ThoroughCare now features Gaps In Care measure automation where patient care plan items can be automatically generated to populate on patient profiles and assist Care Managers in providing clinically effective healthcare suggestions to their patients.
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Overview of Gaps in Care Automation
The Gaps in Care base automations will show suggested care plan items based on the health conditions associated with a patient and demographics such as age and sex. These suggested care plan items can be found in either the ‘Summary of Care’ tab in a patient profile page or under ‘Care Management’ and then the ‘Problems’ tab under any program.
ThoroughCare will cross reference the patient's information with the Gaps in Care Measure criteria to populate suggestions under the 'Gaps in Care' problem.
If a patient meets a condition, then the software creates a ‘Gaps in Care’ section with patient specific suggestions based on demographic information like age and gender and the problem(s)/condition(s) associated with the patient.
If patient information is pulled from an EHR along with ICD10 codes then the ‘Gaps in Care’ suggestions will be made for the patient.
NOTE: Please reach out to your Customer Success Manager to enable this feature
Gaps in Care & Suggested Care Plan Items
In this article, we will follow the user pathway for this feature through the ‘Care Management’ tab.
By default, a new patient that meets the Gaps in Care measures criteria will have several suggested care plan items focused on basic healthcare needs such as care plan completion and patient education on topics like importance and risks of the influenza or pneumonia vaccine.
Note: Even if no condition has been associated with the patient yet, the entered patient information may generate suggested care plan items within the ‘Gaps in Care’ card found in the ‘Problems’ tab under ‘Summary of Care’ or ‘Care Management’ sections on a patient’s profile.
Clicking on ‘Gaps in Care’ will expand out the card in which different sections will allow users to follow suggested care plan items concerning Long Term Goals.
Gaps in Care Automations Based off Patient's Conditions
Once specific conditions have been identified on a patient profile and associated with an ICD-10 code, then the suggested ‘Gaps in Care’ will populate with care plan items associated with the patient condition(s) with respect to their demographic information.
If the patient and condition information trigger the Gaps in Care automation rules, then the user will see that the suggested ‘Gaps in Care’ card will now have a greater number of automatically suggested items.
Clicking on the ‘Gaps in Care’ card will expand out the information within and show the possible care plan items that are connected to a patient’s chart and their condition(s).
Select the appropriate care plan items to assign to the patient chart and hit the ‘Save’ button when ready.
Note: You can still type into a search bar within the ‘Gaps in Care’ section to search for a care plan item that is not initially suggested in a dropdown menu.
Saving care plan items within the ‘Gaps in Care’ card will turn the status to ‘Managing.’
Hitting cancel will create a pop-up modal asking the user if they wish to cancel the ‘Gaps in Care’ problem.
Hitting ‘OK’ will remove the ‘Gaps in Care’ card and any suggested care plan items concerning the patient and their associated condition(s). A notification will appear afterwards indicating a successful cancellation of a patient problem.
The user will then see that the ‘Gaps in Care’ card has been removed from the patient file.
Gaps in Care Automation Behavior for Care Plan Items
Any care plan items generated by Gaps in Care Automation will be tagged with the status of “Suggested.” The item will not be associated with a specific program by default and will appear on all programs under ‘Care Management’ and the ‘Summary of Care’ tab.
All goal-related suggested care plan items will be preselected by default. If the user clicks on the save button, all selected items will be moved to the ‘In Progress’ status.
If a care plan item is already in use for another problem the care plan item on the Gaps in Care will be in the suggested state until saved. Then it will reflect the status of the original care plan item.
Care Manager Notifications
Anytime there is a new Gap in Care automation identified, the primary Care Manager and the program-specific Care Manager will receive notifications that: "Gaps in Care was identified."
To access other helpful ThoroughCare articles in the Knowledge Base or to get help from the ThoroughCare Support team members, click the ‘i’ icon in the top right corner of the software next to the username and use the appropriate link.