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Overdose Outreach Team Form

  • Updated

Contents

Background

Form Features

Inward Referral Tab

View a list of all New Inward Referrals

Screening Tab

Adding Primary and Secondary Workers

Intake Tab

Pod Transfer

Ongoing Care Documentation

Discharge Tab

FAQs

 

Background

As a part of the OOT Re-implementation Project, OOT leadership and the Profile EMR team have been working together to understand the challenges around clinical documentation and data reporting needs in the outreach context.  

This form captures the following workflows around Profile EMR documentation during various stages of the client journey:

  • Inward Referral
  • Screening
  • Intake
  • Discharge
  • Pod Assignment

Ongoing Care documentation workflows are similar to what is currently done but will include the use of Standard Encounter Titles.  

Form Features

The OOT form has been designed to assist users with documentation. Below is a list of features built into the OOT Form to streamline the documentation process.

  1. The Form Status
    • Field options: Parked or Complete
  2. Automatic encounter notes
    • Based on the fields that are selected in the form, when you save the form, an encounter note will be automatically created
  3. Typing templates functionality within the form
    • Within the Encounter Note section, there is a list of most commonly used typing templates which can be generated by clicking on the Update button
  4. Automatic generation of letters
    • Commonly used letters can be generated with one click of a button
  5. Automatic generation of tasks
    • Accompanying Tasks are automatically created with a click of a button
  6. Automatic creation of OOT-specific Care Team roles
    • Pod assignment is automatically created with a click of a button
  7. Mandatory fields
    • The form will not save until the mandatory fields are complete.  A prompt will appear to notify you of the field that needs to be completed; this includes changing the Form Status from Parked to Complete

Launch the OOT Form

  1. Click on the New Encounter Icon from the toolbar
  2. In the body of the New Encounter, type in OOTF\
  3. The form will appear

Inward Referral Tab

The Inward Referral Tab has been designed to automatically create an Inward Referral in the Inward Referral Module based on what is entered in the OOT Form.  At the top right corner of the form is the “Create an Inward Referral” checkbox.  By default, it is ticked on opening a new Inward Referral.  On completing the Inward Referral tab and saving the form, a link to the Inward Referral is created, which results in this checkbox becoming disabled and greyed out.  This link enables changes to the corresponding referral in the Inward Referral Module when we make changes to the OOT form.  

Complete the following fields to create the Inward Referral.  

Important Note: Be mindful of using the scroll wheel of your mouse or laptop trackpad as these can inadvertently change the most recent dropdown menu selection until another window or field is selected.

Previous Overdose Outreach Team Inward Referrals

This section of the form will display the last 5 referrals to the Overdose Outreach Team and is read-only for your reference.  The list is in reverse chronological order; the most recent Referral Date Received will appear first.

Save the Inward Referral Tab

When selecting the Save & Close button in the Inward Referral Tab, the system automatically creates an Inward Referral.   

View the Inward Referral that was created in the Client’s Medical Record

A prompt will appear to notify you that the Inward Referral was created and ask if you would like to go to the Referral window of the client medical record for review.

Click on the Yes button to be directed to the Referrals section of the Client’s Medical Record. Selecting No will return you to the client's encounter notes in the medical record.

To review the automatically created Inward Referral, double click on the Referral you just created.

Automatic Creation of Encounter Note

On clicking Save & Close, an automatic encounter note will be created with the following information based on your selection:

Encounter Note Title: OOT Referral Received

The text in the body of the encounter note will include:

  • Referral Received Date: < Date referral received >
  • Referring Program/Service/Source: < Referring Program/Service/Source >
  • Referral reason(s): < list of referral reasons with commas between if more than 1 >
  • Client aware of referral to Overdose Outreach Team OR Client not aware of Referral to Overdose Outreach Team

Trigger: If Date of ED visit is entered, the following is included in the encounter note:

  • Date of ED Visit: < Date of ED visit >

Screening

View a list of all New Inward Referrals

  1. Click on Work Center, Referrals
  2. Click on the ellipsis button beside Referral View filter
  3. From the dropdown, select the following View Filter:

In - Inward Referrals – For All Clinicians – Open and Decision Pending (Current POS)

Open an existing OOT form

  1. To open an existing OOT Form, select a client and bring them into context
  2. Click on: New Encounter icon in the Tool Bar
  3. In the Body of a New Encounter, type: OOTF\
  4. You will receive the following prompted if there is a Parked OOT Form: “There is an active Overdose Outreach Team Form(s) for this client.  Do you want to open an existing form?”
  5. To open an existing form, click on the Yes button
  6. The Overdose Outreach Team List for < Client > will appear
  7. Select from the list which form you would like to use
  8. Click on: Open Selected button to bring up the form

Screening Tab

To begin documenting in the Screening tab:

  1. Select which Shared Care Pod is conducting the screening
  2. Select the Date Screening Initiated using the calendar dropdown
  3. The full name of the logged on user will appear in the Screening Completed by field

Safety & Collateral Review

The Safety and Collateral Review section is meant to act as a reminder to assist you with your chart review. Once you have completed this review, tick the “Completed” checkbox. 

At the bottom of this section, click on the Risk Screen button if you have enough information to complete a Risk Screen.  Then, tick the “Completed Risk Screen” checkbox to make this documentation step complete.

Outcome

This Outcome section has been specifically designed to write back to the Inward Referral Module based on your selections.

Scenario 1: Client accepted, and has not yet been assigned to a Pod

Based on our first scenario, the client has been screened, has met mandate, contact is being attempted, but no Pod has been assigned.

This how you complete the Outcome Section of this tab, based on this scenario:

Note: If Referral Decision set to Accepted the Encounter Note section will become mandatory.  You will need to click on the Add button to assign the Care Team role to the Pod.

Enter OOT as ALT POS

For any scenario where a client has been accepted to a program, the POS is attached to the client record in the yellow bar. For Overdose Outreach Team, you will be adding OOT as ALT POS.

Scenario 2: Client accepted, and has been assigned to a Pod

In scenario 2, the client is assigned to the Substance Use Stabilization (SUS) Pod. You are attempting to contact the client. This how you complete the Outcome Section of this tab, based on this scenario:

Note: Once the Pod has been identified, you will still need to create a Task for the designated Pod so the new referral can be reviewed at Huddle and a Primary and Secondary Worker can be assigned.

Scenario 3: Referral Decision is Pending

In this scenario, you do not have enough information to make a decision, so you will indicate Referral Decision as Pending and Tracking will be set to: Clinical Review, as in the image below:

Scenario 4: Mandate Screen is complete and Referral Decision is Declined

In this scenario, the client meets mandate, lives in a private condo and you are unable to reach the client. In addition to completing the same fields you have completed in the above scenarios, you will also: a) send a Hospital Referral Contact Letter to the client; and b) change the Form Status from Parked to Complete.

Create a Contact Letter for Client & Tasking CSC Group

On clicking the Create Letters and Task buttons, the respective letter will be generated and appear on the screen.  On saving the form, the Task will be automatically created for Admin to send the letter.

The automatic CSC Group task will look like this:

Client Contact Details

There are two reminder checkboxes in this section:

  • Update client contact details via Client Registration
  • Update client’s External Providers

Once you have confirmed this information, tick the relevant box to mark this activity as complete.

If updates are required, you can click on either Client Registration or Care Team buttons to make your updates.

Note: This reminder is to add Client’s External Provider to the Care Team Module. You will no longer be adding your role in the Care Team Module, as this will now be done in the Pod Assignment tab where you will identify yourself as Primary or Secondary Worker. 

Client Contact Attempts

In this section, you will record the First Attempted Contact and the First Contact Made.  The dates entered in these fields will carry over into the Intake and Discharge tabs.   A free-text box has been created so you can record any Contact Notes. These notes will be carried over into the Intake Tab. 

Note: On selecting a date in the First Contact Made field, you will notice that the Tracking Outcome will be updated to Complete. This will also update in the Inward Referral Module.

Screening Encounter Note

You will notice at the bottom of the tab there is a Screening Encounter Note section. In the dropdown menu you will be able to select two specific typing templates. To insert the template into the body of the Screening Encounter Note, click on the Update button.

You can use other typing templates if more appropriate for your documentation (see Quick Reference document).

Automatic Creation of Encounter Note

On saving the form, an automatic encounter note will be created with the following information based on your selection:

Encounter Note Title: OOT Mandate Screen

If Referral Decision is Pending:

  • A new Encounter Note Title will be added: Referral Decision Pending
  • The text in the body of the encounter note will read: Overdose Outreach Team is currently reviewing this referral. A decision has not yet been made.

If Referral Decision is Accepted:

  • A new Encounter Note Title will be added: Referral Decision Accepted
  • The text in the body of the encounter note will include:
    • Decision Date: < Decision Date >
    • Does Client Meet Mandate?: < Yes > or < No > (from radio button)
    • Referral Decision: < Accepted >
    • < Screening Encounter Note textbox content >

If Referral Decision is Declined:

  • A new Encounter Note Title will be added: Referral Decision Declined
  • The text in the body of the encounter note will include:
    • Decision Date: < Decision Date >
    • Referral Decision: < Declined >
    • Primary Reason Declined: < Primary Reason Declined >
    • Secondary Reason Declined: < Secondary Reason Declined >
    • < Screening Encounter Note textbox content >
    • A hyperlink to the completed letter if < Create Contact Letter > button(s) are initiated in the form

Pod Huddle

At your daily Pod huddles, each Pod will review their new Inward Referral tasks for assignment of primary and secondary worker.

View a list of all New Inward Referral Tasks

  1. Click on Work Center, Tasks
  2. Select View Filter: Pending Clinic Tasks (created at Current POS)
  3. Bring the client into context and open the Client Medical Record
  4. Double click on the Parked OOT Form in the Notification Box to bring up the form
  5. Click on the Pod Assignment Tab

Pod Assignment Tab (part I)

In this tab, you will be able to see a list of all OOT Care Team Roles added since the Inward Referral Received Date. 

A Primary and Secondary Worker is added to the Care team using the Pod Assignment Tab.

Intake Tab

The Intake Tab is completed once you have gathered enough information from the client in order to complete Intake documentation.

Client Acuity Intervention Button

On clicking this button a Client Acuity Intervention will be created. In the Interventions Set section of the client medical record under: Recalls(_NOPLAN), you will notice an Intervention has been created with the following information:

  • Reason Text Description: Client Acuity
  • Intervention Due: 1 Month
  • Settings for Reoccurrence: 3 months

See: Overdose Outreach Client Acuity Form for more information.

Client Consent

You will be able to record client consent under this section with a dropdown list and date field.

OAT

The OAT section is where you record your Client’s OAT status at Intake. You will also find this section in the Discharge Tab. You are able to access the Care Team Module by clicking on the “Go to Care Team” button to make any changes to the External Care Team, such as when updating OAT Provider or Pharmacy.

If you select First time starting/titrating, Re-starting/Re-titrating, or On Maintenance Dose as OAT Status, you must select at least one of the medications in the list below.

Intake Encounter Note

This section provides a free-text box where you can select a typing template for your Intake Encounter Note. Similar to the Screening Encounter Note section, typing templates can be launched within the window for your documentation.

If you need to review or create a new Risk Screen form or Intervention Set, click on the relevant button to navigate to that window.

Automatic Creation of Encounter Note

On saving the form, an automatic encounter note will be created with the following information based on your selection:

Encounter Note Title: OOT Client Intake Visit

The text in the body of the encounter note will include:

  • OAT Status (Client Reported): < selection from drop down >
  • Current OAT Medication(s): < list of selected check boxes with commas between if more than 1 >
  • < Intake Encounter Note textbox content >

Ongoing Care Documentation

Complete ongoing care documentation directly into the encounter note of the medical record. Refer to the Quick Reference document for Standard Encounter Titles Typing templates. These are to be used for visits with clients aside from the initial referral, screening, intake, and discharge visits. Examples include a second or third outreach contact attempt, second or third outreach visit with contact made, or care coordination. 

Pod Assignment Tab (part II)

Use the following workflow when considering client transition to a different Pod:

  1. Discuss with your Team Lead regarding Pod transfer
  2. Discuss Pod transfer with New and Existing Pod
  3. Book outreach appointment with the new Pod and client for warm introduction
  4. Once the visit is complete and the client has accepted the transfer to new Pod, update the OOT Form Pod Assignment tab
  5. Remove the Existing Pod, Primary and Secondary Worker
  6. Add New Pod, Primary and Secondary Worker

Add the new Pod and Primary and Secondary workers using the workflow in Part I.

Discharge Tab

The Form Status field appears in all tabs of the OOT Form. All Form Status fields are synced. If you change the Form Status in one tab, it will automatically change the Form Status in the other tabs.  When a client is no longer in the care of OOT, the Form Status must be changed from Parked to Complete.  This can happen at both Screening and Discharge.

Information entered into the fields in the previous tabs will be pulled into the fields in the Discharge tab. These fields will be set to read-only.     

A Discharge Checklist has been created to remind you of the activities to conduct on discharging a client from the program.  

Outcome Section

In the Outcome Section of this tab you will be able to indicate the discharge reason.

Select the appropriate radio button (yes/no) to indicate if the client was or was not connected to services during the current referral period, as well as the Additional Discharge Reason, if applicable.

If the client is connected to services, you will be able to record the following information:

  1. Program/Service Category
  2. Program/Service Name
  3. Connection type (i.e. newly connected, re-connected, or already connected)

On selecting a menu option from the Category dropdown, the Program/Service Name menu will display a selection based on your Category chosen.

OAT Section

As noted above, in Intake Tab section.

Creating a Discharge Letter & Task for CSC Group

On clicking the Discharge Letter buttons, the letter you select will be generated and appear on the screen. On saving the form, the Task will be automatically created.

Encounter Notes

  1. Click on the dropdown list to see OOTDN\ typing template.
  2. Click on the Update button to generate the typing template into the body of the encounter section.

Pharmaceutical Alternative Data

A section has been included where the Pharmaceutical Alternatives Team (PAT) can document the client’s current status and if client’s needs are being met. Only PAT is required to complete this section.

Automatic Creation of Encounter Note

On saving the form, an automatic encounter note will be created with the following information based on your selection:

Encounter Note Title: OOT Discharge Note

The text in the body of the encounter note will include:

  • Date Discharge Completed: < Date discharged completed >
  • Was Contact Made: < Yes > or < No >
  • Client Connected to Services: < Yes > or < No >
    • Additional Discharge Reason (if selected): < Discharge Reason selected >
    • Service Connected to: (if selected) < If table options have been selected, the contents of the table will be displayed >
  • OAT Status (Client Reported): < selection from drop down >
  • Current OAT Medication(s): < list of selected check boxes with commas between if more than 1 >
  • < Intake Encounter Note textbox content >
  • A hyperlink to the completed letter if "Create Contact Letter" button(s) are initiated in the form

FAQs

Coming Soon!