Care Pathways Process Guide - Amazon S3

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Care Pathways Process Guide Provider and User Guide

The Enterprise System


Document Revision History

Date Description of Revision

08/10/2018 Initial version of the document



Table of Contents Overview ................................................................................................................................. 1

Care Pathways ......................................................................................................................... 2

Enrolling a Patient in a Care Pathway ....................................................................................................... 3

Care Path Visit Tab .................................................................................................................................... 5

Care Path Dashboard ................................................................................................................................ 6

Alert Results .............................................................................................................................................. 7

Alert Note .................................................................................................................................................. 8

On-Call Users ............................................................................................................................................. 9

On-Call Caregivers ................................................................................................................................... 10

Alert Email for Users/Caregivers ............................................................................................................. 11

Admin Functions .................................................................................................................... 12

Permissions ............................................................................................................................................. 12

Agency Profile Changes ........................................................................................................................... 12

Reference Table Change ......................................................................................................................... 13

Call Dashboard Changes ........................................................................................................ 14


Care Pathways Process Guide Page | 1 Provider and User Guide Overview Proprietary & Confidential

Overview Care Pathways (clinical pathway) is a tool used to manage a Patient’s medical care plan based on quality standards of care in the industry. Implementing Care Pathways improve outcomes and reduce hospitalizations through early identification of changes in a Patient’s condition. Through the Care Pathways functionality, Caregivers can answer predefined questions and enter observations of a Patient’s condition using the HHAeXchange Mobile Application directly from their mobile device when performing EVV Clock Out (at the end of their shift). This process guide covers the Care Pathways functionality in the HHAeXchange (HHAX) Enterprise system. Please direct any questions, thoughts, or concerns regarding the content herein to HHAeXchange Customer Support.

The Care Pathways feature is activated by System Administration. Please contact HHAX Support Team for details, setup, and guidance. This feature is used in conjunction with the Caregiver’s HHAeXchange Mobile App.

HHAX System Key Terms and Definitions

The following provides basic definition of HHAX System key terms applicable throughout the document.

Term Definition

Patient Refers to the Member, Consumer, or Recipient. The Patient is the person receiving services.

Caregiver Refers to the Aide, Homecare Aide, Homecare Worker, or Worker. The Caregiver is the person providing services.

Provider Refers to the Agency or organization coordinating services.

Payer Refers to the Managed Care Organization (MCO), Contract, or HHS. The Payer is the organization placing Patients with Providers.

HHAX Acronym for HHAeXchange

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Care Pathways Process Guide Page | 2 Provider and User Guide Care Pathways Proprietary & Confidential

Care Pathways The Care Pathways functionality allows Agencies to better monitor Patient well-being using disease-specific clinical pathways. Each Care Pathway consists of several basic Yes or No questions related to a specific diagnosis (such as Diabetes and Asthma). When a Caregiver using the HHAeXchange Mobile App provides service to a Patient enrolled in a Care Pathway, they are required to answer the associated questions at Clock Out, like POC Duties. Their responses are recorded in the system on the associated Patient’s Visit Window. In addition, the functionality includes an Observation feature allowing Caregivers to send information regarding their current service directly to the Agencies. In addition to the Patient’s health, the Observations feature helps a Caregiver also report on the condition of the Patient’s home, their medical equipment, and their social lives. Refer to the Mobile App Care Pathways Job Aid for Caregiver guidance. Both Care Pathway questions and Observations may be configured to issue an alert which is captured by the new Care Pathway Dashboard in the system. These alerts allow Agencies to respond quickly if the Patient’s condition or wellbeing is threatened by worsening symptoms or issues in their home. The following are Care Pathway diagnoses/conditions are currently available on the HHAeXchange system.

Current Care Pathways in HHAeXchange • Asthma • CAD • Cerebral Vascular Accident/ Stroke • COPD/Emphysema • Cognitive disorders (Dementia/ Alzheimer’s) • Colitis • Congestive Heart Failure/CHF • Crohn’s • Degenerative Joint Disease/Arthritis • Diabetes

• GERD/Reflux • Fall (History) • Hypertension • Immunocompromised (HIV, AIDS, Cancer) • Liver Disease • Mood Disorders • Pneumonia • Renal / Kidney disease • Wound

https://s3.amazonaws.com/hhaxsupport/SupportDocs/Enterprise/Job+Aids/Enterprise+Job+Aid+-+Mobile+App+Care+Path.pdf



Enrolling a Patient in a Care Pathway A new Care Pathway page (Patient > Care Path) is now available where a Patient may be enrolled in a Care Pathway based on their diagnosis(es) with a matching ICD-10 Code entered on their Clinical > Info page. Complete the following steps to enroll a Patient in a Care Pathway.

Step Action 1 Navigate to the Patient’s Info page (Patient > Info) to ensure that a diagnosis and associated ICD-

10 Code has been entered. To add a Diagnosis, click the Add button.

Patient Diagnosis Section

2 The Patient Diagnosis Info window opens. Click the “?” link to apply the applicable ICD Code (required) field.

3 The Diagnosis Search window opens. Enter condition (or part of) in the Description field and click the Search button. The results generate associated ICD-10 Codes (as illustrated in the image. From the list, select and click on the ICD-10 to apply.

Applying an ICD-10 Code

4 The ICD-10 Code populates in the ICD field on the Patient Diagnosis Info window. Complete the remaining field (as applicable) and click Save to continue.

Patient Diagnosis

3 Navigate to the Care Path page and select the Add button, as seen below. Refer to the available Care Path Table (in the previous section) to review the list of current available pathways.



Step Action

Patient Care Path Page

2 The Care Path Setup window opens. Complete the required fields (as denoted by the red asterisk) and described in the table below. Click Save to continue.

Assigning a Care Path to a Patient

Field Description

Use Primary Diagnosis Select the Use Primary Diagnosis checkbox if the Care Pathway applies to the primary diagnosis.

Select Care Path Select the Care Path from the required dropdown. Care Pathways may be selected for one or more diagnoses, provided that matching ICD-10 Codes have been identified.

Enrollment Period (From/To)

Define a date range in which the Patient will be tracked for the selected Care Pathway(s). The Caregiver servicing the enrolled Patient only answers Care Pathway questions during the enrollment period.

Note: If a Patient’s Primary diagnosis is not linked to a Care Pathway, then the primary diagnosis cannot be used.

3 Once all required fields are completed and saved, the Care Pathway is displayed on the Patient’s Care Path page.

Patient Care Path



Step Action 4 Click on the diagnosis Care Pathway link in the leftmost column to view the information and

questions associated with the pathway which includes each Question with the corresponding Frequency, Priority, and enabled Alert.

Care Path Questions and Information

5 Repeat steps 1-3 to add more Care Pathways, as needed.

Care Path Visit Tab A new Care Path tab has been added to the Visit Window for both Skilled and Non-Skilled Visits and is applicable to Patient and Caregiver Calendars once a Patient is assigned to a Care Pathway. Navigate to the Calendar > Visit > Care Path to access. This page provides the responses given by a Caregiver from their Mobile App for that Visit. If no response is provided, the “No Records Found” message is displayed. Alerts highlighted in Red indicate a Critical priority, while those in Orange indicate High priority alerting the assigned On-Call User and/or Caregiver to take necessary action. Alerts with an Informational or Moderate priority level are not highlighted. These priority indicators also appear on the Care Path Dashboard (next section).

Visit Window - Care Path Tab



Care Path Dashboard The Care Path Dashboard (Action > Care Path Dashboard) contains a search function Alert results (directly underneath). The Care Path Dashboard refreshes every 30 seconds. Search filters are available on the top of the page, as described in the table below the image.

Care Path Dashboard

Field Description

Office Select a specific Office(s).

Status Select the status: All, In Progress, Open, or Closed

Priority* (Required) Select the reported priority: All, Informational, Moderate, High, or Critical.

Caregiver Team Select a specific Caregiver team(s).

Caregiver Location Select a specific Caregiver location(s).

Patient Name Enter the Patient’s Name to search for Alerts by Patient.

Patient Team Select a specific Patient team(s).

Patient Location Select a specific Patient location(s).

From / To Date* (Required) Specify a date range.

Nurse Select the Nurse associated with the Alert.

Coordinator Select the Patient’s Coordinator.



Alert Results The Alert Results displays all incoming alerts, with new alerts appearing on top of the feed. An Alert consists of a single line item containing information as described in the table below the image.

Care Path Dashboard – Alert Results

Field Description

Priority The priority of the Alert. Critical priority alerts are highlighted in red while those in orange indicate a High priority level. Alerts with an Informational or Moderate priority level are not highlighted.

Received The date and time the Alert was received.

Time Elapsed The time elapsed since the Alert was received. This continues to be recorded until the status of the Alert is set to Closed.

Alert An Alert text specifying whether the Alert was caused by an Observation or a Care Pathway response.

Patient The Patient with the applied Care Pathway.

Coordinator The Coordinator assigned to the Patient

Caregiver The Caregiver who issued the Alert (or whose mobile app entry triggered the alert).

Nurse The Patient’s assigned Nurse.

Alert Status

Status Description

Open A new or unattended Alert.

In Progress An Alert which has been reviewed by a user who is currently working on resolving the Alert issue. (status must be manually updated).

Closed An Alert which has been addressed and dismissed



Field Description

Note(s) / Follow up

The black note icon ( ) indicates that no Alert Notes have been entered. A blue note icon ( ) indicates that a Note(s) has been entered for an Alert. Hovering the cursor over this icon provides information regarding the last time a Note/Status change was made.

Alert Note Alert Notes can be entered directly from the Dashboard. Click the black note icon ( ) to enter a new Alert Note (illustrated in the image below). The Alert Note is comprised of three sections, the Header, Records, and New Note as described in the table underneath the image.

Alert Note

Section Description

Header Contains information pertaining to the Visit, Patient, and particulars such as the alert date and time as well as the priority.

Records Displays any previously entered Alerts and Notes details to include Date/Time, User, Action Taken, and Alert Status.

New Note

The New Note section is used to enter notes to include: Care Pathway Action Taken, Nurse, Note text box, and the Alert Status. Select Save to save the note followed by the Close button to maintain the “In Progress” status for the Note. Note: Selecting the Save & Close button moves the Status to Close.

The note icon displays in blue when a Note is entered for an Alert. This indicates that there is one or more Notes associated with the Alert.



On-Call Users The On-Call Users functionality allows Agencies to designate specific users as “On-Call” for Care Pathway alerts. These specific users receive automated email alerts when the system receives Care Path/Observation Alerts issued to the user’s Primary Office. Complete the steps below to activate an On-Call User.

Step Action 1 Navigate to Admin > User Management > Search User and locate the specific user. 2 Click the Edit link to open the User Account. 3 On the Update User Account page, select the Clinical Pathway On-Call User checkbox.

User Account Page – Clinical Pathway On-Call User Option

4 When Clinical Pathway On-Call User is selected, the Edit On-Call Schedule window opens. Specify the On-Call Schedule by selecting the required date range (From/To Dates) and specify the Days and Hours per selected days. The default values for the date fields are 0800 to 0800 (24 hours). If no value is entered for a specific day, the system does not send On-Call alerts for that given day at any time. Click Save to finalize.

Setting On-Call Schedule for a User

5 Once the User Call Details are saved, an Edit Schedule link below the Clinical Pathway On-Call User checkbox populates. Use this link to edit/update the User’s On-Call schedule.

Edit On-Call Schedule



Step Action 6 In addition to setting the On-Call

Schedule, alert priority settings can also be defined by selecting the On Call for Selected Alert Priority checkbox (available only if the "Clinical Pathway On-Call User" checkbox is selected). Select the Alert Priority levels to prompt the system to issue an On-Call email to the user.

Selecting Alert Priorities

Note: Changes made to an Observation/Care Pathway, or On-Call setup do not apply retroactively.

On-Call Caregivers The On-Call Caregivers functionality allows Agencies to designate specific Clinicians (Skilled Caregivers such as an RNs) as “On-Call” for Care Pathway/Observation alerts. These specific Caregivers receive automated email alerts when the system receives Care Pathway/Observation alerts issued to their assigned Patients. This function only applies to Skilled Caregivers. Complete the steps below to activate an On-Call Caregiver.

Step Action 1 Navigate to Caregiver > Search Caregiver and locate the specific Caregiver. 2 Click on the Caregiver Name link to access the Caregiver Profile. 3 Scroll to the Notification Preferences section (at the bottom of the page) and select the Receive

Care Path Alert Email checkbox. Ensure an email is entered where the Caregiver is to receive the alerts. On the Send Email for Alert Priority field, select the priority alert levels to prompt the system to issue an On-Call email to the Caregiver for the selected priority level. By default, all priority levels trigger an email for the Caregiver.

On-Call Caregiver Settings

4 Click Save to finalize.



Alert Email for Users/Caregivers The image below illustrates a sample of an email alert as issued by the system for On-Call Users and Caregivers. The email contains the HHAeXchange Login link (https://app.hhaexchange.com/hhax/Login.aspx) where Caregivers can access the system.

Caregiver Email Alert


Care Pathways Process Guide Page | 12 Provider and User Guide Admin Functions Proprietary & Confidential

Admin Functions The following sections apply to the Agency Admin functions to include Permission assignment, Agency Profile updates, and Reference Table Management.

Permissions An Add Edit Care Path and Care Path Visit Tab permission (User Management > User Roles) have been added for the new Care Path related changes (as illustrated in the image).

Care Path Permissions

The Add Edit Care Path permission enables Patient Enrollment. The Care Path Visit Tab permission enables the Care Path tab on Visit page.

In addition, the Care Path Dashboard permissions have also been added (as illustrated in the image).

Care Path Dashboard Permissions

The Care Path Dashboard permission enables the Care Path Dashboard link under the Action tab. The Care Path Alert Note permission allows the addition of notes to a Care Path Alert.

Agency Profile Changes The Care Path Qualification Message and Care Path Dashboard Default Coordinator/Nurse checkboxes have been added to the Agency Profile page under the General section to enable certain functionality, as described in the table below the image.

Agency Profile – Care Path Options


Care Pathways Process Guide Page | 13 Provider and User Guide Admin Functions Proprietary & Confidential

Field Description

Care Path Qualification Message

Selecting this checkbox displays any Qualification Message on the Patient Profile > Clinical Info > Diagnosis page when an ICD Code linked to the Care Pathway is added in the Patient Profile. Selecting this checkbox also activates the Care Path Qualification Message to alert users when a diagnosis is entered that may be tracked using the Care Pathway function. The Care Path Qualification Message is only issued the first time an ICD Code associated with a specific Care Pathway is saved.

Care Path Default Coordinator and Nurse

Selecting this checkbox displays the “View Care Path Alerts for” column on User Management page. This assigns a default value for either the Coordinator or Nurse field on the Care Path Dashboard for each system user. Assigning a default value is completed in the User Account page.

Reference Table Change A new Reference Table (Admin > Reference Table Management) has been added to the Clinical section titled Clinical Pathway Action Taken (as illustrated in the image below). This table is currently read-only for all Providers. Contact HHAX Support for further details.

Reference Table: Clinical Pathway Action Taken


Care Pathways Process Guide Page | 14 Provider and User Guide Call Dashboard Changes Proprietary & Confidential

Call Dashboard Changes EVV that ends up on the Call Maintenance page displays Clinical Pathway data when applicable. The Call Type column has been updated to display the total number (count) of entered Duties, answered Care Pathway questions and submitted Observations in parenthesis. Selecting the link opens the "EVV and Duty Information" window.

Call Maintenance Page

The EVV and Duty Information window (pictured below) includes sections for Duties Entered, Care Path, and Observations which display entered duties, as well as answers and observations for the associated Visit. If no Care Path or Observations data is available for the Visit, then the "No Care Path Responses Found" or "No Observations Found" message is displayed, respectively.

EVV and Duty Information Window

Note: This functionality also applies to the Rejected Calls > Call Type column. A Caregiver can enter a Care Pathway for an Unscheduled Visits. When those Visits are converted to Scheduled Visits, the same Care Path information is transferred to the Scheduled Visits.

Care Pathways Process Guide - Amazon S3

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