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," a task titled "Referral Confirmation" will automatically be created for this patient and tracked.
*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.
5.) Populate Targets & Tasks - the initial measurement bundles for the patient. Click "Begin Active Treatment" to automatically create and begin tracking an "Enrollment and Intake" task and move the patient into "Active Treatment."
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.
6.) Patient Enrollment Complete - Tasks added to patient.
Intake
Complete patient intake for CoCM
The application automatically starts time tracking for a new task called “Enrollment and Intake”. This task is meant to cover anything that might happen during the intake process, like talking to the patient or caregivers. You can expand this task to enter additional information in the “Note” field.
From here, the user can either immediately continue administering the intake scales by clicking on “Continue with Intake” or close the dialog by clicking on “Finish”. If they close the dialog, they can come back to the intake scales workflow at any time using the “Finish Intake” button, which is now enabled on the patient record.
1.) Click on the “Continue with Intake” button.
2.) The next screen lists the surveys included in the measurement bundles you selected during enrollment. You have the option to “Start Interview” and complete the survey in person with the patient and related people (if applicable), or to “Send Email/Text” to the patient and related people (if applicable) for them to take the survey at a later time. You may create these recipients at this time by clicking the indicated area below the measure name.
3.) If administering now, select the surveys you would like to start, then click “Save”.
You will be directed to the next screen with a button to “Administer X survey(s)” (X = number of surveys to administer for the person). Click on the “Administer X Survey(s)” button.
A new window will open with the survey questions. Populate the answers, then click “Save” or “Save & View Report".
Once you have saved the survey answers, navigate back to the intake screen. Click on the “Check Complete” button to confirm the surveys have been administered.
Once you have checked the survey answers are complete, click the “Finish Intake” button
If sending email/text, select the surveys you would like to send, then click “Save”. You will get a confirmation with details on which surveys were sent to each recipient. Click “Finish Intake” to complete the intake process.
4.) You will have one more opportunity to add tasks to the patient's record. Once you have confirmed / added any additional tasks, click " Finish".
5.) 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.
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: