02 — Capability · BC-1820.30
Care Planning & Coordination
Keep everyone caring for a patient during an episode working to one plan, from consults and shift handoffs to a safe discharge with the next provider informed. Programs that manage patients across episodes and over months are population health.
- Care Coordination
- Interdisciplinary Care Planning
- Transitions of Care
- Hospital Case Management
In scope
- Interdisciplinary care plans and goals for the episode
- Consult requests and secure communication within the care team
- Shift and service handoffs
- Utilization review, discharge planning and transition summaries to the next provider
Out of scope
- Care management programs across episodes (see BC-1860.20)
- Social needs screening and community resource referrals (see BC-1860.50)
- The exchange mechanics for sending records to other organizations (see BC-1880.30)
- The payer's own concurrent review of a stay (see BC-1870.50)
Realized by · 4
- ServiceNow · Healthcare and Life Sciences Service Managementpartial via BC-1820.30.40
- Epic · Inpatient Nursingcore via BC-1820.30.30
- Oracle Health · Health Information Management and Acute Case Managementstrong via BC-1820.30.50
- MEDITECH Expanse · Expanse Patient Carecore via BC-1820.30.30
Used in · 2
Build it · 0
- Nothing in the library points here yet.
Decomposes into · 6
- BC-1820.30.10Interdisciplinary Care PlansSet and update one plan of goals and interventions for the episode that physicians, nurses and therapists all work from and record progress against.
- BC-1820.30.20Clinical Consult RequestsRequest a consult from another service, track it until it is seen, and get the recommendations back to the requesting team.
- BC-1820.30.30Care Team HandoffsPass responsibility for a patient between shifts, teams and units with a structured handoff, so nothing pending is lost.
- BC-1820.30.40Discharge PlanningPlan each discharge from early in the stay, arrange post-acute placement, equipment and services, and send a transition summary to the next provider and the patient.
- BC-1820.30.50Hospital Utilization ReviewReview each stay against admission and continued-stay criteria, settle inpatient or observation status, send clinical reviews to payers for concurrent authorization, give the required status notices and track avoidable days.
- BC-1820.30.60Clinical Team CommunicationReach the right clinician quickly through secure messaging, current on-call schedules and routed nurse call and device alarm notifications, with each message tied to the patient where it matters.