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Mango ACO
Care Management
One place to see who to call today, log every attempt, work the assessment across calls and book the follow-up before the TOC period runs out.
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Due today
Due today
Pending
Not reached after 3 attempts
Active TOC
Inside their 30-day period
Follow-up calls this week
Program standard: 3 attempts within 5 business days of the notification, the first within 1 business day, on different days and times of day · notify the PCP office within 1 business day whether or not the patient is reached · voicemail: your name, “calling from Dr. [PCP]’s team”, callback number, nothing else · document the same business day.
New: first attempt due
| Patient | Trigger | Discharged · day of 30 | Due today | Follow-up visit target | Practice · PCP | Status |
|---|
No first attempts due.
Re-attempt
· a different time of day than the last attempt| Patient | Trigger | Discharged · day of 30 | Due today | Follow-up visit target | Practice · PCP | Status |
|---|
No re-attempts due.
TOC follow-up
| Patient | Trigger | Discharged · day of 30 | Due today | Follow-up visit | Practice · PCP | Status |
|---|
No follow-up calls due today.
Follow-up visit targets come from the program standard: ED within 7 days · inpatient 7 days (high risk) or 14 days (moderate) · SNF admission once a discharge date is known · SNF discharge within 5 days of coming home. Observation stays use the inpatient target.
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Not reached after 3 attempts
Pending
When one calls back, log the inbound call and complete the assessment for the original trigger. The follow-up visit target still applies.
Program standard: after attempt 3 the case moves to Pending and the PCP office is told the patient could not be reached · a Pending case closes at day 30 with the reason “Not reached, TOC period ended” · an inbound call reopens it as Active TOC.
| Patient | Trigger | Discharged · day of 30 | The 3 attempts | Pending since · PCP told | Follow-up visit target | TOC ends | Status | Action |
|---|
Nothing pending.
No episodes closed in this period.
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Scheduled RN follow-up calls
Pick a day to see who. A patient’s next call moves here when you set it on the log or in section 11.
Weekends are shaded.
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Patient and practice
-
- State
- Practice
- PCP
- Medicare ID
Status
Statuses move by themselves from the log: a reached attempt makes Active TOC, a third unanswered attempt makes Pending, a declined call closes. Close by hand below when the follow-up visit is booked or done, urgent issues are resolved or handed to the PCP, and the patient knows to call the PCP office before the ED; or at day 30.
Episode
- Trigger
- Source
- Notification date
- Facility
- Admit · discharge
- Diagnosis
- Day of 30
- Follow-up visit target
- Follow-up visit
- Edit in assessment section 11
- Next RN contact
Outreach log
· documented the same business day| Date · time | Contact type | Nurse | Outcome | Reached | 2 IDs verified | Next contact | Notes |
|---|
No contact yet. Log the first attempt below.
Log this call
Assessment
Escalation
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·
Progress
of applicable complete
General notes
Anything that fits none of the sections. Added, never overwritten.No general notes yet.
Section rules, tiers and targets are the assessment document’s; section 12, PCP summary and documentation, is out for now, and the PCP summary date lives on the escalation card.