The Anatomy of an Intervention: How Care for the Whole Person Happens

Screen-to-intervene efforts are only as successful as the interventions. This is why proper and effective screening is critical to developing the right intervention for a client’s needs. Our team at Activate Care has carefully designed an intervention workflow to guide care coordinators through the screen-to-intervene process, from identifying a patient's or client's full set of needs, all the way to ensuring not just that their service referrals are completed, but that their needs are actually met.

To provide a full picture of the thought process behind an intervention workflow, I have broken down the phases of our standard care process framework and how it’s carefully crafted with the user of the technology, along with the patient or client, at the front of our mind. Activate Care's technology uniquely allows case managers and care coordinators to track their patients’ progress in each phase and how long it takes them to complete them. 

Over the past eight years, Activate Care has developed this care process framework in partnership with hundreds of leaders in provider settings, payer organizations, community-based social services, as well as government agencies, HIEs, and 211s. The beauty of this process framework is its simplicity, which allows the intent and effect of your interventions to truly shine.

 

Step 1: Record Creation

Care coordinators can create a patient record in the platform through manual information input or upload the patient information from another platform with our integration capabilities. 

 

Step 2: Enrollment

The enrollment phase involves outreach to the patient or client, and meetings to obtain consent and participation form signatures. This documentation can be verified and accessed at any time via the Activate Care platform.

 

Step 3: Intake and Intervention

In step three, care coordinators gather the patient’s social and medical information and input it into the Activate CareHub™ platform. They can choose from our list of clinically validated, standard assessments to further understand the client’s medical and social information and needs.

With this information, the care coordinator can create a comprehensive patient plan, or shared plan of care. This is a longitudinal, living document that outlines patient-specific goals and interventions in detail, encompassing the person's whole set of needs (medical, behavioral, and social.)

While referrals can play a significant role in helping the patient get the right help they need, they must be carried out correctly and effectively as part of the shared plan of care. Care coordinators can better utilize referrals to ensure their patients are progressing towards their goals by doing the following:

  • Maintaining consistent communication across your care team. By keeping members of the care team up to date with the patient’s progress, everyone involved in the care of the client has a full view into what’s going on, allowing for true whole person care. Use the Activate Care platform to reschedule tasks and send messages to members of your care team within the platform.

  • Staying informed of the results of appointments and program outcomes. Staying in contact with patients before/ after their appointments provides insight into the overall process and helps you better understand any barriers or struggles that could have arisen. This knowledge not only can help inform your intervention for that specific client, but future ones also. 

 

Step 4: Follow-Up and/or Re-Assessment

With a shared plan of care in place, care coordinators can stay on top of their patients by tracking their patients' goals and quickly getting insight into upcoming events and tasks.

Phase four involves follow-up meetings to address the patients’ goal progress, along with any necessary re-assessments. As patients' needs change, so do their goals, so this phase also involves a re-evaluation of the care plan.

These offerings in the platform support the care coordinator’s efforts to ensure the patient is making progress towards getting their needs met. 

 

Step 5: Program Graduation and Case Closing

Program graduation only happens when all client referrals are completed, and the patient reaches their goals. Care coordinators can then close a client case through a disenrollment form along with any necessary closing documents. 

Unfortunately, many referrals don’t end up successfully solving clients’ needs, whether it’s because the program wasn’t the right solution or the loop was not closed. We’re on a mission to facilitate successful screen-to-intervene efforts every time, which is why the Activate Care platform is designed to capture and store all patient data in a structured way that’s easy to access and navigate.

Now more than ever, with remote communication and outreach due to COVID-19, capturing every important detail about a client’s case is critical to ensure they stay on track with their goals. 

New call-to-action

Topics: Care Coordination