After a patient has been enrolled and completed the Initial Monthly Workflow, the circles will change to reflect the Ongoing Monthly Workflow. Beginning at the first of each month, each of the circles for ongoing monthly workflow will reset with the exception of the Enrollment and Consent circle. Just as you did with the initial monthly workflow, you may also use the circles to establish progress. From the patient's Care Management tab, select Ongoing Monthly Workflow, in the View Checklists section on the right side of the page.

The only mandatory step to complete the Ongoing Monthly Workflow is the Monthly Care Plan Review and Updates.

Using the tabs, you may toggle through Problems, Goals, Barriers and Interventions adding any updates you wish.

You may document progress at any level (problem, outcome, goal, barrier and/or intervention) but we recommend each organization follow the same standards for documentation requirements.

To update a problem, select the Problems tab then the problem you would like to manage with your patient.

You may Include Cancelled/Removed Problems by selecting the checkbox in the upper right corner or add a problem by selecting the blue + also in the upper right corner.

Once you select a problem, the following sections will appear to help you manage the problem with your patient: Desired Outcomes, Symptoms, Long Term Goals, SMART Goals, Interventions and Barriers.

For managed problems, previous responses to each question will be listed. You may update the problem if additional responses are needed.

For unmanaged problems, step through each question with your patient: Desired Outcomes, Symptoms, Long Term Goals, SMART Goals, Interventions and Barriers.

Each question will contain response checkboxes and a response dropdown menu. To add a response from the dropdown menu, simply click inside the menu box and select the patient’s response.

If your selection is not listed in the dropdown, begin typing the response; a list of pre-populated, standard best practice responses will display for you to choose from.

After all problem items have been completed, click Save in the bottom right corner for the Problem Notes section to appear. You may add additional information in the Problem Notes box. It may be helpful to include broad, condition-specific information here, such as:

Example: Patient was diagnosed with HTN in 2017 following a heart attack where 2 stents were placed. Dr. John Rogers, cardiologist and PCP manages this condition. Currently, patient is seeing cardiologist every 6 months. Patient reports he is asymptomatic. Currently taking losartan and propranolol to manage the condition. Patient occasionally checks blood pressure (apx 4x a month) with the last reading being 146/88.

It may be helpful to use the Problem Notes section as a condition overview to be read as a quick refresher.

Once the Problem Notes are complete, select a Status of Managing, Resolved or Canceled from the dropdown to indicate the current status of the problem. Select Save in the bottom right corner.

Your notes will now appear in the Previous Updates section with date stamp and user name. Previous Updates are read-only and cannot be edited.

To update a goal, select the Goals tab then the goal you would like to manage with your patient.

Once you select a goal, the following fields will appear: Status, Date, Notes, Previous Updates, Scale and Assign to Current Problem.

Select a status from the dropdown box, today's date will default in the date box and add your goal notes.

For the scale, you can update the patient's readiness to change.

The patient can select a number 1-10 to indicate their motivation to address this specific goal. This is especially helpful to the care manager, who is making concerted effort to engage the patient.

By focusing on goals the patient is more motivated to achieve, you increase the likelihood of the patient making positive changes.

Once the goal is updated, click Save in the bottom right corner. You will now see your goal updates appear in the Previous Updates box with date stamp and user name. Previous Updates are read-only and cannot be edited.

To update a barrier, select the Barriers tab then the barrier you would like to manage with your patient.

Once you select a barrier, the following fields will appear: Status, Date, Notes, Previous Updates and Assign to Current Problem.

Select a status from the dropdown box, today's date will default in the date box and add your barrier notes.

Once the barrier is updated, click Save in the bottom right corner. You will now see your barrier updates appear in the Previous Updates box with date stamp and user name. Previous Updates are read-only and cannot be edited.

If you decide that this barrier is a problem for your patient, you may select Add as Problem for this barrier to be removed from the Barriers tab and added to the Problems tab to now be managed as a problem.

To update an intervention, select the Interventions tab then the intervention you would like to manage with your patient.

Once you select an intervention, the following fields will appear: Status, Date, Notes, Previous Updates and Assign to Current Problem.

Select a status from the dropdown box, today's date will default in the date box and add your intervention notes.

Once the intervention is updated, click Save in the bottom right corner. You will now see your intervention update appear in the Previous Updates box with date stamp and user name. Previous Updates are read-only and cannot be edited.

On the Clinical Review tab, you can see all Care Plan Assessments for your patient. The left side of this tab will highlight areas in the selected Care Plan Assessment including Goals Important to the Patient, Potential Barriers, Interventions, etc.

The right side of the Clinical Review tab contains current Patient Centered Care Plan Updates. Here you can compare monthly updates by clicking the checkbox in the top right corner, filter updates based on user and add additional information pertaining to their current monthly review.

Once the Clinical Review tab is complete, select Mark as Reviewed in the bottom right corner.

NOTE: User and Date must be populated under Patient Centered Care Plan Updates for the Mark as Reviewed button to be enabled.

A confirmation box will appear to confirm the Clinical Review is complete. Select Save to save your information or Cancel to return to the care plan.

Once the Clinical Review is saved, the Monthly Care Plan Review and Updates circle is now complete.

If the practice options are turned on for the two optional tasks, Monthly Provider Sign Off and Re-assessment of Conditions, these will need to be completed for the Ongoing Monthly Workflow to be finalized.

To complete the Monthly Provider Sign Off circle, a provider must review the care plan and select the Sign Off on Care Plan button under the Provider Sign Off section of the Provider Review tab.

The Provider Sign-off modal will appear. Sign-off Date will default to today's date. Click Save to complete the Provider Sign Off portion of the Ongoing Monthly Workflow.

The final optional step is completing the Re-assessment of Conditions. After selecting the circle, review the conditions that are listed on the Edit Patient Conditions modal.

Select the Save & Close button to save any changes made to the conditions. This action will also complete the Re-assessment of Conditions portion of the Ongoing Monthly Workflow.

Your Ongoing Monthly Workflow is now complete.