Care management: Coordinate care plans and care teams

Concisely communicate the right information, at the right time, to the right people, to provide coordinated care to the patient. Easily create, personalize, and enable new care plans for patients, and also manage care team members.

Key capabilities for Care management include:

  • Care team: View and collaborate with care teams to provide the best care for the patient.

  • Care plan: Create and assign care plans and automate adherence to improve care coordination for your patients.

  • Clinical timeline: See a concise, sequential, and interactive view of patient's clinical occurrences.

  • Virtual clinic: Provide your care team members the ability to perform virtual appointments with patients.

To help providers create, personalize, and enable new care plans and manage care team members, the Care management app provides capabilities in three categories:

  • Administration for managing organizational data

  • Care management to support delivering care to patients

  • Clinical Data to manage medical information, such as allergies and medical records

Care management creates a model-driven app within Microsoft Power Platform to provide healthcare-specific capabilities as part of Microsoft Cloud for Healthcare. Learn more about how to deploy and configure Care management.

To access Care management, select Care management from your Microsoft Dynamics 365 home page after deployment.

Administration

Within the Administration category, view high-level analytical dashboards, manage patients or practitioners, and manage medical organization accounts.

Health Analytics

In the Health Analytics area, the Care Coordinator dashboard is a template for viewing care plan specifics, appointments, and a personalized timeline.

Care Coordinator dashboard.

In the Health Analytics area, you can also select the Care Plan Management view.

Care Plan Management view.

People - Patients and Practitioners

In the People area, you can filter your view to see Active Patients or Active Practitioners, among others.

When listing patients, select a patient and select Edit. The Patient form provides basic patient information and links to the patient’s clinical data, the care team, and the healthcare activity timeline. You can customize this form to suit your patient care practices.

From the Patient form, select the Related tab to select a related activity or category to add as a tab on the form.

People form.

Clinical Timeline

Select the Clinical Timeline tab on the patient form to view patient care events. The timeline has two panes:

  • The calendar pane on the left displays events for the selected week.

  • The agenda pane on the right displays either previous events or upcoming events.

Clinical timeline.

Select the filter dropdown list in the calendar pane to filter events on the calendar.

Filtering events in the calendar pane.

To create events directly from the timeline, select New, and then select an option from the dropdown list.

Adding events from the clinical timeline.

After selecting New and an option from the dropdown list, a quick-create form opens in the right pane. Fill in the information for the event, and then select Save & Close.

Creating an appointment from the clinical timeline.

Clicking on a tile in either the calendar view or the agenda view also opens a form where event details can be edited. Update the information for the event, and then select Save & Close.

Editing an appointment from the clinical timeline.

In the agenda pane, you can view either previous events or upcoming events. Note that today's events are shown in Upcoming events, not Previous events.

Show previous or upcoming events.

Care Team

Select the Care Team tab for a view of the medical professionals, family members, and other authorized people involved in the patient’s care, including their names, role on the care team, and the associated care plan and condition. For more information, go to Care Teams.

Care Teams.

Multiple medical identifiers

You can use multiple medical identifiers like medical record number (MRN) and driver's license number:

Multiple medical identifiers subgrid

According to the FHIR standard, patient links "link to another patient resource that concerns the same actual patient." In Microsoft Cloud for Healthcare, a record’s links display in the Linked Records tab on the patient form. A number also displays in the tab header that indicates how many links the record has.

Note

The Linked Records tab doesn't display if a record has no links.

Links can be grouped by the link type or any other column. If the record has any links of type Inactive, See Also, or Refer to, a notification displays: "This patient record has been linked to other existing records. Review the related records in the 'Linked records' tab."

Linked records tab.

Tooltips provide information about the link type.

Link type tooltips.

If the record has any Primary links, a notification is displayed: "This record is inactive. It has been replaced by a primary patient record. Go to the 'Linked records' tab to review the current record."

Note

If the record has any Primary links, or there is another patient with an Inactive link to the record, the record will be deactivated and made read-only.

Inactive record notifications.

Organizations

In the Organizations area, select New to create an account for an organization. Select the arrow to choose the account type. On the Summary tab, enter an account name, and then fill in the information you want for the account. Select Save or Save & Close to save the account.

From the list of views, select the arrow, and then select the type of accounts to view. You can see Active Accounts or All Accounts, among others. Select a listed account and select an action on the command bar. Select Edit to open the account, and then select a tab on the heading bar. You can also select a listed account in the Account Name column to open the account directly.

Locations

In the Locations area, select New to create a new location record for a medical organization. On the General tab, enter a name for the location and fill in the information you want for the location. Select Save or Save & Close to save the location.

From the list of views, select the arrow, and then select the type of locations to view. From the list of location records, select a record and select a command on the command bar. Select Edit to open the location record. From an open location, select the Related tab to select a related activity or category to add as a tab on the form.

Care management

Within the Care management category, create and manage patient care plans, care plan activities, and care plan goals.

Care Plans

Care Plans allow care providers to provide distinct actions that both patients and caregivers can perform in order to proactively help a patient achieve health goals. The care plan tool within Microsoft Cloud for Healthcare provides users with the ability to add care plans, as well as accompanying activities and goals, to a patient's record.

In the Care Plans area, select New to create a care plan. On the Plan details tab, enter a name for the plan and a status, and then fill in the information you want for the care plan. Select Save or Save & Close to save the care plan.

From the list of views, select the arrow, and then select the type of care plans to view. From the list of care plans, select a record and select a command on the command bar. Select Edit to open the care plan.

Care plan.

From within a care plan, you can add activities and the associated goals to the individual care plan. You can also select a care plan template, which allows you to use certain default portions of the care plan and the associated activities and goals.

Care plan goals.

Care Plan Activities

In the Care Plan Activities area, select New to create a care plan activity. On the General tab, enter a name and care plan goal for the care plan activity, and then select a status. Specify a start and end date for the activity, and then select an activity definition type. Fill in the information you want for the care plan activity. Select Save or Save & Close to save the care plan activity.

From the list of views, select the arrow, and then select a view such as Active Care Plan Activities. Select a listed record and select a command on the command bar. Select Edit to open the care plan activity.

Care plan activities.

Care Plan Goals

In the Care Plan Goals area, select New to create a care plan goal. On the General tab and Conflicts Tab, enter the required information for the care plan goal. Select Save or Save & Close to save the care plan goal.

From the list of views, select the arrow, and then select a view such as Active Care Plan Goals. Select a listed record and select a command on the command bar. Select Edit to open the care plan goal.

Care Plan Templates

In the Care Plan Templates area, you can create templates that will streamline the creation of a care plan. To create a new care plan template, select New on the command bar. Enter all necessary information and select Save. You can also add associated Care Plan Goal templates and Care Plan Activity templates in the Goals & Activities tab of a care plan.

Care plan template.

You can also import care plan templates directly into Microsoft Cloud for Healthcare. On the command bar, select Import Templates. This opens a dialog that allows you to import a care plan template.

Import templates.

Import care plan template.

Clinical Data

Within the Clinical Data category, create and manage patient observations, care plan activities, patient procedures, and appointments.

Observations

In the Observations area, select New to create an observation. On the General tab, enter the owner of the observation and fill in the information you want for the observation. Select Save or Save & Close to save the observation.

From the list of views, select the arrow, and then select a view such as Active Observations or Inactive Observations. Select a listed observation and select a command on the command bar. Select Edit to open the observation.

Encounters

In the Encounters area, select New to create an encounter record. On the General tab, enter a name for the new encounter and fill in the information you want for the encounter. Select Save or Save & Close to save the encounter.

From the list of views, select the arrow, and then select a view such as Active Encounters or Inactive Encounters. Select a listed encounter record and select a command on the command bar. Select Edit to open the encounter record.

Encounters.

Procedures

In the Procedures area, select New to create a procedure record. On the General tab, enter a description for the new procedure and fill in the information you want for the procedure. Select Save or Save & Close to save the procedure.

From the list of views, select the arrow, and then select a view such as Active Procedures, Inactive Procedures, or Patient Details Active Procedures. Select a listed procedure record and select a command on the command bar. Select Edit to open the procedure record.

Appointments

From the Appointments area, select New to create an appointment. On the General tab, enter a subject for the appointment and fill in the information you want for the appointment. Select Save or Save & Close to save the appointment.

From the list of views, select the arrow, and then select a view such as My Open Appointments (EMR). Select a Due value to filter the appointments. Select a listed appointment and select a command on the command bar. Select Edit to open the appointment.

Appointments.

Care Teams

To add a new care team for the patient, select Add Care Team from the upper-right corner of the care team pane. Fill in the fields of the Care Team Creation Wizard to add the appropriate care team information and members.

Add care team.

To view and interact with the members of the care team, select the care team. You can view the details of the care team members, communicate with the members, and also view corresponding care plan and medication details.

Care team view.

Virtual Clinic

Virtual Clinic allows users to access scheduled and instant visits that have been created within the Patient access portal or through Patient Scheduling within the Patient service center app. Virtual Clinic is a model-driven app that lets users perform the following actions:

  • View dashboards that provide a list of scheduled and instant virtual visits
  • Join virtual visits directly from within a dashboard
  • Access full appointment details in context of virtual visit
  • Access holistic patient view and embedded care management tools during virtual visit

Virtual Clinic timeline.

Virtual Clinic dashboards

The Virtual Clinic app provides two separate dashboards. These dashboards allow users to directly access scheduled or instant visits. Both dashboards use a custom code component created using the Power Apps component framework that provides a view into the virtual visits. These visits have been scheduled in either Patient access or within the scheduling functionality in Patient service center.

Scheduled Virtual Appointments dashboard

The Scheduled Virtual Appointments dashboard lets users view a list of scheduled visits. The dashboard view shows the start time, patient, practitioner, and appointment status. It offers a virtual appointment button that allows the user to join the visit.

Scheduled Virtual Appointments dashboard.

Within the list, the user can select the Join meeting button to enter the visit.

Important

  • The appointment must be in a status of "Booked" for the user to select it to enter the visit.

  • Your system administrator must have enabled health assistant for it to appear in Virtual Clinic dashboards. For prerequisites, how to enable the feature, and how to set it up, go to Configure health assistant.

Instant Virtual visits dashboard

The Instant Virtual visits dashboard lets users view a refreshed list of patients as they join the queue for a virtual appointment within the Patient access portal. The dashboard view shows the start time, patient, and appointment status. It offers a virtual appointment button that allows the user to join the visit.

Instant Virtual visits dashboard.

Within the list, the user can select the Join meeting button to enter the visit.

Important

  • The appointment must be in a status of "Booked" for the user to select it to enter the visit.

  • Your system administrator must have enabled health assistant for it to appear in Virtual Clinic dashboards. For prerequisites, how to enable the feature, and how to set it up, go to Configure health assistant.

Virtual appointments

Virtual Clinic uses the Appointment(EMR) entity as a baseline for the creation and allocation of appointments to caregivers. The appointments tab allows users to view a listing of "My Appointments", "Instant Virtual Appointments", and "Scheduled Virtual Appointments". Selecting an appointment will take you to the full appointment view.

Virtual appointment view.

Note

Users can also access virtual appointments by selecting the appointment from within the Instant Virtual visits dashboard or Scheduled Virtual Appointments dashboard.

From within an appointment record, the user can view comprehensive information regarding the appointment and associated patient. The following sections explain each part of the appointment form.

General tab

The General tab outlines information specific to the appointment. The information includes the anticipated start and end times for the appointment, the participant type, and a timeline section for creating notes during a visit. While in the appointment record itself, a user can select Join meeting on the command bar to join the appointment.

General tab join meeting.

Patient Information tab

The Patient Information tab provides a full view of a patient's clinical data. This tab includes a view into a patient's previous and upcoming appointments, allergies, conditions, medications, and procedures. If the user has sufficient rights, the user can add data directly to these sections as needed.

Patient's clinical data.

Virtual Appointment join experience

In Virtual Clinic, there are multiple ways to join a visit based on the preference of the caregiver. The dashboard and appointment records provide buttons that allow for the caregiver to join the appointment; however, the mode in which Microsoft Teams reacts varies based on the type of Teams client that the caregiver is using.

Join on Microsoft Teams desktop client

When joining from the Microsoft Teams desktop client, the Join meeting button will launch a full-sized Teams window. In order to contextually view the patient record while conversing with the patient, just slide the newly launched window to the side of the screen.

Note

For the best experience, use two monitors.

Join Microsoft Teams meeting within browser

Upon selecting the Join meeting button when using Microsoft Teams in a browser, the user might be prompted to select the method by which the user would like to join the meeting experience.

Teams join method.

For the best experience, simply continue using the browser. This will open a window directly within the browser. Upon selecting this option, Microsoft Teams will prompt the user to join the meeting.

Join meeting in browser.

After joining the meeting, select Teams in the left pane.

Use Teams in meeting.

This approach allows the user to directly converse with the patient while also being within the dashboard or the appointment or patient record.

Viewing patient appointment and care plan while in virtual meeting.

See also

Basic navigation in a model-driven app
Deploy healthcare solutions
Configure healthcare solutions
Configure Virtual Clinic