Family First Health Patient Retention Flow-Chart – Referral & Case Management

1. Family First Health Patient Retention Flow-Chart – Referral & Case Management Key: FFH = Family First Health NCM = Nurse Care Manager CM = Case Manager CSS = Clinical Support Staff Work-in = An appointment that is scheduled the same day CM coaches client on bringing in docs. Problem: if the client does not bring in documentation they can no longer utilize CM services A new client is referred to Caring Together Appointment is made for the client to see an NCM for intake CM follows up with client as dictated in the plan Problem: client unresponsive, phone number/addresses frequently change CM completes intake paperwork, certification, acuity, and develops a plan Yes No The kept appt. The client has cert. docs CM attempts to reschedule the intake No Yes A doctors appointment is made for a client, new to FFH or already established (see page 2) Yes No No Problem: the client cannot be seen by a CM until documents are received NCM attempts to reschedule The kept appt. No NCM performs a medical intake, gathers certification documents, and assigns CM The Client wants CM services Client brings certification documents Yes Yes Intake scheduled with CM

2. Family First Health Patient Retention Flow-Chart – Appointment Scheduling & Follow-Through Data Specialist prints client encounter form and gives to the CSS the week prior to next appt. An appointment is made for a client, new to FFH or already established NCM attempts to reschedule The kept appt. No Results sent automatically to electronic health records for encounter form Yes Yes No appointment rescheduled Check in at front desk client makes appt. for blood work Problem: lack of client follow-through, reminder calls do not always happen The kept appt. The cancel or no-show Triaged by CSS CSS completes items on the form as needed The encounter form present Check out desk schedules next appt. NCM processes blood work Provider sees the patient and completes encounter form as needed Problem: encounter form not always completed Yes Encounter form not present Problem: the patient is a work-in, CSS may not know what client needs done CSS uses a blank form and notes what has been done Provider advises follow-up timeline Problem: Some providers are requesting 6 month visits No