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A customization care management tool for everyday workflows 

The Care Coordination Tool, where patient management comes first! 

Welcome to the Care Coordination Tool (CCT) User Guide

 

CCT is an event-based management tool (including ADT events). This customizable power tool allows you to create care plans and program types that are specific to your care team needs. It centers around everyday workflows in managing patient documentation.

 

On this page, you will find overview videos and step-by-step instructions to help guide you through the process of managing your tools. ​​​

Schedule Training

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  • 60-Minute Full Team Training 

  • 30-Minute Specific Feature Training 

Care Coordination Roles 

Before you begin

Your security official will need to create admin accounts for all of the desired team members that will be working in CCT. The security official will need to select the desired CCT role that each user will require in order to complete their designated workflow. 

 
Config Panel 

Event Types

This reflects what type of event you are creating. E.g., phone call, in-office visit, etc.

Step 1. 

Click the Add Event Type button to generate a text field.

Step 2. 

Enter the desired event type name in the text field.  

Step 3. 

Once you have entered your desired event type name, click the Submit Changes button.

Step 4. 

Click the Edit button to update the event type name. Note: Updates will affect historical event types. 

Step 5. 

Click on the Delete button to archive an event type. Note: Historical events will no will not be editable. 

Step 6. 

Click the Show Deleted button, a new pop-up window will display the deleted event types.

Click the Restore button to reactivate event type. 

Service Provider

Service Providers are associated to event types. This will allow you to build care teams for specific events that can be created by users such as nurses, social workers, pharmacists, etc. 

Important Notice: The list of Service Providers will be generated based on the My Team user CC roles. A user must have a Gold or Silver role in order to populate in the config panel. Please refer to your Security Official to request the proper CC role. 

Step 1. 

Click on the drop-down menu next to the service providers name. Select the event types in which you would like the service provider to be associated to. You may de-select event types as needed. 

Step 2. 

If a Service Provider has the edit button next to their name, this indicates that this is an admin user that has and needs to be associated to My Team admin account. 

Step 3. 

When editing the Service Provider, checkmark the Contact already has a user account. A test box will then open for you to enter the admin users login username. 

Step 4. 

Once you have entered the Service Providers login username, click save. 

Step 5. 

Once you hit save, your page will refresh back to the Config Panel. The Service Provider will no longer have the edit button available next to their name. The Service Provider is now associated to the My Team user account. 

Program Types

Create Program types or use the already existing system types. Enroll patients in specific programs such as chronic care management, medication management, high risk, etc. 

Step 1. 

Click Add Program Type to generate a new text field. 

Step 2. 

Enter the desired Program Type name in the text field. 

Step 3. 

Once you have entered your desired event program type name, click the Submit Changes button. 

Step 4. 

Click the Edit button to update the program type name. ** Updates will affect historical event types. 

Step 5. 

Click on the Delete button to archive a program type. ** Note that System Program Types cannot be edited

Step 6. 

Click the Show Deleted button to view deleted items. Click the Restore button to reactivate program types. 

 
Manage Templates Home Screen

Step 1.

Download Pre-Built Templates

To download a Health Endeavors pre-built template OR download from your master practice by clicking the drop-down menu and selecting a desired template. Then, click the download icon. Templates downloaded will become active by default. You may edit these templates to your specific needs. 

Step 2. 

Archived Templates

Click on the trashcan icon to be taken to the list of archived templates. From the archived templates page, click the restore arrows icon to re-add the template to your list of available templates. 

Step 3. 

Click Documentation Templates + to create a new template. 

Step 4. 

To activate, click on the checkbox to activate the template. Activated templates will become available for selection when a service provider is creating and editing events. 

Step 5. 

To edit the template name, click the pencil icon. Make name changes and then click the checkmark button to save. 

Step 6. 

To view and edit the template contents, click on the eye icon.

Step 7. 

To archive a template, click the folded document icon. The template will then go into the list of archived templated. 

 
Manage Templates Creating a Template 

Step 1. 

Click the Documentation Templates heading to begin creating a new documentation template.

Step 2. 

In the Create Custom Templates page, start building under the Your Template header.

Step 3. 

Click the Template Name field, enter your desired name, then click Save.

Step 4. 

Select one of the three category components. The category you choose will determine the format in which you want your field to capture information. See list of categories below: 

Documentation Component  Categories 

Input Category 

Text Input - The answer given must be a free-form text response. 

Date Input - The answer given must be a specific date, using a calendar selection. 

Email Input - The answer given must be in an email address. 

Phone Input - The answer given must be a phone number. 

Select Category

Select Basic - This field creates a drop-down menu with one or more choices. The answer given must be from one of these choices.

Radios / Checkboxes Categories

Inline Checkboxes - Provides a horizontal row of options. More than checkbox may be selected.

Multiple Checkboxes - Provides a vertical row of options. More than one checkbox may be selected. 

Inline Radios - Provides a horizontal row of options. Only one radio button may be selected. 

Multiple Radios - Provides a vertical row of options. Only one radio button may be selected.

Step 5. 

Once you have chosen the format of the response field, click and drag the selected response from left to right, directly into the grey area under Your Template. 

Step 6. 

On the right side of the page, a pop-up will appear prompting the filling of several fields, Once these, have been configured, click the Save button. 

Step 7. 

You may drag and drop template fields in the order in which you desire. 


Click the edit icon to edit the field.


Click the delete icon to delete a field. 

** Deleted items will become greyed out. Click the restore icon to reactivate the field.

Step 8. 

Templates are automatically saved to your Manage template list of templates.

 
Calendar View

The Calendar view is based off of the follow-up dates scheduled in events, choose whether you would like to view the calendar by month, week, or day. 
 

LEGEND 

  • Open: Event has been saved in an open status. 

  • Closed: Event has been saved in a closed status.

  • Overdue: Will display all events previous to the current date, if the event is highlighted orange this will indicate that the event is still in an open status. 

  • Patient-Generated: These events are created once a patient has completed a "Your Health" template in the Get Your Health Record App. 

  • Chat: No event is created, however the patient has a chat history on this date while they were logged into Get Your Health Record App.
     

+ NEW EVENT
Click this button to search for a patient. Once your patient name is displayed in the search you may select their name to be taken to the create an event page. 
 

- HIDE FILTERS
Click this button to hide the calendar view filters and get a larger view of the calendar. Click again to show filters. 
 

CARE MANAGER NAME 
Search the calendar by specific care managers. 
 

REFERRAL PARTNER 
Search the calendar by specific referral partners.
 

DUE DATE 

  • Due Today: Click check box to focus on events are due on the current date. 

  • Overdue: Click check box to see events that have follow-up dates prior to the current date. 
     

STATUS 

  • Open: View events that have been saved in an open status.

  • Closed: View events that have been saved in a closed status. 
     

MONTHLY TIME

  • < 20 minutes: View events with less than 20 minutes of accumulated time for the current month.

  • >= 20 minutes: View events with 20 minutes or greater of accumulated time for the month.

  • >= 60 minute: View events with 60 minutes or greater of accumulated time for the month. 
     

OTHER 

  • Patient-Generated Event: These events are created once a patient has completed a "Your Health" template in the Get Your Health Record App. 

  • Chat Dates: No event is created, however the patient has a chat history on this date while they were logged into Get Your Health Record App

 
View Events 

How to access View Events 

Option 1. 

From the Patient Lookup window, click on the CCT tab. Click View Event in the drop-down menu. 

Option 2. 

From the Patient Master Dashboard - Calendar View

 

a. Double click on a patient name displayed in the calendar. 

b. Use the + Search Patient button. Once your list of patients is generated, click View Event.

Option 3. 

From the Patient Master Dashboard - Filter View search for your patient. Once the list of patient(s) generates, click the arrow next to the patient name. Then, click view event.

View Event Features

+ Demographics 

The demographics tab will display a list items including contact details. Anything with a text field can be edited. Other items include: 

Text Alert Enrolled
Indicates if a patient is enrolled in the Get Your Health Record application. 

Dual Eligible Status
Indicates whether a patient is eligible for Medicare and Medicaid. 

CCM Time

Indicates how much time has been accumulated for the current month. 

Status
Indicates if the patient is attributed or non-attributed to the assigned practice per CMS. 

Enrolling Practices 
Indicates what program the patient is enrolled and by which practice (associated within your ACO). 

 

Program Types
Indicates in which programs the patient is enrolled in. Click on the toggle to turn on/off an enrollment of a program. ** Note that a patient must remain enrolled in at least program type. 

 

CCM Enrollment Codes
The Enrollment codes will populate based on data entry of the CCM Master Consent Notification template. 

 

CCM Conflicting Codes 
Indicates and provides details to claims that are conflicting to CCM billing services e.g., home health, dialysis and other CCM services. 

Viewing Events

Event history will display in chronological order for review. 

Origination Date 

Indicates the date that the event was created in the Health Endeavors platform. 

Follow-up Date

Indicates and prompts in the calendar view as to when the referral partner is scheduled to follow-up with the patient. 

Creation Date 
Indicates the date that the true event happened. By default this date is stamped to reflect the current date however, a referral partner may edit. 

Created By
system populated based on the admin user who is logged in to Health Endeavors. 

Status

The status of an event is based on a workflow designated in the Calendar View. Open will display on the calendar referring to a scheduled follow-up still needing to be completed. Closed will refer to a follow-up being completed. 

Event Types 
Indicates what type of event was created e.g., phone call, in-office, social worker, pharmacy. 

Service Provider(s) 
Indicates the Service Provider who will be associated to this patient. 

Templates

Indicates which template(s) was used in the event. 

Description
This field is used to notate and provide details of the event. 
 

Follow-up Note: 

This field is used to note important information for future follow-ups. 

Print Event
Allows you to print or download the event. 

View Event
This page will provide a full preview of the event details including the template questions and entries. 

Close Event 

Updates an open event into a closed status. 

Delete
Allows you to delete an event. ** This feature is only available to the created by user. 

Copy Event

Saves event, closes current event, and copies current event into a new event. 

Mark as Done
Saves event, closes current event and opens a brand new event. 

Add Sub Event 

Allows you to create a child event that will be saved under the parent event. 

Add Follow-up Note 

Allows additional users to add follow-up notes to an event to document items such as e.g., messages.

** An email will generate to the referral partner that a follow-up note has been added.  

Upload Button
Allows you to upload documents related to the event. 

Uploaded Documents

You may download or delete documents that have been uploaded to an event. ** Documents provided by patients via a patient-generated event may not be deleted. 

 
Create Events 

How to access Create Event 

Option 1. 

From the Patient Lookup window, click on the CCT tab. Click View Event in the drop-down menu. 

Option 2. 

In the Calendar View use the + Search Patient button. Once your list of patients is generated, click View Event. 

Option 3. 

In the Patient Master Dashboard - Filter View, search for your patient. Once the list of patients generates, click on the arrow next to the patient name. Then, click create event. 

Create Event Features 

Timer

Any time that you are creating or editing an event, your timer will start running. The time accumulated is captured in the time report for patients that are enrolled in the CCM Enrolled program. You may pause and/or reset timer. 

Template 

A list of active templates (Care Plans) will display. You may select those that you would like to use in your event. 

Event Date

The system will automatically time stamp the event date for you. You may edit the date and time by clicking on the calendar and clock icons. 

Choose Event Type

From the drop down menu, select what type of event you would like to create for your documentation e.g., phone call, in-office visit. 

Service Provider 

If you are a Service Provider that is associated to the selected event type, your name will auto-generate. Otherwise, you may select a Service Provider from the drop down menu. Selecting a Service Provider is referencing who is going to be working and following up with the patient. There is no max of users that can be selected. 

Description

This field is used to notate and provide details of the event. 

Add Follow Up Notes 

This field is used to note important information for future follow-ups. 

Send Email Alert

Checking this box will generate a field populating with the associated partners. You may select additional partners or deselect partners. The selected partners will receive an email alert 15-mins prior to the scheduled follow up date as a reminder. 

Program Types

If the patient is already enrolled in a program, this field will auto-populate. However, you may update the program type in this field. There is no max of program types that a patient can be enrolled in. 
 

** Program type field is only available when creating an event. It is not available while in edit mode. 

Attaching a document 

You may upload a document that you would like to be associated to this event e.g., CCM consent form. 

Follow up Date 

Click the calendar icon to select a follow up date. The time will auto-populate based on the time that you started your event. Click the clock icon to change the time. 

Save Event 

Save your event in an open status. 

Close Event 

Updates an open event into a closed status. 

Copy Event

Saves event, closes current event, and copies current event into a new event.

Mark as Done 

Saves event, closes current event and opens a brand new event.

Create Event/Update 

After you have selected your save (bubble) choices, click create event. Your page will refresh and direct you to the view events page of the patient. 

 
Template Reports 

Step 1. 

From the Care drop-down menu, select Template Reports. 

Step 2. 

Template Type: by default, all with data responses will be selected. click the drop-down menu to edit the selection. 

Step 3. 

Template: Choose which template you would like to generate in your report. You may also type the template name (in the text field) you would like to search for as well. 

Step 4. 

Available Fields: once you have chosen your template, the fields within will generate to choose from. Drag and drop your desired fields into the Chosen Fields box. 

Step 5. 

Once you have dropped items into the Chosen Fields box, the additional filters will become available. 

Step 6. 

Event Status: by default, all statuses is selected. Click the drop-down menu to edit the selection.

Step 7. 

Event Type: by default, all event types is selected. Click the drop-down menu to edit the selection. 

Step 8. 

Event Create Date: choose the from-to date range in which an event was created.

Step 9. 

Event Follow-up Date: choose the from-to date range in which a patient(s) is scheduled for a follow-up.

Step 10. 

Once all of your desired filters are selected, click GO! 

Export / Save Templates 

Step 1. 

Once your list of patients has generate, you may export your list into a Excel or PDF.  

Step 2. 

Click on the arrow icon next to the patients name to view their listed responses. 

Step 3. 

You may also save your report in the Report History. Enter the title of your report, then click save. Your list of saved reports will populated in the report history box. 

 
Time  Reports 

Important Notice

Time accumulated in the Time Report is specific to patients who are enrolled in the CCM program for billing purposes. 

When logged in as a division or subTIN account. The data available will be affected by those roles. With the division role assigned, you will be shown time reports for all accessible practices within the division. With the SubTIN role assigned, you will only be able to see time reports for that SubTIN

Step 1. 

From the Care drop-down menu, select Time Report. 

Step 2. 

Choose the start and end time frame in which you would like to run your report. 

Step 3. 

The billable only check box will be selected by default. This will generate patients who have had 20 minute or more accumulated for the selected time frame. 

Uncheck the box to view times accumulated for all patients. 

Step 4. 

Click GO! to generate your report. Your report will generate each episode of accumulated time on a patient. 

Step 5. 

You may export the report in a excel or PDF. 

Step 6. 

The Collapse Group button will collapse all patient time accumulated encounters and display only the patient name and total time. 

 
FAQs

Need Additional Assistance?

You may Submit a Request under the Admin drop-down menu in your Health Endeavors portal. Be sure to include as much detail and steps for proper review of your ticket. 

Q. When attempting to add a new patient to the system via the Add Patient button in the Patient Master Dashboard, the following message is displayed: The MBI format is invalid.
 

A. Ensure your MBI is formatted correctly using the following details:

  1. The MBI must have 11 characters

  2. The MBI must be unique

  3. The MBI must be in a specific format:

    1. The MBI’s 2nd, 5th, 8th, and 9th characters will always be a letter.

    2. Characters 1, 4, 7, 10, and 11 will always be a number.

    3. The 3rd and 6th characters will be a letter or a number.

    4. The dashes aren’t used as part of the MBI. They won’t be entered into computer systems or used in file formats.

 

An example MBI: 1EG4-TE5-MK73

When entering this into Health Endeavors, it would look like this: 1EG4TE5MK73.

Click here for a full PDF article regarding MBI format

Q. When attempting to add a new patient I am receiving a message "MBI already in use by an existing patient". 
 

A. Ensure that if searching for a patient in the Patient Master Dashboard - Filter View, you have incorporated the following filters: 

         1. Populations --> Population --> Select All 

         2. Patient Attributes --> Patient Attributions --> All Patients 

         3. Patient Search --> MBI 

If you are still unable to locate the patient, they may exist at the master ACO/practice level. Contact your designated security official to request a patient to practice assignment.