Core concepts

Questionnaires, Surveys, and Submissions

You can use Questionnaires to gather information about anonymous or registered users via questions that have either free text or formatted answer options.

You may surface public Surveys designed using Questionnaires on marketing websites or link to them via email. Submissions to anonymous Surveys are comprised of responses to questions in a Questionnaire and can be linked to Patients once these users are authenticated in the Capable Health system.

You can also employ private Surveys at any point during the customer journey after registration. For example, users may take such Surveys during intake, onboarding, or when checking in during care.

These anonymous or linked Submissions can also be exported or analyzed via downstream analytics tools.

Care plans

A Care Plan is the container for all of a Patient's Goals and Tasks. Patients may have multiple Care Plans.

A Care Plan's status represents the status of a patient's Care Plan. You can determine logic for how to code Care Plan status. Possible statuses compatible with the FHIR framework are listed below.

  • Active - The request is in force and ready to be acted upon. For example, the Care Plan is active when a patient is undergoing treatment that is defined by it.
  • Completed - The activity described by the request has been fully performed. No further activity will occur. For example, the Care Plan is completed when all the tasks and goals have an achievement status of completed.
  • Revoked - The request (and any implicit authorization to act) has been terminated before the known full completion of the intended actions. No further activity should occur. For example, the Care Plan is revoked when its validity or operation is ended before completion.

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Statuses currently have no effect on business logic on the Capable Health side. They are there to help with implementation and business logic on the client-side.

Goals

When you think about a Patient and their Care Plan, it’s likely they have a key complaint – a specific condition that is being addressed. In order to address that condition, their care team will set them certain Goals.

Goals have a few features:

  • There is some sort of achievement status: in-progress, achieved, improving, worsening, or abandoned.
  • Goals can be time bounded either through a due date or recurrence every day/week/month.
  • Achievement status represents the status of a Patient's Goal. You can determine logic for how to code achievement status. Possible statuses and corresponding FHIR definitions are listed below.
    • Achieved: The Goal has been met
    • Improving: The Goal is being sought, and is progressing
    • In Progress: The Goal is being sought but has not yet been reached
    • No Change: The Goal is being sought, but the trend is flat
    • No Progress: The Goal has not been met and little to no progress towards the target
    • Not Achieved: The Goal has not been met and there might or might not have been progressing towards the target
    • Not Attainable: The Goal is not possible to be met
    • Sustaining: The Goal has been met, but ongoing activity is needed to sustain the goal objective
    • Worsening: The Goal is being sought, but is regressing

With these things in mind we have created a way to manage all Goals your application might need with Goal Templates. These templates can then be contextualized through assignment to individual Patients and Care Plans.

Goals must be associated with Goal Templates when being created.

Targets

Targets are measures specific to a Patient. They are automatically created when a Goal is created from a Goal Template, inheriting any values from the Target Templates associated with the given Goal Template. Targets are used to assess whether a specific Goal is reached.

Tasks

Tasks are the things we do to help us achieve our goals. They are consumable and actionable items Patients can take to work towards a Goal. Often they are educational.

Just like Goals have Goal Templates, Tasks do, too. Task Templates are standardized Tasks that we can associate with a Patients's Care Plan at any time. Tasks must be associated with a Task Template when being created.

Products

Products are a resource that can be recommended and assigned to a patient. Products may be prescriptions, over the counter medications, or physical goods.

Observations

Observations are the data that can be used to assess progress towards a specific patient's Goal Targets and ultimately is the data to determine if all Targets were met and the goal was successfully completed.

Templates

For each of Care Plans, Goals, and Tasks, you may create templates. These templates serve as generic versions of the aforementioned items to allow for easier management and organization. Any time a Care Plan, Goal, or Task is created, you may specify a Care Plan Template, Goal Template, or Task Template from which it will pull its initial settings.

Tagging

Tags provide a way to group or otherwise organize any of the following resources:

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Any tags on a template will automatically be copied to an instance upon creation. That is, a Goal will inherit any tags on the GoalTemplate it was created from.

For example, you would like to group all Tasks for a patient according to difficulty levels of "beginner" and "advanced". When creating the Task Template for these Tasks, be sure to add the "beginner" or "advanced" tags. Any Tasks created from these templates will be associated with the relevant tag, and these tags will be returned when retrieving Tasks from the API.

Workflows

Workflows can be used to automate processes, such as care plan or product recommendations pre- or post-registration. Add custom business logic to efficiently personalize care. You can also use Workflows to illustrate your personalized logic pre-acquisition, thus signaling the value of your offering and increasing conversion. Capable Health's Workflows allow you to eliminate tedious and inefficient manual tasks and augment the data stored in Capable Health to ensure that you have a log of how recommendations were created.


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