Care Management Plus - Information Technology Tools for the Care of Seniors Oregon Health and Science University
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Care Management Tracking Software


The CMT is usually implemented in a standalone Access database. It is not necessary to use the CMT to implement Care Management Plus; however, most electronic medical records do not include all the key functions that are available in the CMT. The Care Manager Tracking Database enables the Care Manager to:
  • Flexibly plan chronic care tasks such as
    • classes
    • lab work
    • referrals
  • Schedule visits and phone calls
  • Create reminder lists based on patient criteria (tickler lists) which facilitates patient contact and documentation of adherence to care plan
  • Manage workflow and evaluate efficiency of resource use
The CMT Access database is not only a valuable clinical tool for the Care Managers, but is also helpful for Clinic Managers to evaluate the success of Care Management Plus. Administrative Reports generated from CMT demonstrate the level of adoption, list providers and their use of Care Managers and for what purposes, and the effectiveness and productivity of the Care Managers. The reports can be generated for any time period. Some of the more useful reports include:
  • Number of patients referred by physician
  • Diagnoses and Payers
  • Trends in outcomes for depression (PHQ-9) and diabetes (Hemoglobin A1C, patient goals)
  • Work breakdown by Encounter Type such as phone calls, face-to-face visits, administrative, clinic visits and the time for each.
To download the database and user guides, please see the Download page.  

 

  The John A. Hartford Foundation
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Care Management Plus is sponsored by the John A. Hartford Foundation and the Oregon Health & Science University.