With the MedicalDirector Care Plan solution we are committed to making care plans easier for you and all health practitioners in Australia.  We understand the importance of care plans to combat chronic illness, but also understand that it’s a lengthy process to create a solid care plan.

Benefits for Patients

Empower your patients with a tool to better understand and manage their health.

Motivate regular monitoring - patients have access to their care plan which helps them monitor their own health.

Optimise health outcomes - patients can better understand their condition and how to improve their health.

Benefits for GPs and Nurse Practitioners

Easy to use modern interface and direct integration into your MedicalDirector software will make it easier to create and view care plans.

Saves time - templates provide a customisable base to build care plans, ultimately saving you time.

Minimise data entry errors - templates auto-fill with the most current patient measurement values to save time and reduce errors.

Reduce clinical risk - templates based on leading industry standards and recommendations and recommendations by peak industry organisations ensure you have the most up-to-date information.

Benefits for Practices

Create more care plans by reducing the time needed to build each care plan, giving you more time to spend with your patient.

Easier revenue management - with simple tracking of care plan status, as well as dashboards, you can easily track completing and billing. This reduces your reporting burden.

Support 7 days a week - unlimited software support from MedicalDirector.

Before You Begin

o      The MedicalDirector Care widget requires MedicalDirector Clinical 3.18 or later.

o      You will need to install the MedicalDirector Care Widget. See Managing Widgets for  instructions.

o      You will need to create and save a default eSignature.

o      The MedicalDirector Care widget requires Google Chrome, Microsoft Edge, or Mozilla Firefox.

Create an eSignature

• For information about electronic signatures, see Electronic Signatures.
• Note that an electronic signature is only effective if the person receiving it (e.g. a specialist) accepts the signature in that form.

1.      Open the MedicalDirector Care widget from the Sidebar and select User Settings.

2.      Locate and click the eSignatures settings button, as shown below.

o      If this is the first time you have created an eSignature, the Default eSignature Preview window will be blank, as shown in the example.

 

3.      Select either the Upload sSignature tab or the Draw eSignature tab to enter a new eSignature.

o      The Upload eSignature tab allows you to upload an image of a signature that you already have saved on your computer.

o      The Draw eSignature tab allows you to create a new eSignature, manually, by using your finger or stylus on a touch-screen or tablet.

 

4.      You will be presented with a preview of the eSignature, and prompted to use it as the default. Tick the Use as Default eSignature checkbox to confirm.

 

5.      The eSignatures settings window will now display your default selected eSignature. This will be used for all future Care Plans created in MedicalDirector Care, unless you choose to delete it and create a new one. No other configuration is required.

Create a Care Plan

Obtain consent, review the patient’s health summary and choose focus areas.  Assign team members and generate documentation.

Overview

1. Obtain the patient’s consent.
2.. Assign the primary GP.
3. Discuss and record the patient’s overarching goal.
4. Review the patient’s health summary.
5. Select a template and choose focus areas.
6. Customise care plan to suit the patient.
7. Set goals, tasks and metrics.
8. Assign team members, generate referrals.
9. Set tracking and billing options.
10. Generate a printed care plan.

MedicalDirector Care is able to create printed care plans.

Care plan - Health summary	Care plan – Focus areas

 

Process

Launch a care plan, obtain patient consent and discuss the patient’s overarching health goal

1.      From within the patient's record, open the MedicalDirector Care widget from the Sidebar and choose Create Care Plan.

2.      Gain the patient’s consent to create a care plan.

 

3.      Click

o      You may be required to log into the MD Care site.

o      The Care Plan Setup will commence.

 

4.      You will be presented with the Patient Consent window where you can review the conditions of consent.

o      This step can be skipped and recorded later in the patient dashboard.

 

5.      Click to continue.

o      On the Select Primary GP window, accept the default healthcare professional selected or choose another.

 

 

6.      Click the associated Goal button to continue. You are presented with an opportunity to record the patient's goal, in their words.

 

7.      Click Review the patient’s health summary, select a template and choose focus areas.

o      All data appearing in the Health Summary is taken directly from MedicalDirector Clinical.  As such, MedicalDirector Clinical remains the source of truth for the care plan. If data needs to be corrected, correct it in Clinical and relaunch the care plan. Review Conditions (past medical history), Medications, Allergies, Immunisations, Family History and Social History. Ensure the data is correct and is suitable for sharing with team members outside the practice. Use the check boxes to decide what will (and won’t) be shown on the care plan.

o      The data chosen in the previous screens all make up the patient summary part of the care plan, including:

•       The patient’s goal.

•       Social and family history.

•       Patient demographic details.

•       Medications.

•       Conditions (Past medical history).

 

 

8.      After navigating the patient's Health Summary and making modifications as required, click to choose a plan template that suits this patient.

o      The Supplied tab on this window contains supplied templates.

o      Supplied templates can be modified to suit your practice’s needs. Modified templates appear in the Customised tab.

 

 

9.      Select a plan to customise.

 

10.   Click to create the care plan.

11.    You can set goals, tasks and metrics for each focus area.

o      Health summary pages.

o      Focus areas pages.

o      Care plan.

o      Roles and team members & team member documentation.

o      Admin tasks (billing and reminders).

o      Finalise and generate the care plan document.

o      Timeline of all consult notes, correspondence, pathology and imaging results for this patient.

o      Goal progress.

o      Clinical goals for the patient.

o      Automatically pre-fills latest metrics and measurements retrieved from MedicalDirector Clinical, minimising data entry errors.

 

 

12.   Review and edit patient clinical goals if required.

 

13.   Review and edit patient metrics if required.

o      The metrics are pre-defined as part of a template.

o      For each metric selected, all available measurements will be automatically imported from MedicalDirector Clinical.

o      Only the most recent measurements are shown here. To see older measurements click View History.

o      To add a new metric, click Add Metric.

 

14.   Review and edit tasks if required.

o      Competed tasks will show in the Completed view.

o      Task descriptions can be changed, roles added or removed and the duration and due dates can be set (if required).

o      There are two default roles; GP and Patient.

o      Tasks can be assigned more than one role. Assign roles to providers in the Team Members page.

 

15.   Assign team members and generate referrals.

1. Via the Team Members list located in the left-hand margin of this window, select the type of healthcare professional you wish to assign to the care plan. In the example below, we have selected Physiotherapist.

• The Team Members list is dynamic, based on the roles you assigned to the various tasks of the care plan.

• The list of available healthcare professionals/providers is drawn from the MedicalDirector Clinical Address Book.
  
  
  
  
  

2. Click  to locate and select a healthcare provider of the type you wish to add to your team.

• Click against the provider you wish to select.
  
  
  
  
  

• You will be returned to the Team Members page where your selected provider now appears.
  
  
  
  
  
  

16.   Optionally generate a Team Participation letter and an Allied Health Referral letter. Select the Documentation tab and click .

 

 

17.   Optionally view/print an Allied Health Services referral letter and/or Team Participation letter.

 

 

18.   Set tracking and billing options.

o      Assign to another member of the practice to review once the care plan has been finished (optional).

 

o      Set the care plan type (optional).  Each type has pre-set expected MBS item code(s). These are tracked on the patient and practice dashboards, using billing data extracted from Pracsoft.

 

o      Set the review period which will control when the next review for the care plan is due (optional). Upcoming and overdue care plans show in the practice dashboard.

 

 

19.   Generate a printed care plan.

o      Finalise the care plan and generate the care plan document. The care plan will automatically be saved to MedicalDirector Clinical.

 

o      View or print the generated care plan and (optionally) save to the patient record it if has not been previously saved. The goals, metrics, tasks and correspondence shown in the previous screens are used to create the printed version of the care plan.

Create or Edit a Care Plan Template

MedicalDirector Care comes provided with a variety of care plan templates, and you can create your own by using one of the supplied templates as a base. The following instructions cover creating new templates and can assist with editing templates you have already created.

 

1.      From the MedicalDirector Care widget, select Manage Templates.

2.      The Template Management window appears. By default, you are presented with the Supplied tab as shown in the example below. The Customised tab is where your customised templates will appear once you have created one. To create your first customised template, you must first select a supplied template to base it on. In our example, we are going to select the Multidisciplinary Care Plan template as shown in the example below.

3.      After selecting a base for your new template, you will be presented with a list of patient problems, needs and conditions to choose from which can be added to your new template.

• Select 1 or more items to add to your new template.

• You can rename as existing item by clicking its associated button.

• You can create a new item by clicking

4.      In our example, we have selected 'Recurrent Skin Cancer Risk'. Select at least one item to add to your new template, and click .

5.      You will be presented with the details of your first selected item. In our example, it's the Recurrent Skin Cancer Risk item.

6.      If you have selected multiple items to edit, you can toggle between them via the panel on the left of the window. In the following example we want to edit our Obesity plan details, so we select it here.

7.      At the top of the window, you are presented with the various goals associated with the item you selected. The example below shows our Obesity item and 3 goals we have associated with it: Bio-Medical Blood Checks, Blood Pressure, and Cardiovascular Risk.

o      Add a goal by clicking

o      Switch between goals by clicking the title.

 

8.      Under each goal are associated Progress, Health Needs, Metrics and Measurements, and Tasks.

9.      You can edit each section of the goal. For example, to add a new metric, click

10.   Similarly, you can insert additional tasks.

11.   When you have finished editing the template, click located at the top-right of the editing window.

12.   You will be prompted to name the new template, and optionally give it a description.

13.   Click to save your customised template. Your new template now appears within the Customised list.

Review a Care Plan

Overview

1.      Review correspondence, pathology and imaging results since the last care plan.

2.      Record the patient’s progress and track due tasks.

3.      Review the team members and generate any required documentation.

4.      Set tracking and billing options. Generate a printed care plan, if required.

 

Step-by-Step

1.      Review correspondence, pathology and imaging results since the last care plan.

o      Open a patient’s care plan by clicking on the tracking summary part of the widget or by clicking Open Plan.

o      View summary details about the care plan with the patient dashboard.

The patient dashboard provides a summary view of the care plan including:

•       Primary GP.

•       Patient demographic details.

•       The patient’s overarching goal.

•       Critical dates including the date of the first care plan, when it was last updated and when the care plan is next due for review.

•       Team member participation status.

•       Tasks status.

•       Billing status.

 

o      The patient timeline represents all the documents which are stored in MedicalDirector Clinical for this patient.

•       You can filter by document type or change the date range, to limit the amount of documents shown. Note: the From Date filter will automatically populate with the date of the last care plan to ensure that only the documents which were created since the last care plan are shown.

•       Document navigation:

 

 

•       You can link the team member who authored the document (or role) and then provide a summary of their correspondence.

o      Linked documents (with summary) show in the Team Correspondence tab. Click View to view the original document.

 

 

2.      Update progress notes and review tasks.

o      Record progress notes for this focus area here.

 

o      Mark as complete any tasks which have been done and add any new tasks which should be done on an ongoing basis, should be done by a specific date or tasks which should be reviewed periodically to measure progress.

•       Tasks which have been marked as complete show in the Completed view.

 

 

3.      Check team members status, track the plan and set review dates, generate documentation.

o      Review and update team members.

o      If needed, generate new referrals or team participation letters.

o      Track this plan to ensure it is billed.

o      Set an interval for the next review.

o      Generate the care plan for your records.

Track Care Plans

o      Review upcoming, overdue and in-progress care plans.

o      Ensure the correct billing has been done in a timely manner.

 

The practice dashboard tracks all care plans. The practice dashboard will track all care plans that:

o      Are overdue.

o      Are coming up for review.

o      Have been assigned to a user in the practice.

o      Have been started but not yet finalised.

o      Are awaiting on all team members to agree to participate.

o      Have not been fully billed.

o      Are complete, with no outstanding issues.