Patient assessments now have the ability to automatically make care plan item recommendations that are most effective towards a patient’s conditions and health management needs.

For practices with the 'Assessment Automations' option enabled, Care Managers may start and finalize a CCM Care Plan assessment and have care plan items automatically suggested & populated into a patient’s chart.

To begin the process, navigate to the ‘Care Management’ tab in a patient’s chart who is enrolled in the CCM program.

Under the CCM program, click on the ‘New Care Plan’ button found to the right of the task timer.

The ‘Edit Patient Conditions modal will appear. If all conditions associated with a patient are present, then the user may click the ‘Save & Start Assessment’ button in the bottom right of the modal.

NOTE: At least one chronic condition must be present and associated with the patient to begin the assessment. Two chronic conditions are necessary to bill for the CCM program.

The Care Plan assessment will populate with the following sections to complete:

As a user completes the assessment and answers questions based on the patient’s health, specific answers will trigger care plan items to generate and populate into a patient’s chart under an associated condition/problem.

For example, when asked 'Do you have a history of falling or feeling unsteady while walking?' and the patient answers with ‘Yes’ then the ‘Fall Risk’ condition/problem will be generated under the ‘Problems’ tab under both the ‘Summary of Care’ and ‘Care Management’ sections in a patient’s chart.

The generated condition/problem from the ‘Assessment Recommendation Automation’ will populate in the ‘Suggested’ state.

Clicking on the card will expand it out and show the care plan items attached to the care plan item types such as outcomes and goals. By default, these care plans will be pre-selected.

After reviewing and selecting the care plan items a user wishes to attach to a patient’s chart, the user may then hit the save button.
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After saving, notice that the generated condition/problem left the ‘Suggested’ state and is now labeled as ‘Managing.’

These suggested conditions/problems and associated care plan items can be deleted from a patient’s chart.

Find the condition/problem that you want removed from a patient’s chart. For example, let’s say that a user wanted to remove the ‘Lack of resources and/or support’ from the patient chart.

Find the condition/problem card in the ‘Suggested State’ and click to expand it out. Then scroll down to the bottom to find the ‘Cancel’ button.

Click on the ‘Cancel’ button and confirm within the browser warning that you wish to cancel the problem. Click ‘OK’ to remove the condition/problem.

If a question asking a patient if they have difficulty adhering to their diet is answered in the affirmative, then the ‘Diet’ care plan will be added to their patient profile as a ‘Suggested’ care plan item.

When a patient’s assessment asks them, ‘Do you have a history of falling or feeling unsteady while walking?’ and the patient answers ‘Yes’ then the ‘Fall Risk’ care plan is added and set to the ‘Suggested’ status.

When a patient’s assessment asks them ‘“Do you have any problems with pain?” and the patient answers, ‘Yes, my pain is currently unmanaged’ then the ‘Pain’ care plan is recommended as a ‘Suggested’ action.

When a user gets asked ‘Do you have life planning documents in place?’ and the patient answers “No I do not have life planning documents in place” then the Goal and Intervention corresponding to life planning documents are populated automatically.

When a user is asked the following questions and meets criteria based on their answers, then ‘Lack of Resources and/or Support’ care plans will be automatically generated and suggested:

‘Medication Adherence Issues’ care plans will be automatically generated and suggested should a patient meet any of the following criteria during an assessment screening:

​NOTE: Care plan recommendations may be removed from a patient care plan.