Open Forum

Good morning! I am a RN in a primary care office which is part of a larger organization. I'm new-ish to the ambulatory world and come from an inpatient setting as well as a quality and patient safety background. We have a few patients that are complex care patients who frequently visit the ED. On the inpatient side, these patients have a complex care plan. I'm reaching out to determine what complex care plans look like in the primary setting in your organizations and the process you have in place to coordinate this. I appreciate the information!

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Stephanie McDowell BSN RN
Yuma AZ
9283366545
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Hi,

I've been trying to sort this as well. The ones I have access to in OCHIN Epic (we are just starting Compass Rose) are not helpful.

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Rebekah Sherman
La Clinica de Valle
Medford OR
(541) 221-3040
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In my setting we don't use Care Plans, but we have PCMH through NCQA and TJC, and use motivational interviewing to have patients define their own health goals.  We then help patients move toward achieving their goals.

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Lisa Duncan, DNP, MBA, RN, AMB-BC, CIC, NEA-BC
VP, Regulatory and Compliance
Family Health Centers of San Diego
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Hi - 

We have a similar process of complex care plans in the hospital setting and account for that in the outpatient setting with a similar plan of care supported by centralized care management which is where I work. We are transitioning to Epic in a few weeks health planet and compass rose and have built these templates into our Epic. I would be happy to connect with anyone who would like more detail 

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Hallie Bleau MBA ACNP-BC
Vice President – Care Management
Northwell Health
Lynbrook NY
917-543-4706
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