Call Status

The outcome of the last call made from either the patient’s landing page or the call scheduler this month, which is reflected by a color phone icon. This column resets monthly. Users can select the call icon to view details of the last call. The following colors are available for the call outcome and their indications include:

● Green: Successful

● Yellow: Talked to patient, Talked to other person

● Blue: Left voicemail (displays yellow on call scheduler)

● Bright Red: No answer (displays yellow on call scheduler)

● Dark Red: Phone inactive (displays yellow on call scheduler)

● Grey: No call has been documented this month

Last Successful Call

The amount of time since the last successful call. N/A indicates there has not been a successful call. Users can hover over the date to see the exact date and time of the last successful call. This column does not reset monthly.

Last Call Attempt

The date of the last documented call attempt regardless of the outcome. This column does not reset monthly.

Call Attempts

The total number of call attempts made this month regardless of outcome. This column resets monthly.

Unsuccessful Call Attempts

The total number of unsuccessful call attempts made this month from either the patient’s landing page or call scheduler. This column resets monthly.

Last PCP Visit

The date of the last entered primary care provider visit in the ‘Last PCP Visit’ section of the patient information shown at the top of the patient landing page.

Flags

Flags assigned to the patient. If there is no flag present, the ‘add/modify flag’ icon is shown so users can select and add.

Risk

The patient’s calculated risk level. The categories include Low, Medium and High Risk. If there is no risk score present, the ‘add/modify’ icon is shown so users can select and add.

EHR ID

The patient’s EHR ID number. Selecting the displayed blue text will take users to the patient landing page.

Patient Name

The patient name in the format of last name, first name, middle name. Selecting the hyperlink will take users to the patient landing page.

Phone Number

The patient’s preferred phone number which users can indicate by editing patient information and selecting the applicable radio button under Preferred Phone.

DOB

The patient’s date of birth in the format month/day/year.

Policy ID

The patient’s insurance policy ID number as entered on the Insurances tab of the patient’s landing page.

Insurance Name

The patient’s insurance name as entered on the insurances tab of the patient’s landing page.

Lang

An abbreviation for the patient’s documented primary language.

Department

The department the patient is assigned to.

CCM Care Manager

The care manager that is assigned in the Chronic Care Management program.

CCM Physician

The provider that is assigned in the Chronic Care Management program.

Primary Care Manager

The user that is assigned as the Primary Care Manager. This user may not be the program specific care manager.

Primary Physician

The user that is assigned to the patient as the Primary Physician. This may not be the program specific provider.

Follow Up

The date of the next scheduled follow up call with the patient. N/A indicates that no follow up call has been scheduled.

Insurance Coverage

The percentage amount that is covered by the patient’s insurance.

Enroll Date

The date the patient enrolled in Chronic Care Management.

Last CP

The date that the patient’s last Initial Patient-Centered Care Plan was completed. If the care plan was started but not finished, a blue ‘Finish’ button will be present. If the patient was enrolled in the program and has no care plan started, a blue ‘new’ button will be present.

Mins

The total number of minutes logged by a Care Manager for the month in billable time. This number resets monthly on the worklist.

Prov Mins

The total number of minutes logged by a Provider for the month in billable time. This number resets monthly on the worklist.

Goal

The number of CCM goal minutes for the month.

RAF

The Risk Adjustment Factor, which can be entered in the ‘Create Patient’ modal when creating a new patient, or may be entered or edited in the ‘Patient Info’ tab on the patient landing page.

Actions

The ‘CCM’ button navigates to the patient’s landing page. The ‘Status’ button allows users to update the CCM program status.