A Patient Enrollment includes two parts:
Referral, which includes gathering consent, assigning a care team, and assigning measurement bundles
Active Treatment, which begins when initial measurements are sent out and encompasses everything until discharge
Thus, when this page says "Enrollment", it means patients in either the Referral or Active Treatment phases.
Enrollment
Navigating to an unenrolled patient’s record
There are two easy ways to identify a patient who is not enrolled:
1.) On the patient search page, patients who are not enrolled in collaborative care will have “Unenrolled” badge in the Status column
2.) On the patient details page, patients who are not enrolled in collaborative care will have an “Unenrolled” badge in place of the status badge. Only unenrolled patients will have the “Enroll” button enabled to start the enrollment workflow.
How to enroll a patient in CoCM
Patient Enrollment includes the process of bringing a new patient into the CoCM treatment model which includes program referral, gathering consent, assigning a care team, and sending intake measures.
*Note - Before enrolling a patient, it is useful to add related people to the patient’s profile (parents, caregivers, teachers) in order to facilitate the intake process.
1.) Click the “Enroll” button on the patient’s record.
2.) Populate Treatment Details - this includes the Panel, Primary Care Provider, Care Manager, Enrollment Date and Unit.
3.) Populate Referral Details - this includes consent date and referral details for the patient
After clicking "Continue to Diagnoses," the app will automatically start tracking a timer called "Referral Confirmation" if automatic task creation is enabled for your institute.
*Note - Mirah and the CoCM app does not collect the consent or store the records of consent having been collected. Instead, this screen asks the user to confirm that consent has been collected already following your organization’s standard policies/procedures.
4.) Optionally search for or create diagnosis codes. These will appear on the monthly billing summary for these patients. Diagnosis can always be added, removed, or modified at any time later. If automatic task creation is enabled, you will see the "Referral Confirmation" timer at the bottom of the page. If it is not, this banner will not be present. You can skip adding a diagnosis by clicking "Continue to Measures & Tasks"
5.) Populate Targets & Tasks - the initial measurement bundles for the patient. If you are not ready to enroll the patient here, you can click “Save and Close” to save the Treatment, Referral, and Diagnosis details now and enter the bundles at a future time. "Save and Close" does not save your bundle selection.
If you are ready to proceed to measurement collection, type in the search box to select the measurement bundles and click on the check mark to add them to the patient. Click on "Continue to Review & Begin" If you have automatic task creation enabled, this will create the "Enrollment and Intake" task and automatically start tracking time for it.
6.) If the patient has opted out of the program for any reason and you do not wish to continue with the enrollment, you can click "Close Referral". This will prompt you for a reason from a list configured by your administrator.
7.) Review Participants - This screen has you review the participant(s) that will receive measurements via text or email.
The contact information for the participant can be edited by clicking the “Edit Contact Info” button if it appears incorrect on the screen. If measures require a related person such as a guardian/caregiver or teacher, you can add them here as well. If there is an additional related person that should be added for notifications, you can add them using the generic “Add Caregiver” button.
For each participant, you can pause notifications by selecting "Administer Later.” This would give you the opportunity to talk to the patient before their phone receives a notification. You are also able to administer the first measurements via interview on the next page or opt to send notifications.
If you notice there is an incorrect caregiver receiving notifications, you can also deactivate a caregiver by clicking on the deactivate button to turn off receipt of any notifications (but you can only re-active a care giver from the related person table on the patient details page).
Once you have reviewed all the participants and their notifications, click on “Begin Active Treatment” to send all applicable notifications and collect measurements.
Success
You have completed enrollment. You can close this window if you are done or you can use this screen to finish up any intake you did not complete now. The next screen lists the surveys included in the measurement bundles you selected during enrollment.
Important Note on Initial Measurement Bundles: During enrollment, you are prompted to complete the predefined measurement scales for the selected bundle. Customization of individual scales outside of scales included in these bundles is not available at this stage. You send other scales by clicking out of this window by clicking "Send Measurement" on the top right of the patient profile. See article here. Note you can re-enter the Intake flow after sending this scale.
Measurements
For participants you selected “Administer Later”, you have the option to “Start Interview” and complete the survey in person with the patient and related people (if applicable), or to “Send Text SMS/Email” to the patient and related people (if applicable) for them to take the survey at a later time. Important note, if you add a related person (caregiver or teacher) in the Success screen, there is no way to delay notifications.
Make sure to update the Enrollment and Intake timer appropriately, as this timer will still be in progress until you “Save Progress” or “Complete” the timer.
Clicking on the “Start Interview” will open a new window to administer the measurements for that participant
Populate the answers, then click “Save” or “Save & View Report"
Once you have saved the answers, you can close this open window. Navigate back to the enrollment window where you clicked Start Interview originally. Now, if you click on the “Refresh Status” button, you should see a green check mark to indicate we have received the data from the measurement survey.
To administer surveys or send notifications after you’ve closed the enrollment form, you can access these at any time from the patient detail page Measurement Administration History table.
Tasks
Below the participants list is an area to add any additional follow up tasks that you might want to remember to do for this patient. Any existing tasks that were created during enrollment should appear here as well. When you are done adding tasks, you can click “Finish”
Make sure to update the Enrollment and Intake task appropriately, as this task timer will still be in progress until you “Save Progress” or “Complete” the task
Deactivating Enrollment
If you've accidentally created an enrollment and the participants have not returned any feedback yet, you are able to "cancel" the enrollment by clicking the "Deactivate Enrollment" button the patient details page. If any of the participants have answered questions, the enrollment must be discharged instead.
Editing a Care Team after Enrollment
1.) Once a patient is enrolled with a panel, you can see the panel and care team in the Patient Info card here:
2.) 3.)The "Edit" button next to the panel will let you edit the whole care team:
3.) The "Primary Care Provider" and "Care Manager" fields will only let you select providers who are serving that function on the selected panel. To change which providers are on which panel, see How to Create and Edit Panels. Selecting a different panel here will let you select from that panel's PCPs and care managers:
4.) Once you hit save, the changes will be reflected on the Patient Info card: