A New Approach to Clinical Care Classification in Epic

If you have been dinged by The Joint Commission for not providing easy individualization of Care Plans, your Care Plan workflow is cumbersome and not clearly linked to other documentation, or maybe your organization has difficulty coding Care Plan documentation, you’re not alone.

These are common problems, and Dr. Virginia Saba has come up with a revolutionary solution. Her free (just complete a permission form on her website) Clinical Care Classification (CCC) System ^TM allows healthcare organizations to clearly and automatically code based on nurses' Care Plans and linked supporting documentation (www.sabacare.com).

Additionally, we have built the CCC System in Epic, to rave reviews from nursing staff and consistent approval from The Joint Commission. We recommend beginning with the 60 major Inpatient Nursing and Behavioral Health categories and building out the related Care Plan Templates (LCE master file), Problems (LTP), Goals (IGT) with easy-to-enter expected end dates, and Interventions (LTI). To really make the workflow efficient for your nurses, we strongly recommend allowing for:

• Easy selection via a SmartForm-based Navigator section (LQF, VCN, LVN)
• Efficient customization by incorporating BPAs (LGL, CER)
• Linked shift documentation (Improving, Stabilizing, or Deteriorating) via Flowsheets (FLT/FLO)
• Automatic creation of Patient Education (IED/LTT/LTR)
• Reminders based on required documentation (LSD and/or DEP - version-dependent)
• Clear coding by ensuring the CCC diagnoses, goals, interventions, outcomes, etc., all have the same code assigned
• Easier reporting on Care Plan documentation - and trends in patient illnesses - due to the consistent coding

We estimate that building out the Inpatient Nursing or Behavioral Health collections of Care Plans will take one dedicated analyst around nine months to analyze the system, build, test, and bring the workflow live (double that for both collections).

Next Steps

If you don't have the time or resources to build out the CCC System Care Plans in your Epic EHR, we have put together a project that includes leveraging our live build, manually building out those additional necessary customized records, testing, educating your analysts, and providing end-user training materials, in one-third of that time. We are happy to provide a presentation and demo of the build and workflow, grounded in the SabaCare Clinical Classification System. Contact info@cerecore.net for a discussion.

Click here to download an overview of our solution.