Overview

Throughout a patient’s care journey, we are helping health and wellness pioneers build cohesive experiences to assist their members in achieving long term care outcomes. Through Capable’s care creation and authoring product, clinical teams, content managers and administrators are able to provide care at scale by delivering their care models seamlessly and digitally.

Core Concepts and Terminology

The different media for care to drive patient engagement includes four key components: Care Plans, Tasks, Goals and Targets. Care teams are able to create templates for these mechanisms that can be individually applied, recommended and/or modified by practitioners to suit the patient’s needs and unique experience.

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What is a template?

Templates in Capable Health are generic versions of Care Plans, Goals, Targets and Tasks that can be applied to Patients, either manually or via automation using our Workflows tool. Once applied to a Patient, you can modify the Care Plan’s Goals, Tasks and Targets to ensure personalized care.

When curating care in Capable, you’ll you will start by creating Goal and Task templates that will be added to your Care Plan template.

When adapting your care model into Capable’s care format, we suggest thinking of the main objective for the Care Plan. For instance, if this is an onboarding Care Plan for your Member App, you may want some tasks to complete your profile or book an appointment. Or, perhaps the Care Plan you are creating is specifically for Diabetic patients who are looking to quit smoking. Start with a specific use case in mind and build from there.

Inside a Care Plan

The crux of scaling program care delivery begins with Care Plan templates, a container for a patient’s Goals, Tasks and Target metrics. These templates can either be automatically applied or suggested for patients and later reviewed and modified if needed by their practitioner once it is instantiated on the patient. Care plans can contain Tasks and Goals, in addition to other content such as links, media and visuals when used in tandem with our Contentful integration.

Task templates

Tasks are actionable to-dos for a Patient. Currently, tasks are not recurring.

Examples:

• Chat with your care team.
• Read more about the importance of heart health for Diabetes patients.
• Book your initial appointment.

Goal templates

Goals are specific objectives for a patient. Patient’s can log data of specific observation types until a target value is met and the goal is achieved.

Examples:

• Drink 8 glasses of water a day.
• Lower your cholesterol to 180 mm/dL.
• Log 10 minutes of exercise daily.

Inside a Goal: Observations and Targets

When you think about a Patient and a Care Plan for that Patient, it’s likely they have a key complaint – a specific condition that is being addressed. Their care team may set them certain Goals to address that condition. Goals have a few features:

• There is an achievement status.
  • Statuses: n-Progress, Achieved, Improving, Worsening, or Abandoned.
• Unlike Tasks, Goals can be time-bounded either through a due date or recurrence (such as every day/week/month).
• All Goal templates can also have an associated Target Template. Targets are used to assess whether a specific Goal is being reached.
  • For example, a Target for an exercise goal could be 30 minutes of exercise a day.
• Observations are the data that can be used to assess progress toward a specific Patient's Goal Targets and ultimately is the data to determine if all Targets were met and the Goal was successfully completed.
  • The Capable portal has example Observation Types based on LOINC codes automatically added to your system. You can also add your own observation types in the portal.
• As with all care templates, once a Goal template and any associated Target templates are applied to a specific Patient, they can be modified to fit the Patient’s care and health goals by a Practitioner.

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Here's an example of a goal:

Patient’s Goal to work out 15 minutes every day. The Observation Type is “Minutes of exercise” and the Target is “15 minutes daily.”

Assigning Care to a Patient

Once you have created your care templates and have a library of Care Plans with associated Tasks, Goals and Targets, you’re ready to assign care to a patient. You can assign care to a patient two different ways:

1.) Manually: On the patient profile, you’re able to add care objects to a patient.

2.) Automatically: By leveraging our Workflows automation product, you’re able to automatically assign are to patients via the logic you create. You’re also able to recommend care utilizing workflows, which allows practitioner to review outcomes and commit/dismiss care accordingly.

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Coming soon! (Q1 2023)

A new care creation and authoring experience. Join our mailing list to be the first to take it for a test drive!