Starting a care plan for a patient

The family is one way into ExpressAgain, not the only one. Whoever has the patient's information first can start the care plan: the family, a home care agency, a case manager, a doctor's office or clinic, a hospital or discharge team, a foundation or nonprofit, an insurer or health plan, EMS or a first responder, or another professional. The door is one public page, Start a care plan, which asks who is starting it. There is one care plan per patient, whoever starts it, and nothing is entered twice: what you fill in is what the family finds when they arrive.

The family's path. A family member who picks The family goes to the family sign-up and the guided setup, exactly as before. The account is theirs from the first moment.

An organization has two ways in. Refer a family is for a referrer: a case manager, a doctor's office, a discharge team, a foundation, an insurer or EMS that tells a family to use the app. It needs no organization account. You start the care plan with what you know, the family gets a private link, claims the account, owns it and is on the family's own plan. Referring is free. The family owns the account. There is never a referral fee. My organization sponsors patients is for an organization that carries its patients on ExpressAgain, such as a home care agency, a practice or a program: you sign in to your organization, or sign it up, and Add a client opens on Patients with the patient's name already filled in, then the client's care plan; the patient takes a place in your preview or your plan like any enrollment, and your organization sponsors the account.

Case managers: a referral account of your own. A case manager or a discharge planner who refers families often gets a referral account, with no limit on referrals and no charge: an organization of the case management kind, referral-only, with no patient slots and no sponsorship. ExpressAgain for case managers says what it is for your clients and opens the account. Refer, in your organization panel, is the page you read with the patient, in plain words, as your case manager, I'd like to help you communicate again; you sign the patient up right there and the care plan starts on that page with what you know. My referrals, in your organization panel, lists each family you referred: referred on, claimed, signed in, active days, and what has been logged as counts, never a value. When the family keeps you on the Care Team at claim, My referrals also opens the Care Team view of that patient.

What the family sees at claim. The claim page names you as the referrer and keeps you on the patient's Care Team by default; the family can turn that off on the claim page, or later on the Care team page, and the account is theirs either way. A referrer who stays on the Care Team reads the day plan and the shared clinical picture from the care-team dashboard like any clinician, never the family feed.

Add a client, for a sponsoring organization. Add a client is open to every organization kind, not only home care agencies: it asks for the patient's first and last name, the city and state, and who will own the account (the patient, a family member or a representative, never your organization), and you can add the owner's email or cell now or later. The client is enrolled at once and the client's care plan opens: the Home Care Team Plan's 25 sections, where you fill in what you already know, a diagnosis, the medications, the routine, the people, and leave the rest for the family.

The claim link. On either path the family gets a private claim link by email or text; for a sponsoring organization it is sent from Manage on the client's row, under Who will own the account. The link names no patient and nothing about health, it is never shown to anyone at your organization, and it can never go to, or be claimed with, an address of anyone at your organization. When the family opens it they choose a password and own the account; your service to the patient is recorded as their consent. From then on the family decides, on their Care team page, what your organization keeps managing, and you keep the access your role allows: your clinical people on the patient's care plan and the care-team dashboard, your office on scheduling and the team.

Direct, or a proposal. A clinical person on the client's coverage, or a clinical administrator, fills in the client's Home Care Team Plan, all 25 sections, each on its own page: Patients, then Manage on the client's row, then Home Care Team Plan, then Open the care plan to fill it in (or Edit this section). While the account is not yet claimed, or the family lets your organization manage the care plan, a field saves at once and reads your organization's name with (managing until claimed) or (managing for the owner). When the family keeps the care plan, every field is proposed: it reads Proposed, and the family accepts or declines it on Care team under Care plan sections; nothing is written into the plan until they do, and Manage shows each proposal as waiting, accepted or declined. Values the family keeps on its own pages (the Patient Profile, the Emergency Plan Card, Prescriptions, Menu & Kitchen) are shown but change only there. The same direct-or-proposal rule covers the client's Day, the shift checklist, the medications list and the emergency card. A referrer on the Care Team reads the plan from the care-team dashboard like any clinician and does not manage it.

The office wall. An organization's office and schedulers, and an owner or administrator with no clinical work role, read the staffing view of the plan only: the weekly coverage, the hours, the team roster and the readiness statements. They never see a health section, a reading, a medication, a note or an alert. Your clinical people see the whole plan on the patients whose coverage they are on.

What the family sees. The patient's account looks the same as any family's: the care plan you started, with your organization's name on what you filled in, the day plan, the medications and the Care team page where they can see your organization and decide what it manages. If the family already has an ExpressAgain account for the patient, use Enroll a patient instead and the family accepts the link; the one care plan stays the family's.