Care coordination

A visit can finish while another care action remains open. A care task records the patient, task, assigned person, due date, completion date and status. The Licensed Clinician can assign follow-up work and see whether it is Open, in progress, Completed, Escalated or Cancelled. A separate care-team assignment records which clinician is assigned to a patient, for what purpose, and across which effective dates. The Clinical Governance Administrator maintains that assignment.

For example, a clinician completes an encounter and assigns a follow-up call due the next day. The task remains attached to the patient and named assignee even after the encounter reaches Completed. If the original person cannot complete it, the team can use Escalated to show that the work needs attention. The coordinator and clinician can review the same open-task list before the next shift begins.

• Follow-up work. Care tasks keep the action, assignee, due date and state on a patient record.
• Access period. Care-team assignments distinguish Active from Ended and carry effective dates and an access purpose.
• People. A person record names the clinician or staff member connected to a user account and active status.

Agree who may create a task, who may change an assignee and what counts as completion. Decide how the team uses Escalated, and how overdue tasks are reviewed. A completed task should have a completion date that matches the actual work. Check that an ended care-team assignment is not treated as current access in the operating procedure. Assign an owner to review dates and access purposes regularly.

The Clinical Governance Administrator manages care-team assignments and people records. Licensed Clinicians manage care tasks; Clinical Coordinators can also manage tasks. An assignment records intended access, so the administrator should review it whenever staffing changes. Check the person named on each task before the pilot team starts its handoff.

Create a patient and an active care-team assignment for the clinician who will follow the case. Record a task with a clear action, assignee and due date. Confirm that the task appears in the open list with the assigned person named. Change its state to in progress, then complete it with a completion date. It should leave the open list while remaining visible in the patient’s history.

Repeat with a task that cannot be finished by the due date. Mark it Escalated and hand it to the appropriate person under the agreed policy. End the earlier care-team assignment on its effective date and verify that the team knows who owns the patient’s continuing work. This test makes the distinction between task ownership and clinical access clear.

• Open care tasks — Active and escalated follow-up by patient, assignee and due date.
• Arrived encounters — Current visits that may lead to continuing care work.

Follow the care handoff and prepare the pilot.