With the new theme the Chronic Care Management Page will be getting an upgrade! All the new and old features will be explained throughout this article. Lets start with navigating to the CCM page...

It is easiest to navigate to a patient's CCM page by clicking the target patient's "CCM" button located underneath the "Actions" column.

Understanding the CCM Page:

The first part of the CCM page a user will see is the patient's Basic Information and Note sections. Here you can see the patients Name, DOB, Gender, EHR ID, and relevant patient note.

Note: If you wish to edit the patient note from this screen simply click the note and type your edit.

The next section is the patient "Contact Information" which is displayed in the highlighted box below, this would come in handy if a user was needing to reference the patients phone number from the CCM Page.

Note: If a phone number was not provided for the patient the phone number/email will show as "N/A".

Next, is the patient "Conditions Information" section. Here users can click the "?" to the right of a listed condition to open a new page which provides talking points for care managers to reference during a patient call.

Talking points example:

If a user wishes to edit a patient's conditions they may do so by clicking the "View All" button located below the listed conditions.

Once clicked, an "Edit Patient Conditions" pop-up will appear, an example of the pop-up is shown below. To learn how to add patient conditions click here.

The next section to the right of "Condition Information" and "Contact Information" would be ThoroughCare's time logger. To learn how to use the time logger click here.

After that, users will come to a small section that lists the patient's Physician, Care Manager, CCM Status, and Enrollment Date.

Users have the abilities to edit any of these fields by simply clicking the provider/care manager name, status type, or date which the patient was enrolled on.

The last part of the patient information users can see from the CCM page are the "Flags" and patient "Risk". Again user can click either of these to edit the information shown.

Note: If no patient "Flags" or "Risk" has been specified these fields will show a small edit pencil icon.

Care Plan Management:

To continue to manage the care plan a user must navigate to the bottom of the CCM Page.

Care Plan Review:

The first tab shown automatically will be the patient's "Care Plan Review" tab. From here users can view the most recent care plan answers, and make updates to the care plan as the patient progresses through the program.

Under the "Patient Centered Care Plan" section users will see the patient answers gathered from the the most current care plan assessment.

Note: This will be empty if you have yet to complete a care plan assessment.

If a user wishes to begin a new care plan assessment, simply click the "New" button located at the top of the "Patient Centered Care Plan".

Because this section may document a large amount of patient health information, ThoroughCare has added the "Expand All" and "Collapse All" buttons to help save space if a care manager needs to condense the information shown.

Note: The care plan will let the user know the last time it has been updated.

The section immediately to the right of the "Patient Centered Care Plan" is labeled "CCM Conditions Updates".

Note: If you wish to view notes from different months use the arrows in the upper right hand side of the screen to switch the month you are viewing.

Prior to logging an update, make sure the user's name and date is correct to the user that originally completed or took down the update .

When a user would like to log an update, click the "Add Update" button located in the text box to the right of the Care Plan section the update is for.

Note: The update box will appear as "N/A" until an update is added.

By clicking the "Add Update" button, a pop-up to add an update will appear. Click the text box to type the update.

When the update is completed, save it by clicking the "Save" button.

Note: If you click out of the pop-up without saving the update will not be added to the Care Plan.

When the update has been saved it will appear under the section it had been added to.

If a user wishes to manage a patients Goals and Barriers, click the "Manage" button under either the "Monthly Barriers" or the "Monthly Goals" section.

Clicking the "Manage" button will navigate the user to the next tab on the "Care Plan Management" page. The "Care Plan Progress" page is used to document the progression of goals and barriers as the patient moves through the program. To learn how to navigate/use the Care Plan Progress Goals and Barriers click here.

The next tab users will see is the "Provider Review" tab (shown below). Here ThoroughCare providers will sign off on a care plan, add notes, and review the most recent care plan.

To sign off on a care plan click the "Sign off on Care Plan" button. This is located in the "Provider Sign off Required" box.

If any notes need to be added simply click the text box and begin typing.

Notice that once the provider has signed off on the program, the "Provider Review" tab will become white, just like the other tabs. Once the user is finished editing the patient notes remember to click the "Save" button at the top of the screen.

The second to the last tab displayed on the CCM page, is the "Time Logs" tab. Under this tab users are able to edit and delete time logs.

Note: For more information on how to create time logs and time log reports click here.

If a user wishes to edit a time log, they can simply click the "Edit" button located underneath the "Actions" button.

If a time log needs deleted, a user can delete a time log by clicking the "Delete" button located underneath the "actions" column.

The final tab on the CCM management page contains the "Notes" section. Here care managers can add any additional notes that do not fit in the previously explained sections.

The notes section actually breaks down into two different sub-sections. The "New Conditions Notes" is the first section that is highlighted below. It contains notes for:

  • New Concerns identified by patients

  • Interventions to patient concerns

  • Patient Goals / to-do list for next 30 days

  • Care Team / to-do list for next 30 days

  • Other notes about this month's engagement

The second section listed is the "Other Notes" section. It contains notes for:

  • Other notes to appear on this month's Care Plan

  • Provider Monthly Review Notes

  • Appointment Notes

  • Time Logging notes

  • Treatment Notes / Recent Labs

  • Patient Updates

If you wish to add notes to any of these note sections, first, make sure the user name and the date in which the note will be logged from are correct, second, click the "+" button to pull up a note pop-up.

Enter the note within the text box provided.

When the notes is added and the user is finished, click the "Save" button.

For more information on the CCM management page, not discussed in this article, chat with a ThoroughCare professional by clicking the blue chat bubble in the bottom right hand corner of every ThoroughCare screen!

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