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Care Plans

Explain it to me in 15 seconds…
MMEx Care plans include a range of activities that can each have multiple events. They can be used to drive chronic disease management, administrative requirements and recalls for all of those.

  • MMEx provides a suite of Global Care Plans that you can use, clone or unsubscribe from
  • your organisation can create and manage your own care plans to support local protocols and needs
  • Each care plan can be tailored for each patient
  • In the care plan view, each coloured square indicates a scheduled activity event
    • Red - Overdue
    • Green - Completed
    • Blue - Pending
  • You can reschedule events and mark when a patient has declined an action/activity
  • Click on:
    • Care plans tab to see the careplans already applied to the patient
    • Add Care Plan to Patient to add a new plan
    • Schedule to see the grid view of the activity schedule
    • A care plan to see the content
    • An event square, then the date link to complete an activity
  • Many activities are configured to complete automatically as you undertake your work elsewhere int eh clinical record
  • You can also complete and apply care plan activities from the To-Do List

Watch a tutorial video here.


About MMEx Care Plans
MMEx provides a comprehensive care planning system that allows a series of activities to be linked, including pathology, imaging, referrals (specialist and allied health), care instructions (e.g. observations, dietary status etc.), planned procedures, medications, immunisations, review and follow up schedule into a single coherent view of a patient's treatment plan to maximise wellness and preventative health provision.

MMEx care plan templates are comprised of a prescribed list of scheduled activities to be performed as part of the management / treatment of a particular condition, but can also be used to track activities such as obtaining consent, pre and post-treatment measures etc.

A suite of global care plans is available for organisations to use or unsubscribe from as they wish. Organisations can also create their own custom care plans.

A patient may be assigned multiple care plans incorporating multiple providers and activities, in a consolidated view to achieve a collaborative approach to patient care.

Where care plans contain the same activities but with differing recurring intervals, MMEx will automatically combine care plan activities into a unified view that will not trigger over or under-testing of the patient.

Introduction

With the patient record open, select the Care Plans tab.

The patient record Care Plans screen will show a list of care plans that have already been applied to the patient record. If the page is blank, there are no care plans applied to this patient record.

There are some button options at the top of the page:

  • Add New Care Plan - open the care plan selection function
  • All/Active/Archived filter - displays the relevant list of care plans for this patient
  • View all Activities - opens a schedule view of ALL activities from ALL careplans
  • To Do list - Opens the To Do list for this patient to the Care Plan Activities tab to review careplan activities. You can also update and add/remove activies from this To Do list tab for care plan activities.

To see the content of a care plan, click on it.
The care plan schedule, a visual representation of the included tasks, will display.

Each square indicates that an activity (or activities) are scheduled to be completed at that time. The colour of the square indicates the status of that activity.

= Pending
= Overdue
= Rescheduled
= Declined
= In Progress
= Completed
= Missed, but subsequently completed
= Finished, Archived or Ceased

Careplan schedules and the displayed colours can provide you with high-level information about the patient's engagement with their health care service and the data recording of the service.

ColoursWhat it might indicate
Mostly green and blue A fully-engaged patient in a service where data is being recorded correctly
Mostly red and blue Patient may not be engaged with their services; patient may be engaged, but clinicians may not be recording data correctly

Using Care Plans

Adding a Care Plan

To add a new care plan, click the Add New Care Plan button
and select the appropriate care plan from the list provided by clicking on it.

You can browse through the list alphabetically by using the page numbers at the bottom, or alternatively use the Search field at the top of the table to find the care plan you are looking for.
The list of care plans displayed is automatically filtered for your patient's age, gender and ethnicity as well as your user privacy settings.
You may modify some filters to search or a plan that is not immediately visible if it is required.

Select the required care plan from the list:

  • If the care plan has already been applied to the patient, you will see this message:

  • If the care plans have been configured as mutually exclusive care plans you will see this message:

Select a care plan.
The care plan content will display the activities included in that care plan in a list. If this is the care plan you wanted, click the Choose This Care Plan For Patient button.

If this does not appear to be the care plan you were looking for, click the Back button and try another.

If the care plan is the one you want, modify the start date (if not today) and add the Diagnosis date if required/desired, then click Choose This Care Plan For Patient button.
The new care plan will now appear in the list of applied Care Plans.


Choosing the correct start date is important if you want to autocomplete activities already completed for the patient. Activities completed prior to the care plan start date will not auto-complete an activity.

Completing Care Plan activities

Auto-completion

MMEx is designed and care plans configured to auto-complete care plan activities where possible. Care plan activities can be configured with a range of activity items that facilitate auto-completion.
Examples of auto-completion include:

  • Control - a control (e.g. smoking or alcohol assessment) is a mini-assessment that may be accessed in a number of locations in MMEx.
  • Form - a form from the forms page will trigger activity completion when saved and completed.
  • Observation - entered observations will mark off measurement-type activities where a relevant patient data type trigger has been recorded.
  • Billing Item / Template - billing the patient with a configured item.
  • Medication Event - when recorded in the medications module.
  • Pathology - when the pathology item is added to a request.
  • Immunisation Events - when administered will mark off immunisation activities where the triggering generic immunisation type has been recorded.

Important - Please Note
If applying a care plan after having entered data into MMEx, data that is in the system after the start date for the care plan will mark off included activities providing the required triggers are included in the activities. Data that is in the system before the start date, will not auto-complete the activities of a newly applied care plan UNLESS entered on the same day the care plan is applied.

An effective workflow for pathology items is to configure the activity with both pathology tests to be requested and observations to be recorded when results are received. As a two part workflow, the activity will be moved to in progress when the tests are ordered and complete when the results are received and observations are (automatically) recorded by the system.

Manual Completion

From the care plan schedule view, click on the square for the activity. and then the date link in the information pop-up.

A completion window will appear. The fields that appear in this window will differ from activity to activity depending on the configuration of the activity.

Enter the actual date that the activity was completed if not today - complete all relevant fields.
Click Save.
If all required items have been completed the activity will be marked as Complete, if one or more mandatory items are outstanding, the activity will be marked as In Progress.

Once the details are saved, the square for that item will turn green if complete and Orange if In Progress.

An activity that is configured with mandatory patient data types will require the observation be recorded before the activity can be marked as complete.

Bulk Manual Completion

Using either the To Do List button on the Care Plans page, or the Care Plans tab of the To-Do list, accessible from the Widget or demographic header. You can record multiple activities as complete.

These pages will display all care plan activities, from all applied careplans, that are overdue, in progress and pending, prior to the date specified in the Pending Date until field. A counter at the top of the pop up displays the number of activities at each status.

Select the activities you wish to complete and click Complete Selected Activities button. The selected activities will be opened in a single pop up.

Record the required data.
When finished, click Save at the bottom of the window.

If all mandatory items are recorded the activity will be marked Complete. If mandatory items remain outstanding the activity will be marked In Progress.

Adding an Ad hoc event

Open the To-do list.
Firstly search the current activities list for the activity you want to ensure it is not already applied to the patient.
Click on the Add Activities button.

Use the search field to find the activity/activities you want to apply to the patient. Use the search field to look for search term or category list to filter for a specific category of activity. Click Add Selected Activities
The activity will be added at the top of the list of activities, selected, ready for completion.
Click Complete Selected Activities to open the completion window.

From this screen you can complete the activity, and also add a schedule if you want this activity to repeat or be ongoing.

Adding a New Ongoing Activity

From the schedule or activity view click Add Activity. You will see a list of all available activities, both those that are global (is Global = Yes) and those created at your organisation (is Global = No). Hover over the information icon to see details of the activity content. If no pop up opens the activity has no configured completion requirements or triggers. Review the included items to ensure the activity is the correct one and configure the schedule. Click Save when done to apply the activity. Click Back to select a different activity. The activity will start on the date it is added, they cannot be individually back dated.

Rescheduling an event

A single care plan activity event can be rescheduled to occur on another date.
Rescheduling an event will ensure that the event does not appear in the To Do list as an overdue event until the rescheduled date.

Click on the coloured square for the activity event and click the proposed activity date hyperlink to open the event completion window. Select reschedule from the Action drop down list.

Select the new date for this activity and record a rescheduled reason, the new scheduled date and click Save.

The event item will be marked yellow and a new pending event will be created on the rescheduled date.

Interactions between care plan activity events.

You can view care plans individually, or collectively.

The collective care plan view

Accessed by clicking on View All Activities, care plan activities that have the same name and category will be combined into a single line in this view, with each scheduled or completed event indicated by a coloured square.

A pop up will display when you hover your mouse over a specific activity. This pop up displays the activity name, details of all care plans that the activity is included in, along with the activity's schedule within each care plan.

Individual care plan view

Select a care plan to view by clicking on it in the care plans list view. Care plans will display based on the included activities that are relevant at the displayed time range and age relevance of the activity.

Where a care plan includes an activity that is also included in another care plan, completed activity events will display in the schedule. You will note in this example that this care plan was applied to the patient on 1/12/2017, and despite there being completed activities on 30/11/2017, the activities remain blue. Care plans do not refer to data added to MMEx prior to the start date of the care plan, even if it includes the same activities. Care plans will not back-date completion of activities prior to the nominated start date of the care plan.

In this example, the care plan was applied on 1/10/17, the care plan has detected the patient data types entered on 1/11/17 and automatically marked those activities as complete - merging the activities from the two careplans.

Hovering over the activity, you can see two dates - which indicates there are two instances of this activity (from different care plans) marked as complete.


The activities that were scheduled in this care plan, which was applied after the observations were recorded, but with a start date in advance of the date the observations were recorded, have been automatically marked as “finished, archived or ceased” and replaced by the completed activity on the date the observation was recorded a month later. It is also displaying the tasks of the care plan applied on 1/12/2017 as pending.

Where an activity has been auto-completed, in another care plan, at a date other than when it was scheduled (e.g. the observation was not recorded until 1 month after the due date) the activity square at the scheduled date will be made grey and a new coloured square will display at the date the care plan event was completed. The details of the event that was scheduled at this date are available.

The green square will include the details of both careplan activity events.

A list of event completions will display where multiple activity events were completed by matching events to data entered. You can edit an individual event by clicking on Edit, correcting the date, and entering the data from that date.
The previously cancelled event is now replaced with a completed event.

Care plan activity event schedules will update as events are completed. This ensures that patients are not submitted to over-testing and Clinicians can work most efficiently to provide care to their patients with minimal duplication. Careful configuration of activities ensures that this functions correctly.

When all scheduled events of a care plan activity have been completed, the icon adjacent to the activity name will turn grey.

If the activity is configured with “Event is continuous and doesn't end” the completed activity will remain in the schedule view as time progresses.

Care Plan Navigation

There are a number of buttons and filters for your use on the Care Plans page and on the sub-pages.

  • Add New Care Plan - Select a care plan to add to the patient record.
  • Filter - View Active, Archived or All care plans
  • View All Activities - open a combined view of all activities from all care plans
  • To-Do-List - takes you to the To do List with the Care Plan activities tab selected.


Schedule View - displays the graphical representation of the care plan activities and their current status

  • Back - will take you back to the Care Plans list from any other view
  • View drop down - allows you to change the viewed time period for the care plan. Options include 1 month, 6 months, 2 years, 6 years and 20 years.
  • Relevance drop down - gives you the choice to see only the activities that are:
    • Relevant - scheduled to occur during the selected view period or overdue,
    • All - view all activities for the visible time period including completed, ceased and finished activities.
  • To-Do-List - takes you to the To do List with the Care Plan activities tab selected.
  • Archive - archives the care plan


Criteria View - Displays the Care Plan Description, Criteria, Archived Date and reason if relevant.

  • Archive - archives the care plan

Activities View - lists all of the activities within the care plan along with their Type, Frequency, Location, Contact and Cease Date information.

  • Edit - edit the schedule for the activity
  • Cease Schedule - stop this item from continuing in this patient's care plan
  • Un-Cease Schedule - re-start this item in this patient's care plan
  • Add New Activity - opens new window that allows you to add a care plan item for this patient only
  • Archive - archives the care plan

Editing individual Care Plans

You may add activities to an individual patient's care plan or care plan activity schedule to fully customise to the patient's specific needs.

To understand the fields, options and parameters of a care plan activity please refer here.

Schedule View

On the Schedule view - when viewing a single care plan - you may click on the Add Activity button to add a new activity to the care plan.
Alternatively you may use the icons located in the centre of the activity table. These icons are not visible on the collective schedule view and will disappear from the individual care plan view for any activity that has been ceased.

  • - add a new occurrence of this activity (this icon is also visible when viewing the schedule for all care plan activities.)
  • - Edit this activity
  • - Cease this activity
  • - Add a new activity to the patient's care plan

When viewing a single careplan, if the activity shared by both care plans has been ceased in another care plan, the Edit, Cease and Add buttons will not display. Any changes to the activity will need to be made in the Activities view.

Activities View

On the Activity view - when viewing a single care plan - you may click on the:

  • Edit button for any activity to modify it
  • Cease Schedule button for any activity to cease (cancel) it
  • Add New Activity button to add a new activity to the care plan.

Activities are grouped by catagory name.
A maximum of 10 activities will be shown before pages are used. Move through the pages to find the specific activity you are looking for.
You will notice that some activities appear multiple times, but seem to be the same activity. They are named the same, but have different frequencies and/or starting and completion dates.

In the example above, the activity has different activity frequencies depending on the stage of disease management. One activity is scheduled to occur one month after diagnosis and the other is a regularly occuring activity.

In the schedule they will appear as the same activity, displaying consecutively in a single line. To ensure this, when configuring activities ensure naming, spelling and category titles match.

Care Plan workflows

Care plans can be built into clinical workflows to ensure that activities are completed when the patient is present in the clinic or to recall them for specific activities as required. They can also contribute to significant time savings and efficiencies.

Clinical Workflow

When opening the clinical record, it is suggested that all clinicians should refer to the To-Do list. The To-Do list will display red indicating that there are tasks overdue. It will also display the number of overdue tasks and care plan activities at this time.

Routinely checking this list will increase opportunistic healthcare interventions and facilitate identification of required referrals, immunisations, pathology tests, assessments and reviews. As part of a team-based approach to healthcare, health professionals should complete activities within their professional scope and in line with organisational models of care and workflows.

If there is insufficient time to complete specific tasks during the current appointment you could suggest booking another appointment to attend to the outstanding task, or recommending booking an appointment with the health professional whose area of expertise would cover the task.

In organisations where patients regularly see a health worker or nurse prior to their GP appointment, reviewing this list can generate prompts to the GP about actions required whilst the patient is in the consultation.

Applying Care Plans

When a patient is diagnosed with a chronic condition or a condition that requires complex management, apply a care plan to the patient record. If a relevant care plan does not exist, plan and create a new one for use.

Pathology

Care plan activities feed into pathology requests.
When creating a request, click on the button

You will be shown a list of the overdue care plan activities and activities due within the next four weeks that include pathology items.

The activity name will be noted and the number of pathology items included in that activity noted. Each item will be automatically checked for you to review prior to adding the selected tests to the list of tests required.
When the tests are added to a pathology request the activity will be marked as complete.

For a robust workflow, diagnostics activities should be configured with observation fields that will be populated with the results when received. In this scenario, the activity will be marked as In Progress when the tests are ordered and marked as complete when the results are received.

Immunisations

Utilising a Lifetime Surveillance Care Plan can facilitate recording the patient's immunisation history. see here for more details.

Recalls

Care Plan activities can drive your clinic's recall processes.

For more information about how MMEx reporting can assist with this refer here

Care Plan Management

MMEx maintains a suite of Global Care Plans that organisations can subscribe to. Organisations can also take control of a copy of any of these care plans (a clone) and modify the base plan to suit local requirements and preferences.

Care Plan FAQ

Q. There are lots of care plans in the list that we don't want to see. How do we get rid of them?
A. In the Organisation Centre, on the Care Plan Management tab, you will see a list of Global Care Plan templates. For each, there is an action button. Click on that, select unsubscribe and the care plan will be removed from view in your organisation.

Q. I have two care plan activities with the same name but they're displaying in different lines in the schedule. How do I fix that?
A. Review both activities from the Care Plan Management screen, looking specifically at the spelling (including punctuation) of the activity name and Category.

Q. I have some activities showing at the bottom of the screen in a group called “UnCategorised”. How can I move them into the group they should be in?
A. These activities do not have a category set. Open them up from the Care Plan Management screen and add the desired category name.

Q. I have three care plans that include the same activity (E.g. Weight) but when I look at “All Activities” I can only see one line for “Weight”. Why? Where have the others gone?
A. when you view all care plan activities in one list (using “All Activities”) MMEx will combine the activities that have the same name and category. This provides you with a more streamlined view.

Q. If I complete the (E.g. Weight) activity on the Diabetes care plan, do I also have to go and mark the others as complete?
A. No, if you complete one weight activity by recording the patient's weight, this will automatically mark off any other care plan activities that include the weight patient data type. If you record the patient's weight in the observations, or as an auto-fill observation in your progress note, any care plans that include that patient data type will be automatically marked as complete.

Q. My (e.g. weight) activity is not marking as complete. I have entered the observation already, but it is still showing as red. What is wrong?
A. Review the activity in the Care Plan Management screen, looking specifically at the patient data type section. Confirm that the correct patient data type has been checked as a trigger for the activity. It may also be that the care plan was applied with a start date after the observation was recorded - care plans do not look before their start date for data to automatically complete activities.

Q. I accidentally marked an activity as complete. How do I undo or remove it?
A. You can't.
However you can modify the schedule to add another event the day after the completed one so that the patient's long-term schedule is not too badly impacted. This workaround ONLY works if the event has mandatory items configured. Locate the next event of that activity in the schedule. Open it, change the date to the day after the completed activity. Click Save. A Pending (if today) or overdue (if prior to today) activity event will be added to the schedule.

Q. I am looking at the schedule for one care plan. Why can I see other activity events showing?
A. When you open one care plan, if there are activities in other care plans that match the activities in your current care plan, you may see the the events for those activities included in your display. Whilst this might initially be difficult to interpret, the benefit is that you can see how this care plan interacts with the others that include this same activity

Q. I have administered the immunisation, but the care plan activity is still showing as red. What is wrong?
A. Review the activity in the Care Plan Management screen, looking specifically at the medications. Ensure that all required medications for that immunisation are recorded there (refer to immunisation schedules). If any are missing, select them from MIMS to update the activity

Q. We like the lifetime care plans, but it doesn't quite meet our needs. We want to add some activities that are needed in our state/territory/region/organisation. Can you do that?
A. MMEx lifetime care plans are a generic care plan (based on RACGP guidelines) that are for the use of all MMEx user organisations. We cannot tailor them to specific location or organisation needs. Because of this we developed the clone feature.
You can clone the global care plan for use at your organisation. You can rename it (please include your org name in the title of lifetime plans) and then modify to suit your organisation's needs. See cloning care plans for more information.

Q. We have cloned our lifetime careplans and we want them to be applied automatically to our new patients. How do we do that?
A. Send this request, along with the names of your lifetime careplans (please ensure your org name is in the title somewhere) to help@mmex.net.au. Our helpdesk will configure this for you.

Q. We don't provide primary care services so care plans wouldn't be useful for us. Would they?
A. Care plans can be created for any purpose, they don't have to be about managing Chronic disease. For example if you are monitoring a group of patients and want to measure the participation rates and impact of a treatment protocol. You could set up a small group of activities that include obtaining consent, activities they will participate in as well as pre and post tests or even post-service satisfaction surveys. Reporting can help you identify which activities are outstanding so you can ensure that all clients receive the same service from your organisation.

If your organisation work is mainly administrative/coordinating, and you need to demonstrate adherence to contracted timelines, you could set up a care plan that ensures that each step in the process that needs to be conducted for your clients is completed.

manual/care_plans.txt · Last modified: 2019/12/09 06:33 by sarahb