Care Management Plus - Information Technology Tools for the Care of Seniors Oregon Health and Science University
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Care Management Tracking Software


Through their research and collaboration with Care Managers across the country, the CM+ Team has developed two distinct tracking systems to help Care Managers monitor their patients.

The Care Manager Tracking Database (CMT) is implemented in a standalone Access database. It is not necessary to use the CMT to implement Care Management Plus; however, most electronic medical records do not include all the key functions that are available in the CMT. The Care Manager Tracking Database enables the Care Manager to: 
  • Flexibly plan chronic care tasks such as
    • classes
    • lab work
    • referrals
  • Schedule visits and phone calls
  • Create reminder lists based on patient criteria (tickler lists) which facilitates patient contact and documentation of adherence to care plan
  • Manage workflow and evaluate efficiency of resource use
The The CMT Access database is not only a valuable clinical tool for the Care Managers, but is also helpful for Clinic Managers to evaluate the success of Care Management Plus. Administrative Reports generated from CMT demonstrate the level of adoption, list providers and their use of Care Managers and for what purposes, and the effectiveness and productivity of the Care Managers. The reports can be generated for any time period. Some of the more useful reports include:
  • Number of patients referred by physician
  • Diagnoses and Payers
  • Trends in outcomes for depression (PHQ-9) and diabetes (Hemoglobin A1C, patient goals)
  • Work breakdown by Encounter Type such as phone calls, face-to-face visits, administrative, clinic visits and the time for each.
To download the database and user guides, please see the Download page.

The Integrated Care Coordination Information System (ICCIS) is the second-generation web-based version of the CMT. This application offers all of the functionalities of the CMT as well as additional reporting capabilities and the ability to interface directly with a clinic’s EHR. To learn more about the ICCIS, please click here.
 

 

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Care Management Plus is sponsored by the John A. Hartford Foundation and the Oregon Health & Science University.