QUALITY CONTROL TIPS

Per Notes 

  • State person names other than patient and relationship to the patient

  • DO NOT PUT IN NOTES PT RUSHED CALL. THIS IS NOT CONSIDERED A  20 MINUTE CALL

  • Educate on two diagnosis

  • Personalize notes

  • Put in most recent vitals or labs ie: cholesterol, TSH, CBC, A1C

  • Last and upcoming appts

  • When pt states they are well managed ask how and add in values if pt cannot recall last BP or blood sugar levels then refer to charts

  • ALL PTS CHARTS SHOULD BE UTILIZED DURING EACH CALL AS A REFERENCE

  • Find out barriers to care. Meaning, that if pts state that they do not check their bp or sugars at home ASK WHY. If they do not have a cuff or blood sugar monitor then that is considered a barrier to care. Send an alert and request that pt get a machine and education on how to use it. 

  • EDUCATION IS KEY TO CHRONIC CARE MANAGEMENT. IT IS CCM'S JOB TO EDUCATE TO FILL CARE GAPS. 

  • Send alerts if pts report being unwell for multiple days.

  • These pts have comorbidities that cause a weakened immune system. A simple cold can send them to hospitals.

  • Any reports of vomiting or diarrhea are a definite alert to PCP because  Potassium gets wasted—potassium is a very very important electrolyte for our hearts. It can cause deadly heart rhythms in pts with pre-existing cardiovascular conditions

  • Alert and oriented or A/O is important to understand when speaking to patients. If pts diagnosed with any mental conditions, especially dementia, and Alzheimer's please ask 

  • First and last name or just full name

  • Birthday 

  • Date Month Year

  • What is going on in the world today or who is the president

  • If pts answer is name and birthday only then pt is only A/O X2 OR SELF. THAT IS A PROBLEM. They are unsafe to be alone

  • If pts are unable to answer these questions carefully listen to make sure they are making sense of what they are saying and if they are living in the present time vs the past. Please also ask pt if they live alone with or without help. If the conversation sounds off please alert PCP and state that pt lives alone and what the A/O status was at the time of communication

  • DO NOT BE AFRAID TO SEND ALERTS THIS IS HOW CCM FILLS THE CARE GAP.

  • Update the care plan and create a care plan upon new enrollment.