Example User Views
Please review these slides to answer the questions provided in the Requirements Gathering Survey. The survey includes 5 sections. The following slides will be necessary to answer the questions in sections 2-5 of the survey.
2: The Worklist
Client Name Address City Zip code Goal Status Risk of Hospitalization Score Number of Avoidable Hospitalizations in last 12 months Last Discharge from Hospital with Support Hospitalization with support to institution ratio Duration of last SNF stay John Smith 111 E Main St Harford 06101 Improving 2 0 6/22/2019 0-0 36 Maria Garcia 253 S Broadway St Harford 06101 Stable 6 4 1/3/2022 4-2 97 Connie Carol 323 N Cook Ct Harford 06138 Stable 5 0 4/30/2021 0-0 112 Carl Connie 744 W Ash Ave Harford 06153 Declining 3 2 6/3/2022 2-1 189 Jesus Reyes 1555 E Hills St Harford 06115 Declining 9 2 4/16/2022 2-2 245 Sara John 636 W 35th Ave Harford 06138 Improving 3 0 8/12/2021 0-0 89 Charisse Smith 1234 Tupelo Ct Harford 06199 Stable 2 0 4/1/2022 0-0 35 Jose Rodriguez 345 Maple St Harford 06161 Stable 4 1 5/21/2022 1-0 67 Slide
worsening from previous time period improving from previous time period Functionality: Sort by any column in the table, filter by key word (i.e. client name)
Goals,
Demographics,
Team
Slide 3: Client Snapshot: Member
Patient
Care
Goal Risk ScoreCare Team Care Team Name Provider Type Phone Dr. Gupta PCP (860) 555-3456 Dr. Smith Specialist (860) 555-1992 Betty Lunch Nutrition (HCBS Provider) (860) 555-1674 Mary Lou Conservator/Legal Rep (860) 555-8276 David Cadence Next of Kin (860) 555-1552 Patient Demographics Primary Language Interpreter Martial status Living arrangement Legal guardian Spanish n/a widowed alone yes Patient Demographics Assessment Summary Hospitalizations Resources Would it be helpful to have member contact info here too? Are there other patient identifiers that would be help beyond their name (DOB, Medicaid ID)? Member Goals Goal Starting State (0) Score Today Date Score Updated Take my dog for a walk around the block Able to walk for 5 minutes before requiring a break -1 3/1/2022
for
Slide 4: Client Snapshot: Universal Assessment
Goal Risk ScoreCare Team Patient Demographics Assessment Summary Hospitalizations Resources
(4) Significant change in status assessment
Services provided #
Housekeeping, meal delivery
3
Visualization of the client’s current status.
Visualization of the client’s current status.
Bathing, ! Dressing, ! Using Toilet
Managing medications,
Making meals,
Moving around indoors
Weight loss
Making themselves understood ! Thinking ability
Moving around in the community
Lack access to nutritional foods
List of areas of concern that created the status
List of areas of concern that created the status
Doing housework, Managing money, Climbing stairs, Shopping, ! Getting around.
Memory
Trend since last (assessment date, 6 months, 12 months?)
Trend since last (assessment date, 6 months, 12 months?)
Universal Assessment Summary Date of last update: 12/1/2021 Reasons
assessment
of meds Basic Daily Activities Complex Daily Activities
Moving Around
Nutrition
and
Weight Communication,
Hearing, Vision Memory Thinking
!
!
!
!
!
!
!
!
!
!
Improving Declining Static
Improving Static Static
Slide 5: Client Snapshot: Risk of Hospitalization Score Variables
Goal Risk ScoreCare Team Patient Demographics Assessment Summary
Hospitalizations Resources
Risk of Hospitalization Score =
Risk Variable
self-reported health
Urinary tract infection in last 30 days
Renal failure
One or more falls in last 90 days
Hip fracture during last 30 days
Other (not hip) fracture over 30 days
Irregularly irregular pulse
Congestive heart failure
Description of the InterRAI algorithm that makes up the risk score, clarifying that the variables below reflect those variables and data from the Universal Assessment
Description of the InterRAI algorithm that makes up the risk score, clarifying that the variables below reflect those variables and data from the Universal Assessment
Last Updated:
Results
Instability of Conditions, Experiencing an acute episode or a flare-up of a recurrent or chronic problem
"Yes"
"Poor"
Functionality: only variables that are relevant for the client will be listed. These represent all possible variable relevant to the risk score.
Functionality: only variables that are relevant for the client will be listed. These represent all possible variable relevant to the risk score.
"One fall"
= Diagnosis present, monitored but no active treatment
Chronic obstructive pulmonary disease (COPD) emphysema
Cancer
Primary diagnosis or diagnoses for current stay
"yes" Loss of appetite In at least of 2 of last 3 days, ate one or fewer meals a day
Weight loss – 5+% 30 days or 10+% 180 days
Vomiting
= Present but not exhibited in last 3 days Pressure Ulcer
Major Skin Problem (includes lesions, second or third degree burns and healing surgical wounds)
Change in ADL status as compared to 90 days ago, or since last assessment if less than 90 days ago:
Indwelling catheter
Treatments: IV medication
Treatments: Oxygen
Treatment: Dialysis
= Any area of persistent skin redness
"Yes"
= 1-2 of last 3 days
6
2/14/22
Patient
1
3
0
1
3
0
0
1 =
0
1
1
1
1
n/a
n/a
n/a
2
n/a
6:
Snapshot: Hospitalization
Goal Risk ScoreCare Team Patient Demographics Assessment Summary
Hospital ED Risk Scale II Variable Description
Hospitalizations Resources
Inpatient acute hospital with overnight stay (last 90 days) - Count 1
Hospital ED Risk Scale II is a list of additional variables that create the Risk of Hospitalization score.
Hospital ED Risk Scale II is a list of additional variables that create the Risk of Hospitalization score.
Emergency room visit (not counting overnight stay) (last 90 days) - Count 1
Hospitalizations
Date ICD-10 Description
to Community
Hospitalizations list of all hospitalizations for the client over a given time, specifying which hospitalizations are considered avoidable
Hospitalizations list of all hospitalizations for the client over a given time, specifying which hospitalizations are considered avoidable
1/3/2022 Pressure ulcer of unspecified hip, unstageable
11/14/2021 Hip fracture due to fall
10/30/2021 Unilateral pulmonary emphysema [MacLeod's syndrome]
9/16/2021 Viral pneumonia, unspecified
support
VNA Hartford
VNA Hartford
N/A
N/A
Slide
Client
Potentially Avoidable Discharge
w/
Yes
Yes
Yes
Yes
Count