Using the "No Response' Filter
Navigate to the Enrolled tab and select the dropdown next to "No Response" under Patient Engagement
Filter your Enrolled patients to patients who have not responded in the last 4 weeks
Is the patient's status appropriate?
Ex: If this is a patient that does not text regularly, is their program status set to manual? Have you attempted a phone call this month? If they don't pick up, is there a follow up task for the next attempted call?
Conversation Completion
One way to see open conversations is by navigating to the Inbox tab, selecting the three lines next to My Inbox in the upper left, and choosing the Care Mgmt inbox
Review all conversations you’ve had with the patient this month
Have all conversations come to a conclusion?
Are there any lingering questions or items of follow up?
Have you created a task for this patient to continue a particular discussion? Continuity of care is critical
Are all message threads closed out after completion?
Care Gaps
Care Gaps will be flagged in patient conversation threads.
Have you identified any care gaps?
Review conversations and suggested care gaps
Tag care gaps in conversations or activity notes as they occur
This helps to track your activity and provide insight into what your patients need the most
Vitals
Are you tracking changes to a patient’s vitals?
Have you reviewed the patient’s recent vitals?
Is this information being documented in your EHR?
Have you noticed any trends or changes that require provider escalation?
Check Ins
Have you reviewed Phamily's Check In Calendar?
Accessible through the Phamily Help Center (question mark "?") in the upper right hand corner of your screen and then selecting the News icon in the bottom right corner of the Messenger. A new check-in calendar is released during the first week of each month,
Is your patient receiving check-ins each month?
Have you crafted personalized follow up when a patient doesn’t answer a check in message? Variety and a personalized touch goes a long way!
If a patient doesn’t consistently answer your texts, have you connected with them via phone call?
Care Plans - Are these up to date?
From the My Day dashboard, expand the Create Care Plans box to see patients without Care Plans.
*We recommend toggling on 'PHI Consented Only' to focus on patients who have completed the consent form.
Does the patient have a care plan?
Does the care plan contain goals?
Have the goals been reviewed with the patient? Have you tracked progress toward those goals each month?
If a patient has reached said goal, has a new one been created for them?
For any changes you have made to a care plan this month, have you marked the care plan as updated to reflect a new timestamp?
Have you re-shared the updated care plan with the patient?
Have you confirmed that the patient has seen and acknowledged those changes?
Tasks - Every patient should have upcoming tasks
Tasks can be accessed from My Day dashboard, or the notepad icon in the upper right hand corner.
Create tasks for upcoming follow up items
Ex: Patient started on new medication? Have you checked in with them about it? Did they pick it up from the pharmacy?
Once a task is completed, have you created another one? Have you set a due date for this task?
Logging Time
Review Phamily’s Qualifying Activities document
When reviewing a patient’s EHR record, look for activities performed by yourself or other team members that have not been documented yet for this month
Documentation should include a thorough note in Phamily for compliance
Recorded activity must correlate to the month it is being documented
Ex: The nurse reviewing labs with a patient via phone call in November, should be documented as part of November’s care.
# of patients: total number of patients assigned to the care manager in Phamily.
Final Questions to Ask Yourself
Did we respond to the patient in an engaging manner?
Did we put detailed notes within Phamily to account for our conversations and chart reviews?
Have tasks been created and closed out in an appropriate manner?
Have we touched base with the patient via phone call or text recently?
Questions?
Contact support@phamily.com, or click the question mark in Phamily, for assistance.