Care coordination requirements and Integrated Care Management capabilities
Key Takeaway
Integrated Care Management recommends care plan problems, goals, and interventions only when single-select or multi-select assessment responses are mapped to the Problem Goal Intervention (PGI) library and processed by a decision table.
Integrated Care Management is the Agentforce Health feature that care managers use to build enhanced care plans and coordinate care for their patients or members. Care plans are built from patient data instead of a blank page, because the feature connects three things: patient assessments, a reusable library of problems, goals, and interventions, and care gaps found by evaluating clinical measures. Integrated Care Management is built on Omnistudio, which makes it flexible to customize for each organization's requirements. During Discovery, you match a customer's desired outcomes to these capabilities, then gather the functional and technical requirements each one needs.
Care plan parts
An Integrated Care Management care plan is a hierarchy with three parts:
- Problems are conditions or social determinants of health.
- Goals are what the plan aims to achieve.
- Interventions are tasks, grouped into action plans, that work toward a goal, resolve a problem, or act on the care plan.
Key care plan objects each have a narrow job:
- Care Plan Detail is the junction that connects a care plan to the Health Condition (problem) it addresses.
- Goal Assignment Detail connects a goal to its parent problem.
- Care Barrier records a social determinant of health in a care plan.