6.  Electronic Record/Single Plan of Care Software

 

             i.     Electronic Information System A Tool to Support Integration

 

A common electronic client record used by all partners across the Network is an essential tool to support the development and delivery of an integrated, single plan of care for each child and family. 

 

Goldcare, a product of Campana Systems Inc., was chosen by the Children’s Treatment Network after a lengthy and thorough process, as the software application of choice.  Campana Systems Inc. has been working together with Children’s Treatment Network to ensure that the software application will meet the needs of our multi-agency Network for collecting, storing and sharing client information.  
 
Once totally implemented, multi-disciplinary teams from partner organizations will be able to

·      record information from a team assessment,

·      develop an integrated single plan of care,

·      share confidential information and clinical notes across multiple organizations securely,

·      prioritize efforts,

·      monitor progress and

·      communicate scheduling information easily   

 

Shared use of this electronic record will also help eliminate duplication of services and allow Network partners to maximize resources to help meet the needs and goals of children and families.

 

The software development and implementation will occur in three phases. 

Phase I Pilot Program  (late November to end of 2006)  -

Service navigators, service coordinators, therapists and clinicians from over 20 Network Partners will pilot the software application.  During this first phase, Network Partners will identify, assess and develop integrated care plans for 30-50 high needs children and their families. Training for the pilot group will begin in mid-November and will focus on processes for developing a single plan of care as well as use of the software application.

Phase II  (January to May 2007) –

Input from the Phase I pilot will be used to refine and streamline the software for rollout to more Network Partners. During Phase II, the software will be fine-tuned in order to increase functionality, streamline connectivity, and begin to build some critical interfaces with network partner systems.  Training will be expanded to include more Network Partner staff.

 

Phase III  (June to end of 2007) –

The balance of 2007 will focus on continued expansion of clinical tools and operational features of the Electronic Client Record system. We will also continue to implement the application with more Network Partners and expand staff training. Throughout the process, we will continue to work with all Partners to identify and transition all children requiring integrated Network services onto the Electronic Client Record system.

 

Elements of the Software

 

Workspace

The Workspace is a unique feature to the software.  The workspace is individualized to each service coordinator and service provider.  The workspace lists client names specific to the clinician and helps in the identification of work elements.  It provides information such as name, local team, phone number and contact names to assist with scheduling and work load management.  The Workspace also has links to reference material such as the CTN website and local team information.  

Four work spaces will be available:

• Service Navigation-- provides a list of all new client referred to CTN, sorts them by service navigator and details what elements of work have been completed
• Service Coordination--provides the Service Coordinator with a list of all clients on his/her caseload, the phase of care the client is in, contact information and details related to the client’s progress
• Service Provider--provides the service provider with a list of all clients on his/her caseload, contact information and details related to the client’s progress.
• Management—this workspace is designed to provide managers of specific organizations and agencies with system wide information as well as general caseload information related to the clients assigned to their agency personnel.

 

Demographics

The demographics section of the electronic client record records information specific to the client and relevant to network partner agencies.  Information captured in the demographic fields is able to auto-populate other sections of Goldcare minimizing duplication of data entry.  Although some fields will be locked once information is entered and saved, changes to most fields can be made easily by all members of the child and family team as families move, schools change and contacts increase.  

 

Child and Family Interview (CFI)

 

The Child and Family Interview (CFI) is a data entry tool used to capture the information the service navigator (SN) collects from the family at the time of Intake.  It is comprehensive and reviews information from the perspective of what issues or concerns can the entire children’s service system address, rather than from the perspective of a single agency.   It is intended to be directed by the family and the questions asked are based on the concerns raised by the family. The software allows for many free text entries in order to capture the family’s story.  Where possible and practical drop down menus have been added to facilitate data entry.    

 

Through the process of conducting the Child and Family Interview the Service Navigator determines together with the family the priority of needs and decides whether service coordination is required or whether the child requires a single service.  Once identified the service navigator contacts the appropriate agency or organization and forwards the demographic and CFI to the agency.  In the initial phases of the software implementation this may involve printing off the electronic client record and faxing it to the agency.  As more agencies are integrated with the system, an email message will trigger the agency to review the client’s file.  Once completed the Child and Family Interview can be reviewed by all team members and can be printed off for the family or for team members who do not yet have access to the electronic client system.  

 

Initial Plan of Assessments and Services (IPAS)

The Initial Plan of Assessments and Services is completed by the service coordinator (SC) and records the initial visions of the family. Completing the IPAS is one of the steps in the development of the Single Plan of Care.   The IPAS builds on the information gathered through the Child and Family Interview and includes additional information gathered by the service coordinator.  The service coordinator uses the tool to document the child and family’s visions and to summarize critical information for the child and family team.  In order to develop the single plan of care and assist the child and family to meet their visions, the service coordinator summarizes the initial plan for the child and family by entering his/her initial concerns, the immediate service needs and the specific clinical assessments required.  As service providers become involved with the child, viewing the IPAS will facilitate the scheduling of joint or transdisciplinary assessments and inform the team as to the range of services and supports the child and family will be accessing.

 

The Team Assessment Summary (TAS)

The Team Assessment Summary re-states the child and family’s visions (auto-populated from the IPAS) and provides free text space for each discipline to record their assessment summaries.

As all assessment summaries are entered and stored within the same section, the TAS facilitates easy review of the summaries of the other disciplines, by every team member.  Full assessment reports can either be entered directly into Goldcare notes or saved as a report in the discipline specific Document Manager folder (see below).  As the software becomes available to increasing numbers of  Network partners the need for printing and faxing reports will be eliminated.  Child and family team members will have easy access to assessment information. 

 

The Single Plan of Care (SPOC)

The Single Plan of Care module within GoldCare provides a framework to record the visions, goals and activities agreed upon by the team members at the Child and Family Team meeting.  The Single Plan of Care module provides a mix of drop downs and free text fields for entry by the Service Coordinator and/or members of the Child and family Team.   Goals and activities listed within the Single Plan of Care can be modified by any one of the team members.  The date for the next meeting to review the Single Plan of Care is entered and appears on the workspace of the service coordinator to assist in with scheduling and work load management.  The Single Plan of Care can be printed for family and team members not linked to GoldCare.  When a new Single Plan of Care is required, the former can be closed and saved.

 

Document Manager

Document Manager is a filing system for discipline specific reports, summaries, and clinical notes.  Because not everyone will be able to enter directly into the electronic record immediately, Document Manager allows for printed and hand written materials to be scanned and filed. In addition to folders that are viewable by the whole team, Document Manager also provides some disciplines with the option of filing items  in a locked folder that is password protected.  Locking should only occur if the family has explicitly placed restrictions on who can view the information. 

 

Clinical Notes

The software facilitates the sharing of information by having most team members document in the same place, providing a chronological listing of the latest notes entered by date and by whom.  Some disciplines have a separate clinical notes section to facilitate securing sensitive information that families may not want shared with the entire team, for example, children’s mental health and child protection services.  A special function within the software allows Clinical Notes to be sorted by discipline should a clinician need a record of all his/her entries. 

 

 

 

 

 

 

 

 

 

Templates for The Initial Plan of Assessments and Services, The Team Assessment Summaries and The Single Plan of Care

 

The following templates show the data fields that make up the 3 key modules that support the development and implementation of the Single Plan of Care.  The templates provide the reader with a view to what information is being collected.  The view will be different from that which appears in the software. 

 

The Initial Plan of Assessments and Services (IPAS)

The Service Coordinator will complete the Initial Plan of Assessments and Services (IPAS) entering a brief summary of information gathered from the Child and Family Interview and from any additional information obtained from contact with the family or the review of reports.  The Service Coordinator will outline concerns and/or needs and what initial actions are required.  The Service Coordinator will contact the appropriate agency/agencies.  The agency will assign a service provider who will enter their name into the IPAS. Once complete, the module will be closed and information from the IPAS such as the Child and Family’s vision(s) will auto-populate to the Team Assessment Summary (TAS) thus reducing the amount of keying. 

 

The Team Assessment Summaries (TAS)

Once all team members have completed their assessments, information is entered into the TAS.  Team members enter the concerns identified through the assessment process, the domain impacted by the concern, their recommendations related to that concern and the optimum timeline for that concern to be addressed (priority).  Once all service providers have entered their summaries the TAS is closed and the Single Plan of Care module can be opened.

 

The Single Plan of Care (SPOC)

The Single Plan of Care module encourages the child and family to confirm the original vision statements and provides a framework for team agreed upon goals and activities.  Goals are meant to be stated in a “SMART” (specific, measurable, achievable, realistic and time limited) while team activities should be meaningful and whenever possible integrated across disciplines, intervention programs, and environments in order to maximize practice and progress.  The Single Plan of Care can be modified by individual team members as progress is made and new activities are implemented.  Single Plan of Care modules can be saved in order to provide the team with a history of the child and family’s progress.