Care Gaps

this is where you can manually manage your open care gaps drop each section down to learn more welcome to care gaps care gap opportunities are opportunities to improve patient care! this is where all your open care gaps are these may be care gaps that were autogenerated after completion of a funnel or ones that you created manually care gaps for each individual patient can also be found in the individual patient profile care gaps are grouped per member what does this mean? the care gaps table displays members who have an open care gap assigned to you, with the most recent care gaps at the top of the table if you own a care gap on a member, you will be able to see all currently open care gaps, in addition to yours for that member this is intentional and is meant to help you understand more holistically all the gaps identified on a member this will also allow you to better understand what another department might be working on for this member and to communicate internally, as needed read below and watch some tutorial videos to learn more about using care gaps! what is a care gap? a care gap, in its simplest definition, is the notification to you that a patient has a health care gap that needs to be closed each care gap has the following information the date that it was generated the owner of that care gap (either an individual or a team) the patient name and id that the care gap is for if the care gap was auto generated by a rule, you will see the rule name that generated it the details of the open care gap (under the care gap column) a priority which you, the user, can determine for each care gap a status, which defaults to new when the care gap is created, and can be changed by the user what can i do with care gaps? care gaps should be acted on, and this is where you can track all those actions care gap actions you can open up the details of each care gap using the button on the right hand side of the table under "manage" in the care gap details, the top section will provide basic details on the intervention the actions section allows you to schedule, track, and save your actions for that care gap possible actions ehr messages, faxes, ai agent calls, and text messages these will track automatically when scheduled and on send scheduling actions you can put care gaps into automations using the automations drop down when a care gap is dropped into an automation, all future actions will be visible with the details on when that action will occur you can remove care gaps from automations doing so will cancel all scheduled future actions that were part of that automation removing an automation will not remove actions that were scheduled manually you can manually schedule an action by clicking on the corresponding action button and either "send now" or pick a future time for the action to occur all scheduled actions can be edited by user if desired tip care gaps in automation will appear in a light blue color in the care gap table log external calls to log a call, select the type of call you made once selected, you will be given fields to track the person called, the number used, and an optional field of the outcome of that call track action history for each care gap, a full history of actions taken are visible in care gap details you can set a reminder date to come back to a care gap tip when the reminder date is reached, the member will appear at the top of your table with a red "!" icon once you open up the care gaps under that member, you will see the care gap due highlighted in red you can edit the owner, the priority, and the status of a care gap you can leave notes on your care gap for appropriate tracking and documentation these notes are fully editable until the care gap is completed tip once a care gap is completed, notes left inside are a permanent part of the patient's profile only addendums can be made bulk care gap actions within the table, click on all the care gaps you wish to act on using the check boxes on the left hand side of the table once all care gaps are selected, pick your desired action utilize the bulk select menu to change the owner, priority, and/or status of all the care gaps selected (make sure you hit save after your selections!) bulk faxing and bulk ehr messaging tips when sending messages in bulk to provider, you can select up to 4 taxonomies, in which case the fax/ehr will preference the send in the order of taxonomies selected as an alternative to selecting taxonomies, you can also select to fax/ehr the provider that most recently wrote the prescription once the provider is found, the fax number will default to what is on file from the pharmacy claims, but if that fax number is missing, it will pull a number from the npi registry ehr messages go directly through direct trust tip fax numbers can be updated in each providers unique page if a provider is missing a fax number or you find an updated one, adding it to the providers profile will save it permanently as the fax number to use when sending faxes every fax/ehr message will show up as its own line item in bulk actions what is the best way to manage my care gaps? it is easy to get lost in the sea of care gaps! we recommend using care gaps filters to find exactly which care gaps you want to work on care gap filters filters will pull on a member level! filtering for any of the below will pull up all members for which you have an assigned care gap that matches the filter being applied you will on default see all open care gaps for that member, even if they are assigned to someone else this is intentional as the goal is to give you a holistic view of the member and all open care gaps rule category find all care gaps that were generated from rules in a specific category rule name find all care gaps that were generated from a specific rule status find all care gaps that meet a specific status (you can select more than one) priority find all care gaps that meet a specific priority (you can select more than one) you can also use the search bar and type in the id number of a patient to see only care gaps on that one patient note you must type in the entire patient id for the search to be successful welcome to actions! the actions tab is where you track all the actions taken over time every action taken in onedash will generate individual actions in this table, allowing you to track and review your effort what are care gap actions? care gap actions appear for each patient on which you performed an action (example sending ten faxes at once will show you 10 bulk actions one for each patient you sent a fax on) the care gap actions table allows you to see when the action was made who the action was made on who was contacted which templates were used, if any who made the action what the status is of each action view a copy of the completed action what can i do with care gap actions? the actions table allows you to refresh and update the status of actions being performed you can view a copy of the completed action under the action column faxes and ehr messages will allow you to view a pdf of what was delivered ai virtual agent calls will allow you to download a transcript of the call text messages and tracked calls provide a hover text of what was delivered or what call outcome was tracked fax resend for faxes that failed to send, the resend button will fax a duplicate copy to a provider and phone number of your choosing what is the best way to manage actions? remember! filters pull on a member level! we recommend using the action filters! these filters allow you to find actions that were made using a specific template actions that are in a specific status (you can select more than one) actions completed by a specific user action statuses you can also use the search bar and type in the id number of a patient to see only actions that were made on that one patient note you must type in the entire patient id for the search to be successful your view of care gaps and care gap actions depends on your user role admin can see all user's care gaps and actions clinical expert can only see care gaps and actions for members that have care gaps assigned to you