CCCM Q&A Doc

CCCM – General Practice Q&A 1. Q – Can I see an overview of all patients assigned to my practice in CCCM?

A – PMS access is patient-by-patient only. You can see an overview list via the CCCM URL access only. If you do not yet have this access, contact your Practice Liaison. For instructions on how to filter this regional list to show only your practice patients, click here.

2. Q – When a patient reports a positive RAT result does this pull through to CCCM?

A – Yes. When a RAT is reported this now automatically creates a Border Health Record for this patient, which creates a record in CCCM - your practice will receive an inbox notification for this in your PMS.

3. Q – Can I create a new record in CCCM for a patient who has had a positive RAT result but doesn’t have MyCovidRecord?

A - GPs can report a RAT result in their PMS, by clicking HealthLink, then selecting 'Supervised Rapid Antigen Test Report' under Referred Services. The report will take approximately 30 minutes to appear in ESR éclair and will trigger the case event in NCTS from there if positive, which feeds through to CCCM.

4. Q – Can I see information that a patient has completed via the Self-Assessment form?

A – No, currently this does not feed through to CCCM, other than ‘Underlying Conditions’ which can be viewed from the “Initial Assessment” page:

5. Q – How can I use CCCM to support management of Higher-Risk patients?

A – It is advised to change the “Care Plan” in CCCM for all High-Risk patients so these can be identified easily via overview lists.

This can be done by changing them from “Self-Management” S to “Active Management” A To do this go to Page 5 of “Reg. Health Check” and select “Active Management” here:

You can then filter your overview list to show only patients under “Active Management” if required.

It is recommended to ensure this is marked for all High Risk patients, as well as adding an Acuity Score.

6. Q – What do the letters and numbers in shapes mean in CCCM?

A – There should be 4 shapes showing in CCCM for new referrals, these represent: 1.

2.

3.

4.

Risk Score Acuity Rating Vaccination Status Care Plan

(automatically added by system – will be circle if blank, rectangle if populated) (added by clinician) (N = Nil, P = Partial, F = Full) (S = Self-Management, A = Active Management)

If any circles (other than Acuity) are showing as blank then this information is not available within NCTS. If referrals are historic, they may only have 1-2 circles showing.

Please note this is a constantly updating space – this information is accurate as of 08/03/2022

CCCM – General Practice Q&A 7. Q - What is the Acuity Rating?

A – This is a score between 1 – 6 to identify clinical needs of higher risk patients. It will show in CCCM within the 2nd grey circle next to the patient information:

This score is added to CCCM by clinicians when establishing a care plan with the patient. You can enter this into the acuity rating on CCCM (in “Regular Health Check” section, p.2). To determine Acuity Score, use clinical judgement and follow the relevant acuity score flow charts (linked below).

Acuity Score Flowcharts can be found on Midland Community Health Pathways Username: midlanduser Password: midlandpassword • • •

Acuity Flowchart - Maori Acuity Flowchart - Pacific Acuity Flowchart - Other Ethnicity

8. Q - What is the Risk Score?

A – This score may not yet be showing in CCCM but should be live from 10th March update. The Risk Score when blank will show as the first grey circle within CCCM:

Once populated with a number, it will show in a rectangle: It will pull through automatically from information stored within NCTS and is based on the following patient information: • Age • Ethnicity • Vaccination Status This should support practices to identify which patients to reach out to. It is advised that for any High-Risk patients, the Acuity Score is used instead of Risk Score as this is based on clinical information.

9. Q – What is the “Whiteboard” used for in CCCM?

A – This is used to add notes to the patient, this can be whatever notes are useful for your management of the patient. They will appear next to the patient name. Examples are shown below:

You can click on notes to view in full e.g. for 2nd line above, click Whiteboard Note to read full details:

Please note this is a constantly updating space – this information is accurate as of 08/03/2022

CCCM – General Practice Q&A 10. Q – How are patients allocated to practice via CCCM?

A – Allocation of enrolled patients is done automatically via NCTS, using patient enrolment information stored in NES. Only unenrolled patients require manual allocation by CPRT to Tunstall.

11. Q – Can the Day 0 showing in CCCM be changed?

A – A recent update should mean Day 0 dates are now showing more accurately than previously – alongside the additional information of “earliest release date” now being auto-populated against patient information:

If Day 0 is still showing incorrectly for a patient, email cprt@healthbop.org.nz to request Day 0 change via NCTS.

12. Q – Do I have to check in on every patient for a health check?

A – With most cases having only mild to moderate illness, most people can self-manage, and no active contact is expected.

Practices are not expected to make contact will all positive cases.

13. Q – How can I report an Isolation Compliance issue? (e.g., patient breaking isolation)

A – Use Page 2 of “Reg. Health Check” in CCCM to report compliance issues by ticking “Yes” to the following question and providing further details via the free text field. Anything marked here is automatically pushed through to NCTS to a Compliance Team, who will follow up as needed.

14. Q - Why do some symptoms in the Initial/Reg. Health Check show in red?

A – This is just to highlight key symptoms – when going through an initial or regular health check with patients, try to mark an answer for these where you can. Certain symptoms (e.g. shortness of breath) will prompt further pop-up questions.

15. Q - The form is very long. Is all the information mandatory to complete?

A - No, you can choose to fill out as much of the form as you deem necessary. There are no mandatory fields.

Please note – “Vaccination Dates” were previously mandatory, but an update has removed this as a mandatory field. You can still add these details if you wish.

16. Q - Why are there 2 Welfare Sections? (Page 2 and page 4 on Reg. Health Check)

A - Page 4 is the important one – this is used to request Welfare/Manaaki support directly from MSD. Pg. 2 is for flagging welfare information for practice internal use only.

For local support needs (e.g. Pulse Oximeter requests, accommodation or complex needs), please continue to contact the Community Co-ordination Hubs directly: WBOP EMAIL: WBOP PHONE:

Welfare.Referral@bopdhb.govt.nz 0800 798 729

EBOP EMAIL: EBOP PHONE:

EBOPCovid@bopdhb.govt.nz

0800 633 277

Please note this is a constantly updating space – this information is accurate as of 08/03/2022

CCCM – General Practice Q&A 17. Q – Why are patients showing on my list long past Day 10? How do I release patient once isolation completed?

A - There is currently a manual process for the case to be “closed” which takes them off CCCM – this process is managed by public health. The software update coming 10th March promises to automatically remove all patients under “Self-Management” from CCCM on Day 11.

For any patients under “Active Management” practices will need to “close” the case on CCCM using the “Reg. Health Check”.

To do this:     

On page 5 of “Reg Health Check” select “Yes” for “Is this person eligible for clinical release from isolation?”

Then click “Complete” Select “Yes” to “Is this the Final Health Check”?

You will see a “Final Health Check” pop-up This will give you the option to release the patient to Public Health. You must select: “Yes - send to Public Health for Release”

For Screenshots of this release process click here.

18. Q - How do we use flags (yellow, blue) & Tasks within CCCM?

A - Regionally we are not using Tasks or Flags within the Covid Hub. Your practice can choose to use these as internal reminders if you choose (e.g. yellow = call daily, blue = prescriptions reviews). Tasks can be used internally in a similar way (e.g. Task set as reminder to request Pulse Ox via email to DHB for certain patients) but these do not go directly to other teams.

If flags are added for practice use, you can choose to filter your CCCM list to show these patients first in your list.

19. Q – Who carries out Initial Assessments?

A – Initial clinical assessment can be undertaken by any member of the general practice team (GP, Nurse, Nurse Practitioner) but please note – only 1 claim can be made per day, so if initial assessment is started but requires GP support, this will still all be only 1 initial assessment for the day.

20. Q – Who carries out Regular Reviews/Health Checks?

A - Regular review can be carried out by any clinical member of the practice team. The frequency of regular reviews for those people under active management can be determined clinically. Guidance is available on Health Pathways. Regular review can be carried out by any clinical member of the practice team

21. Q - When will vaccination information pull through automatically to CCCM?

A – Since this information is held within CIR, not NCTS, this is difficult to integrate. MOH are working on a fix for this, but there is no current ETA. We will update you once we hear more.

22. Q – CCCM is not writing back to Profile PMS correctly.

A - There have been updates which should have resolved this issue. Those of Profile should now be able to use CCCM and accurately write-back using the PDF write-back function.

23. Q – Why can I see non-positive cases in my CCCM list?

A - Disease Contacts (not Positive Cases) are currently showing in CCCM lists. The update due 10th March includes a fix to remove all Disease Contacts (DC) from CCCM lists. This should improve the usability of the CCCM practice overview lists.

Please note this is a constantly updating space – this information is accurate as of 08/03/2022

CCCM – General Practice Q&A Payments for Covid Care in the Community Reminder that all payments for Covid Care in the Community are done via Halcyon.

A summary of the claiming options can be seen here.

1. Q – What are the MOH Conditions of Claiming for Covid Care in the Community?

A-

• • • •

No fee to patient and no claim for claw back.

Limited to one type of claim per day per person, per practice.

Regular reviews that identify a clinical need for additional GP or Nurse Practitioner input are eligible for an additional ‘clinical escalation’ claim per day.

No simultaneous claiming against any other funding stream.

Read MOH Guidelines here.

2. Q – I received an inbox notification saying Initial Assessment complete, but I need to make a Care Plan with this

patient. Should I claim for Initial Assessment or Regular Review rate?

A – If you have not yet made any claim for this patient, and the patient is on Active Management, your first claim should be an Initial Assessment.

A care plan is agreed based on the patient’s clinical condition and risk factors. People may be placed on either an active clinical management or a self-management pathway, and a clinical decision as to frequency of when to carry out Regular Reviews will follow.

3. Q – I claimed a Review and ticked High Needs box but was only paid Standard Rate?

A – Please note – clinicians must ensure they have selected the correct “Assessment Type” for High Needs patients.

If you select “Regular Review - Standard” and tick the box for High Needs within that, that will still go through at Standard rate.

You must select “Regular Review – High Needs” for all High Needs claims.

Please note this is a constantly updating space – this information is accurate as of 08/03/2022