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Integrated Team Care

The Integrated Team Care programme (ITC - previously CCSS), supports activities to improve the prevention, detection, and management of chronic disease in Aboriginal and Torres Strait Islander people.

Better management of these chronic conditions is a key factor in meeting the Government’s target of closing the gap in life expectancy between Indigenous and non-Indigenous Australians within a generation. Primary health care for Aboriginal and Torres Strait Islander people needs to be supported by an organised approach to integration at the primary care level and with other parts of the health system.

This page includes an example of a standard ITC workflow that is supported by a number of features in MMEx. Please use it as an example of how MMEx may be used to support this specialised service.

Example Workflow

Adding New Patients

Adding a new patient is required when you receive a new referral or self-referral and the patient/client is new to the organisation.

Further information on Adding New Patients

Be sure to look out for any incomplete gaps. Reports can be run in “Patient Reporting” to help identify any patients/clients that may have missing mandatory information.


Referrals can be recorded in the patient record. The Referrer must be recorded in the MMEx Address Book initially to display in the Referrals page. All referrals are able to be reported on for any ITC Referrals reports required.

Ensure the appropriate fields are filled in, including specifying whether a referral was made by:

  • GP
  • Other Provider
  • External ITC Provider
  • Self-Referred

The important fields to complete are:

  • Incoming
  • Standard Referral
  • Date Referred [DD/MM/YYYY]
  • Referred By [Name of the Referral – select from Address Book]
  • Referred To [MyOrganisation]
  • Referral Source (e.g. GP, External ITC Provider, Self Referred). * If not in the list, select “Other” and free-text the response.
  • Reason for Referral (e.g. ITC, AHLP, Schools)

Then scan, attach and upload the referral file and Save. The New Patient and Referral details are now recorded.

Further information about using the Address Book

Any referrals recorded will be able to be reported from the MMEx ITC Reports, once a client has commenced the process and you have completed the ITC Forms within MMEx.

Uploading Documents

Uploading documents to a patient record is important to keep track of all external and internal communication.

Any form or message will be in the patient documents.

In addition to this you can also scan files and attach them to patient documents, such as the original referral letter from the GP and a copy of the patient GP Management Plan. This can be done by selection Documents from the clients Clinical Navigator or from the Patient Widget

For futher information Uploading documents


Calendars in MMEx can be used to create and track appointments and can form an important part of the workflows in your organisation.

* From the Calendar, find the available appointment time for the relevant clinician.

  • Double click in the time space. This opens a new dialogue box
  • The Calendar, date and time will default to the ‘space’ that you clicked into

Patients: select the patient for the appointment using

  • Pick a Patient (this opens the Patient Search function) or
  • Type patient name into Search box and click Search

  • Double-click on the Patients name to select them.
  • This will auto-populate into Patients

  • When: Check the date and time are correct
  • Duration: Select the appropriate length of consultation time from the drop-down box
  • Comments field is used for various purposes at each clinic – for example
    • Identifying new patient
    • Information regarding Transport
    • Identifying appointment requirements (eg Health check, scripts etc)
    • Adding provider billing codes at end of consult
  • Participants, Venue and Resources are not commonly used
  • Status, select ‘Booked, Not Yet Arrived’ if this is not the default
  • Type: Standard or another term to describe the appointment type.
  • Patient Reminders – click Send SMS Reminder if the patient requests AND an SMS provider has been set up for the Calendar.
    • If the following shows, then the Providers calendar has NOT been set up for SMS reminders.

For further information on SMS Reminders see SMS Appointment Reminders

  • When all information is correctly entered, click Add

The most important part is keeping track of the appointment. This can be done by right-clicking on the appointment and changing the status of the appointment. You will need to record if an appointment was attended, did not attend or cancelled. This can be done by selecting:

  • Cancelled [If the patient or staff member cancelled the appointment]
  • Completed [If the appointment was attended]
  • Did Not Attend [If the client did not attend but was supposed to]

Note: Use the Comments box on the appointment to record extra information. Such as in the event of a Did Not Attend you could record “Client forgot about the appointment”.

Progress Notes

Progress Notes are an easy way to add information to the patient record. Progress notes can be added from the Clinical Summary of the patient and are used to record events that happened during the time with the client.

Both Progress Notes and Attended Calendar Appointments count as an occasion of service within MMEx. This is important for OCHREStreams nKPI and OSR reporting.

Further information on Progress Notes

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 dictate a prescribed list of scheduled activities to be performed as part of the management / treatment of a particular condition and 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 user or unsubscribe from as they wish. Organisations can also create their own custom careplans.

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

Where care plans contain the same activities but with differing recurring intervals, MMEx will automatically combine care plans into a unified view.

  • It is important to use Care Plans to assist in reporting the diagnosis of a patient.
  • OCHREStreams nKPI reporting will look for patients with a DIABETES and CKD care plan to report on Diabetes and Renal Disease numbers.
  • Care plans should be added when the referral is received or on the date the patient is diagnosed

Further information on Care Plans

ITC Forms

The ITC forms in MMEx are integral to recording and capturing information related to ITC activity for your organisation.

The following forms are available:

  • Care Co-ordination & Supplementary Services - record care coordination, supplementary services, transportation and Medical Aids on the one form (usually used by a Care Co-ordinator)
  • Episode of Care Co-ordination - record an episode of care coordination only
  • Outreach Worker Services - record an activity that is classed as neither care coordination or supplementary services
  • Supplementary Services - record supplementary services only

Each form can be used for one patient at a time and is saved in the patient record when completed.
See here for ITC Forms

Secure Messaging in MMEx

MMEx provides a secure and encrypted mail service. Messages can be sent to other users of MMEx and is a secure way to communicate to other users client information.

You will be alerted that you have a new message waiting by - a red circle with a number will display in the Side Menu.

Click on New Message, in the Messaging menu.

To create a message, simply enter a title or subject into the Subject field - this is the title that will be given to the message when it is saved in the patient record. Then start typing a message directly into the editing area immediately below the formatting toolbar. Format the message using formatting commands familiar to any user of Microsoft Word.

If you wish to use a template for your message, select the patient & refer to options (if/as required), select the template you wish to insert and click the Insert button.
If your chosen template requires a patient context or an Addressee, select your patient and choose your addressee from the Address book in the relevant fields.

Discharge a Patient

The final step in the ITC workflow is to discharge the patient.

  1. Ensure you Discharge the patient on the CCSS Form and obtain any necessary internal approvals
  1. Make the patient Inactive in MMEx

Search for and select the desired patient, and go to the General Tab of Patient Details.

Click Edit

Click Make Inactive if the client no longer attends your clinic or is deceased.

You will be required to enter a reason from the drop down list, as to why you are making the Patient Record Inactive. This list is configurable in the Organisation Centre

Click Save when finished.

If a patient is referred to the program again, you simply search inactive patients and click on Make Active.

See here for ITC Reporting

manual/workflows_itc.txt · Last modified: 2019/06/27 03:07 by sarahb