Chronic Care

Chronic Illness: Storyboard Dr.Primary Care is reviewing the results of the oral glucose tolerance test with Bob Glucose Patient at the healthcare provider clinic. The results lead Dr. Primary Care to diagnose Bob Glucose Patient with type II diabetes. After consulation with Bob Glucose Patient, Dr. Primary Care accesses Bob Glucose Patient’s EMR and adds type II diabetes to the problem list. Dr. Primary Care also activates a diabetic care plan with referrals to a diabetes educator, a podiatrist, an optician, a pharmacist and a psychologist. These healthcare providers have been identified as the care team for diabetic patients. The activated diabetic care plan includes a schedule of Plan tasks that are to be performed by the patient, by the doctor, and by the care team. Dr. Primary care reviews the care plan, adds any final notes and submits the care plan. Dr. Primary Care gives Bob Glucose Patient a copy of the care plan and asks him to make appointments with the providers identified in the plan, the care team. Once the diabetic care plan is submitted, a message is sent in the form of a notification to the care team helping them to know that Bob Glucose Patient will be contacting them to schedule an appointment. As part of the notifification, the message includes the notes and plan tasks associated with the diabetic care plan. Each member on the referral list, on receiving notification, accesses Bob Glucose Patient’s care plan and acknowledges receipt of the notificaiton. This is received in the care plan as a task report. When Bob Glucose Patient schedules an appointment, each care team member submits a simple “task report” that indicates status of the relevant task in the care plan. As Bob Glucose Patient visits with the healthcare provider, each provider submits another instance of the same task indicating the updated status of the plan. They may also choose to submit an encounter record including any reports relating to the encounter. Six months later, Bob Glucose Patient visits Dr. Primary Care for a regular review. Dr. Primary Care is able to access the care plan and can see the documents relating to Bob’s activities including visits to his care team. Bob has also entered data relating to his self monitoring activities including visists to his care team. Bob has entered data relating to his self monitoring activities with random blood glucose and weight records. There is a record of assessment, a diagram and a task report from the podiatrist. The task report indicates that the review task for podiatry is on track. There is an assessment and a task report from the diabetes educator indicating that there is an issue warranting further attention. There is no task report from the optician. Dr. Primary Care finds the assessment from the diabetes educator in the repository, counsels Bob on then encourages Bob to follow up with this coach on the issues flagged by the diabetes educator in the assessment. He also asks Bob if he has visited the Optician, and Bob confirms that there was no appointment made. Dr Primary Care counsels Bob on the risks of retinopathy and advises him to visit the optician for a check as soon as possible.