Description: In this guide you will learn how to use the Care Management Module. The DCI Care Management Module is designed to track the Individual Support Plan of a client. Individual Support Plan (ISP) is defined as documentation of the activities, resources, and supports that an individual, Personal Agent or Service Coordinator, and other designated caregivers agree are important to or for achieving and maintaining personal outcomes. The Individual Support Plan is referred to as Plan of Care in DCI and is specific to the individual receiving care. The Plan of Care is where we will track individual goals.

*Please note:  Care Management is an instance level setting and must be enabled by your DCI Project Manager or account representative. If Care Management is enabled for your organization, the Care Management tab will be visible on the main menu in DCI.

Roles Required: Superuser, Supervisor

Permissions Required: Plan of Care Admin, Client Admin

Setting Up Care Management for a Client

Description:  In this topic you will learn how to set up Care Management for a client. Complete the all the steps included in the instructions 2a through 2e.

a. Enable Care Management for a Client

Description:  In this topic you will learn how to enable Care Management on a client profile.

  1. Log in with appropriate profile
  2. Click Home on the main menu
  3. Click Clients on the submenu
  4. Enter Client Name into search filter and click the Search button
  5. Click anywhere on the client’s row in the table to open the Client Details page
  6. Click Actions button
  7. Click Edit Client from the action’s dropdown
  8. Click the Client Information tab on the Edit Client Details page
  9. Click the Yes checkbox next to Enable Care Management at the bottom of the Edit Client Details page
  10. Click Save
  11. Click Yes in the confirmation alert window
  12. Care Management is enabled for the client, now add a Plan of Care for the client

b. Add Plan of Care for a Client

DescriptionIn this topic you will learn how to add a Plan of Care for a Client that has Care Management enabled their profile.

  1. Log in with appropriate profile
  2. Click Care Management from the main menu
  3. Click Plan of Care from the submenu
  4. Enter Client Name into search filter and click the Search button
  5. Click anywhere on the Client’s Plan of Care in the table to open the Plan of Care Details page
  6. Click Actions button
  7. Click Add New Plan of Care from the action’s dropdown
  8. Complete the Add Plan of Care form wizard
    1. Client: Enter the Client’s name, select the client from the list generated
      1. Please note: If the client’s name does not appear in the list generated, Care Management is not enabled on the client profile
    2. Assessment:  Enter the assessment, a summary plan of care, progress and status of goals  
      1. Assessment field is free text, data based or narrative, and can be edited throughout the life of a Plan of Care
    3. Effective Date – Enter the Date the Plan of Care starts
    4. End Date – Enter the Date the Plan of Care ends
    5. Client Cooperation Level -
    6. Status – Select Active or Inactive from the dropdown
  9. Click Save
  10. Click Yes in the confirmation alert window
  11. The Plan of Care is complete, now add Goals to the Plan of Care

c. Add Goals to Plan of Care

Description:  In this topic you will learn how to add Goals to Plan of Care. A Plan of Care must be established for a client to add Goals.

  1. Log in with appropriate profile
  2. Click Care Management from the main menu
  3. Click Plan of Care from the submenu
  4. Enter Client Name into search filter and click the Search button
  5. Click anywhere on the Client’s Plan of Care in the table to open the Plan of Care Details page
  6. Click Actions button
  7. Click Add New Goal from the action’s dropdown
  8. Complete the Add Goal form wizard
    1. Goal Name: Enter a general name for goal
    2. Summary: Enter information specific to the individual and goals
    3. Target Outcome: Represents the target percentage of met outcomes for all completed tasks under this goal
    4. Effective date: Select an Effective date. Goals can start at any date within the plan of care dates and will display for the caregiver if active within the date range
    5. End date: Select an End date. After this date, the caregiver will no longer see the goal
    6. Status: Active or Inactive from the dropdown
  9. Click Save
  10. Click Yes in the confirmation alert window
  11. Repeat steps 6-10 to add additional goals for the client
  12. The Goal(s) is complete, now add Tasks to Goals

d. Add Tasks to Goals

Description:  In this topic you will learn how to add Tasks to Goals. Goals must be established for a client to add Tasks.

  1. Log in with appropriate profile
  2. Click Care Management from the main menu
  3. Click Plan of Care from the submenu
  4. Enter Client Name into search filter and click the Search button
  5. Click anywhere on the Client’s Plan of Care in the table to open the Plan of Care Details page
  6. Select the Goals tab on the Plan of Care details page
    1. The Goal(s) for the client will be listed
    2. Optionally search for a specific goal or scroll down to view all goals for client
  7. Select the Goal to add Tasks to by clicking anywhere in the row, the Goal Details page will open
  8. Click Actions button
  9. Click Add Task from the actions dropdown
  10. Complete the Add New Task form wizard
    1. Complete Task Details tab
      1. Task Name: Tasks are a component of the overall goal
      2. Summary: Enter the actions the caregiver needs to do for the task
      3. Met Condition: Enter the condition(s) acceptable for task to be marked as Met
      4. Not Met Condition: Enter the condition(s) in which the caregiver should mark Not Met
      5. Additional information: Optional text field available to provide additional information to the caregiver about the task
      6. Required: Click Yes or No
        1. If Yes: The task must get resulted before a care note can be published
        2. If No: The task is not required for care note to be published
      7. Target Outcome: The target percentage of met outcomes of completed tasks
      8. Effective date: The date the task starts, can be any date within the goal dates and the task will be visible for the caregiver if active during date range
      9. End date: After this date, the caregiver will no longer see the task
      10. Status: Select Active or Inactive
    2. Click Next
    3. Complete Tracking Option tab
      1. Allow Refusal: Select Yes to allow the caregiver to select that the client refused to participate
        1. If yes is selected, it will count towards the target outcome goal
        2. If no is selected, it does not count towards the target outcome goal
      2. Allow Barrier: Select Yes to allow the caregiver to select barrier as a task outcome
    4. Click Next
    5. Complete Additional Questions tab
      1. Additional Questions are questions the employee will document with their care note and can be either Canned or Custom question types
      2. Question type: Click Canned or Custom
        1. Canned – this question type applies to more than one client. To add canned task questions see the step by step – Create Canned Task Question
          1. Select Question: Click Select Question dropdown and select the Canned
          2. Required: Click Yes or No
          3. Status: Click Active or Inactive
          4. Click Plus (+) icon to add canned question
          5. Repeat as necessary
        2. Custom – this question type is specific to a client and the documented task
          1. Question: Enter Question text
          2. Required: Click Yes or No
          3. Click Next
          4. Answer: Enter answer text and click plus (+) button
            1. Repeat to add additional answer criteria
          5. Click Save to return to Additional Question screen
        3. Repeat either Canned or Custom process to add additional questions
  11. Click Save
  12. Click Yes in the confirmation alert window

e. Link Goals to Funding Account

Description:  In this topic you will learn how to link Goals to a Funding Account.

  1. Log in with appropriate profile
  2. Click Authorization from the main menu
  3. Click Funding Account from the submenu
  4. Enter the search criteria in the filter (i.e., client, cost center) and click the Search button
  5. Click anywhere on the Funding Account in the table to open the Account Details page
  6. Click Actions button
  7. Click Add/Remove Goals from the action’s dropdown
  8. Click on the Goals in the Available Goals the column
    1. Select the right triangle button to add column to the Selected Goals
    2. Select the double right triangle >> button to add all columns to the Selected Goals
    3. Select the left triangle button to remove the column from the Selected Goals
    4. Select the double left triangle << button to remove all columns from the Selected Goals
  9. Click Save
  10. Click Yes in the confirmation alert window

Create Canned Task Question

Description:  In this topic you will learn how to create canned task questions to be available to add to any client’s tasks.

  1. Log in with appropriate profile
  2. Click Settings from the main menu
  3. Click Task Question from the submenu
  4. Click Actions button
  5. Click Add New Task Question from the actions dropdown
  6. Complete the Add New Task Question form wizard
    1. Question: Enter Question text
    2. Status: Select Active or Inactive
    3. Click Next
    4. Answer: Enter the answer and click plus (+) button
    5. Add additional answers to be available for the question.
    6. Click the Save underneath the answers to add more questions to this task (you will be returned to the question screen)
  7. Click the Save
  8. Click Yes in the confirmation alert window
  9. The task question is now available for use when adding tasks to goals in the Add New Task form under the Additional Questions tab, select Canned for the Question Type.

Care Management Overview

Description:  In this topic you will learn about the Care Management Overview page. How to search for and select a client who has a Plan of Care and view their progress towards goals and care notes.

  1. Login with appropriate profile
  2. Click Care Management from the main menu
  3. Click Overview from the submenu
  4. Enter the search criteria in the filter (i.e., client, employee, cost center) and click the Search button
  5. Click anywhere on the Client’s Name to open the Care Management Overview Detail screen
  6. On the Care Management Overview Detail view
    1. View the Trends widget by selecting a tab
      1. Task Outcomes Over Time tab
      2. Task Submissions By Task tab
      3. Use the radio buttons to change the days displayed in the Trends widget
    2. The Plan of Care widget provides Goal details including goal name, number of tasks, Outcome, Target Outcome, Last Tracked, Effective Date, End Date, Status, and Added By
      1. Select the goal by clicking anywhere in the row to open the Goals Details page
    3. Select a tab i.e., Care Notes, Task Results, Notes, Attachments or Events to view. Select an entry in the table to view the details page.

Reports

Description:  In this topic you will learn about care management reports. The Care Management Reports are accessible in the Reports Module.

  1. Sign into your Personal Profile
  2. Click the Reports tab on the main menu
  3. Select the Care Management Reports submenu
  4. The associated reports are listed on the flyout menu
    1. Pending Care Notes Report
    2. Task Result Details Report
    3. Raw Data Dump Report
    4. Client Diagnosis Report
    5. Diagnosis Code Usage Report
  5. Click the Report to run
  6. Enter desired criteria into the filters
  7. Click the Search button
  8. The records will display in the table below the filters
  9. Optionally, click the Download button and select the columns and the format to download the report

For more information on how to download reports, please see the Run Reports resource.

ICD-10 Codes

Description:  In this topic you will learn about ICD-10 codes. With the Care Management Module enabled, you have access to advanced functionality for storing client diagnosis codes, including:

  • A library of all current ICD-10 Codes
  • The ability to add multiple diagnosis codes to a single client profile

Access and search the ICD-10 code library:

  1. Login with appropriate profile
  2. Click Settings from the main menu
  3. Click Diagnosis Codes from the submenu
  4. Use the search functions to see available codes