical Center has set up a method to track patients positive for and suspected with COVID-19 and assess their needs. They need a method to provide case management and outpatient monitoring for these patients to know when they should come to the clinic or go to the hospital or go for repeat testing. The tool would help monitor vital signs like oxygen saturation if available and symptoms including a walk test and provide feedback to the team. The tool would allow case managers to get remote feedback from patients and call those who have issues or fail to check in remotely.

Subcomponent 1: Risk Calculator for Existing Patients and Follow-Up Risk Reduction Tool (NACHC)

Clinic GoodHealth sees a large proportion of Medicaid and Medicare patients with multiple chronic conditions and needs related to social determinants of health. They are seeking to go through their patients and determine who is at high risk for bad outcomes due to COVID-19 and provide specific patient outreach regarding remaining safe and reducing risk as well as following up on the management of their medications and symptoms and their need for additional services, such as access to food, picking up their medications or concerns about paying their rent. This risk calculator would utilize existing data from the record on clinical conditions and social determinants of health and request missing data where it is deemed critical. The calculator would populate the issues of concern or risk into a care plan template and either suggest follow up actions or allow the care team member to populate a plan for follow up. Data that populates this calculator would also be used for population-level analytics on the risk of the clinic population for negative COVID-19 outcomes and unmet needs related to social determinants of health.

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