Testing, Tracking and Case Management Use Case

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 Test Order:

• Type of test-- code that describes specific test

  • Rapid or not

  • Lot info?

• Location to perform test?

• Rationale

• Ordering provider

  • Contact info

• Contact for patient follow up?

Diagnostic Testing Results:

• Test specimen--sample source

• Test date

• Test product-- code that describes specific test

  • Lot info?

• Test facility

• Test result

  • Test pending

  • Test negative

  • Test positive

  • Inconclusive test

History of Positive Diagnostic Test

• Reporting confirmed to health department and CDC?

Antibody Testing:

• Type of test-- code that describes specific test

  • Rapid or not?

  • Lot info?

• Location

• Rationale

• Ordering provider

• Contact for follow up

• Rapid or not?

Antibody Test Results:

• Test specimen- -sample source

• Test date

• Test product-- code that describes specific test

  • Lot info?

• Test facility

• Test result

  • Test pending

  • Test negative

  • Test positive

  • Inconclusive test

• History of Positive Antibody Test

  • Reporting confirmed to health department and CDC?

Patient Identifiers and Contact Information:

• 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?

History of risk factors but without symptoms and with negative diagnostic test result

History of risk factors including symptoms and no history of testing

Currently At Risk for COVID-19:

• Patient needs evaluation from a medical professional

• Test ordered/pending

• Patient needs evaluation from a medical professional

• Test ordered/pending

Diagnosis of COVID-19

• Patient tested positive at some point

• Patient presumed positive despite negative test or lack of test

• Patient presumed recovered

• Patient tested as convalescent--

  • negative diagnostic test for formerly positive case?

  • positive antibody test only

Follow Up Step:

• Next Action or Contact

  • Date

  • Accountable party

Issues for Follow Up:

• Deduplication-- failure to identify same patient across encounters

• Need for accurate contact information

• Recording multiple test results over time

• Do antibody tests require reporting

• Get ED severity numbers

• Is reporting at local, CDC level or both?

• Current approaches to case management in and outside of EHR

• Confirming patient reported positive diagnostic and antibody testing

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: Tooling to Support COVID-19 Case Management

Users:

• 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)

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.

• 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 5: 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

  Open

  

   

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: