Orchestrate Patient Care with Integrated Care Management

Integrated Care Management Data Model and Permissions
Integrated Care Management uses a data model that’s FHIR R4 and USCDI-aligned to store its data and make it interoperable.

Integrated Care Management and the Discovery Framework
You can author assessments in the discovery framework that your care managers can use to collect information from their patients. When a care manager uses these completed assessments to create a care plan, Integrated Care Management gives them recommendations for what components they can add to that care plan. These recommendations can be problems, goals, or interventions. The recommendations that users see are based on how you map each assessment question and their response options to items in your PGI (Problem Goal Intervention) library. In addition to mapping responses, you also have to set up a decision table to process how those recommendations are mapped to responses.

Enable Integrated Care Management
Before your users can start using Integrated Care Management, you have to enable the feature and some other settings first.

Define a Problem Goal Intervention Library
Setting up a reusable Problem Goal Intervention (PGI) library helps you reduce the number of duplicate records in your org and maintain a certain level of data consistency across similar records. Definitions in this library are used in care plan templates and are instantiated to their corresponding care plan components when users use those templates. A PGI library consists of problem definitions, goal definitions, and action plan templates.

Define Care Plan Templates
Define reusable care plan templates using the definitions you that you set up in your PGI Library. These templates determine the hierarchical structure of the care plans instantiated from them. Your users use these templates when they create care plans to add the problems, goals, and interventions they need.

Get Your Org Ready to Use the Discovery Framework
Health Cloud Assessments uses the power of Discovery Framework and OmniStudio to build complex questionnaires. To use Assessments, you must first install the OmniStudio managed package, enable Discovery Framework, configure sharing and permissions, and place the Assessments component on a patient record page.

Set Up Assessments and Recommendations
To give your users recommendations when they create care plans, first create an assessment that they can use to gather information from patients. Then, map the questions and their responses to appropriate recommendations. And finally, set up a decision table to process that mapping.

Add the Integrated Care Management UI to the Patient Page
To let your users use Integrated Care Management, add the IndustriesHCCarePlanManager FlexCard to a person account record page.

Configure Field-Level Security for Integrated Care Management
To let your users create care plans, you need to give them access to certain fields that are disabled by default for most user profiles.

CRM Analytics for Integrated Care Management
CRM Analytics dashboards for Integrated Care Management give care managers insights into the status and performance of care plans, pending tasks, and their team’s task completion trends. Care managers have a comprehensive overview of patient data, making it easier for them to track high-priority tasks, manage task assignments, and take appropriate action to ensure high-quality patient care.

Care Gaps
When you enable and configure care gaps in Integrated Care Management, care managers can evaluate clinical measures, identify gaps in patient care, and create care plans from care gaps. The care gap FlexCard in the patient record page gives users a comprehensive view of a patient’s care gaps. This FlexCard also has a New Care Gap button that launches the OmniScript flow for evaluating a clinical measure and creating a care gap.

Clinical Measures for Care Gaps
Integrated Care Management supports creating care gaps from clinical measures. An OmniScript flow evaluates a measure against a patient’s data and if the measure isn’t satisfied, the flow automatically creates a care gap record. To close an open care gap, care managers can reevaluate the measure after a patient has received the required care.

Care Gaps Access for Experience Cloud Sites
When you expose the Care Gap, Care Gap Criteria Result, Clinical Measure, Clinical Measure Criteria, and Clinical Measure Criteria Group objects in your Experience site, community users can see the care gaps identified for a patient. Then, care managers, patients, and their care teams can quickly take actions to close these care gaps.

Health Cloud Administration

Reusable Templates and Problem Goal Intervention (PGI) Libraries

Care Gaps

User Interface