Stream: implementers
Topic: Distributed care manager
Grahame Grieve (Jul 21 2016 at 05:00):
question from an implemeter: Have you come across any implementations that are using a FHIR architecture to implement coordinated care / care plans? By this I mean something that:
· Defines the condition being treated and the goals of the care plan.
· Includes tasks that are intended to meet those goals.
· Includes scheduling of those tasks and assignment of participants to those tasks.
· Allows observations to be recorded that can be used to test whether the goals in the care plan are being achieved.
Aleksandra Pavlyshina (Aug 02 2016 at 10:34):
Hello @Grahame Grieve, we, at Health Samurai, are working on FHIR mapping for such a system - Narus Health Solution. This is a custom care management application designed specifically around palliative care, capturing the patient's "care" related needs in addition to their "clinical" needs.
Aleksandra Pavlyshina (Aug 02 2016 at 10:43):
Narus common model is 'Issue-Goal-Action-Outcome'. Now we are applying FHIR architecture to this model.
The decision was made to keep the issue as a CarePlan.description and use separate care plans for each of the issues.
Here is an example:
Issue: Patient has no primary caregiver
Goal: Identify primary caregiver
Actions:
- Determine if this support deficit puts patient at increased risk for medical complications
- Involve Social Worker on this issue
- Involve Nurse Care Manager on this issue
- Assist patient to identify possible primary caregivers
Grahame Grieve (Aug 02 2016 at 21:11):
thx
Last updated: Apr 12 2022 at 19:14 UTC
