How to Manage the Patient List Follow
The Patient List page is the central location for managing patients in the Care Team Portal. The Patient List page is the first page that loads when you log in. The Patient List page defaults to showing all patients, but if you want to customize the list, you can use a robust set of filtering and sorting options. Filtering allows you to find the set of patients that need immediate attention faster when you are monitoring a large group. The recommended settings for the Patient List filter are My Patients, Active Status, and Alerts Only. With these filters applied, you can quickly see your active patients that have alerts that need to be addressed. You can also sort the Patient List. Sorting determines the order in which the patients appear in the Patient List. The most common setting for sorting is Alert Priority.
Hover over the screen to display details about each section.
Middle section of the patient header:
- Biometric data from the patient during their most recent pathway completion.
- Weight, blood pressure, oxygen saturation, pulse, blood glucose, temperature, spirometry
- Notifications that the care team has created or notifications generated based on pathways responses.
- An alert for the patient's program (Alert Types). Alerts most commonly appear for overdue pathways.
Notes that the Care Team has added about the patient or their program (also includes patient's assigned population, provider's name and phone number, program status, and start date and the day of their program.
Alerts are generated based on several situations that occur during a patient's participation in the health monitoring program. You can hover over the alert icon to see a description of the alert. Below the alert icon, you will see the number of days that the pathway is overdue. When patients are overdue for completing their pathway for a configurable number of days, they are considered a non-responder and will appear with the list of non-responders when you use the filter.
Following are reasons why alerts are generated:
- Biometric Levels – When a patient enters their biometric data and the level is below or above the thresholds that were set by the care team, then an alert is generated. The thresholds are configured on the Parameters page and are set for either medium or high alert depending on how low or high the reading is. If a patient has a medium alert based on their biometric entry, then the color of the icon on the Patient Header is yellow. If the patient has a high alert based on the biometric entry, then the color of the Patient Header is red.
- Skipping a Biometric Entry – When a patient chooses to skip a biometric entry, an alert is generated that this data was not recorded.
- Overdue Pathways – When a patient does not complete their assigned Pathways, then an overdue alert is generated and appears on the Patient Header. For more information, see Overdue Alerts or Non-Responder Patient Status.
- Password Reset Request – When a patient requests to reset their password from their device, an alert is generated and appears on the Monitoring tab and Patient Header with an exclamation mark icon.
- IVR Welcome Call Attempts – When a patient is called a specified number of times and the attempts to reach them fail, an alert is generated.
- IVR PIN Validation – When a patient uses the incorrect PIN a specified number of times, an alert is generated, so the Care Team member can contact the patient. The default level for this alert is medium (yellow).
- Patient Texts Stop to SMS Messages – When a patient has sent a STOP text message, the next time the system attempts to send the SMS message to the patient, we will receive a notification from the SMS provider. The alert is then generated and appears on the Monitoring page, so you can engage with the patient and determine if they are finished or if they want to re-initialize program. The default level for this alert is medium (yellow).
- In Use Kit Delivered to Logistics – When a kit is received at the Logistics Center and it is still in the status In Use, then an alert is generated. The following message appears for the alert: "The patient no longer has the health kit. It has been received by the Logistics Center."
- General Alert – A Care Team member can create a general alert from the menu on the patient header. For more information, see How to Add a General Alert.
- External Registration – When a patient is already enrolled in the portal and another enrollment is attempted, an alert is generated. The following message appears: "An external registration system tried to create a new enrollment for this patient; however, this patient is currently being monitored."
- Questionable Data – When a date/time stamp associated with biometric data or responses is transmitted and contains a value that is more than one hour in the future, older than two weeks, or includes a date/time prior to enrollment, an alert is generated.
- Program Start Date – When a pathway has a start date that is changed due to the program start date changing, an alert is generated. The following message appears "Pathways for this patient were modified by the system because the program start date was changed. Please review pathway schedules."
The alert icon is by default configured to be a high alert level, so it is red. If your system is set for overdue alerts to be at a medium level, then the alert icon will be yellow. Following are the colors that can appear in the Patient Header based on alerts:
- Red – A high level alert was generated.
- Yellow – A medium level alert was generated.
- Green – All requirements have been satisfied for that day for the patient (green will only appear if configured for your portal).
- Grey – No alerts are currently active.
The date and time that the Pathway was completed. The answers the patient provides to the questions will indicate a baseline and trigger alerts. For more information, see Pathway Alert Icons and Numbers.
The last weight recorded (lbs and kgs) and the baseline weight.
The last blood pressure recorded (mmHg).
The last oxygen saturation percentage recorded (%).
The last pulse recorded (bpm).
The last blood glucose recorded (mg/dL or mmol/L).
The last temperature recorded (F or C).
The last spirometry reading recorded.
Messages indicating the patient is overdue for their pathway (non-responder), needs a password reset, or has another issue.
A Pathway is a survey that the patient answers about their condition. The Pathway icon appears in the patient's header. When you rollover the icon, the date and time of the last completed Pathway appears.
The numbers under the icon indicate the number of pathways completed out of the number expected to be completed for that given day. For example, the first number shows that the patient completed their pathway for today. The second number shows that we only expected them to complete one pathway today. Therefore, if the pathway number was 1 of 2, that indicates that we are still expecting the patient to complete another pathway. If we see 0 of 1 or 0 of 2, then the patient has not completed their pathways for the day.
The color of the numbers will remain until midnight, when it will reset to black.
No survey alerts in the last 24 hours of survey responses OR no Pathway has been completed today.
Green text and icons are a configurable option that will not appear for your portal unless enabled.
If the numbers are green, then your portal has the green configuration enabled AND the patient was reviewed by the Care Team.
If the numbers are yellow, the highest survey alert in the last 24 hours of survey responses was medium and the Care Team member accepted the alerts. The color of the numbers will change back to black the next day.
If the numbers are red, the highest survey alert in the last 24 hours of survey responses was high and the Care Team member accepted the alerts. The color of the numbers will change back to black the next day.