Page | 1 Version 1.0 5/18/17 POPULATION HEALTH LOGISTICS (PHL) FIELD STAFF USER MANUAL Population Health Logistics (PHL) is a secure web-based, HIPAA compliant electronic data platform developed to assist community-based providers support care across settings and strengthen patient-centered care planning and service delivery. This manual was developed to assist PHL Field Staff Users to understand the features of PHL and how to navigate the platform. This Manual can be used in combination with a variety of short PHL Training Videos and other support documents available within the PHL platform. Please note the examples included in this User Manual are not always full copies of a PHL screen but may be only sections of the page. In addition, text in italics in this Manual indicate “action steps” for PHL Users (i.e. Select the “New Agency” option to open a new page). Table of Contents General PHL Information ................................................................................................................................................... 4 PHL User Rights .................................................................................................................................................................. 6 PHL User Activities ............................................................................................................................................................. 9 PHL Login ........................................................................................................................................................................ 9 Resetting PHL Passwords ............................................................................................................................................. 10 Receiving a Referral in Population Health Logistics (PHL) ........................................................................................... 13 SERVICE DELIVERY-General .............................................................................................................................................. 15 “Field Staff Home” Tab................................................................................................................................................. 15 My Case load ............................................................................................................................................................ 16 Client Service Delivery Program(s) Status ................................................................... Error! Bookmark not defined. Show Scheduler ........................................................................................................... Error! Bookmark not defined. SERVICE DELVERY- CLIENT................................................................................................................................................ 17 “Client’s Demographics” Tab ....................................................................................................................................... 17 “Contact” Tab ............................................................................................................................................................... 19 “Insurance” Tab............................................................................................................................................................ 30 “Emergency Contact” Tab ............................................................................................................................................ 31 Emergency Contact Details ...................................................................................................................................... 32 Emergency Contact’s Contact .................................................................................................................................. 33
Transcript
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POPULATION HEALTH LOGISTICS (PHL) FIELD STAFF USER MANUAL
Population Health Logistics (PHL) is a secure web-based, HIPAA compliant electronic data platform developed to assist community-based providers support care across settings and strengthen patient-centered care planning and service delivery.
This manual was developed to assist PHL Field Staff Users to understand the features of PHL and how to navigate the
platform. This Manual can be used in combination with a variety of short PHL Training Videos and other support
documents available within the PHL platform. Please note the examples included in this User Manual are not always
full copies of a PHL screen but may be only sections of the page. In addition, text in italics in this Manual indicate
“action steps” for PHL Users (i.e. Select the “New Agency” option to open a new page).
Table of Contents
General PHL Information ................................................................................................................................................... 4
PHL User Rights .................................................................................................................................................................. 6
PHL User Activities ............................................................................................................................................................. 9
Receiving a Referral in Population Health Logistics (PHL) ........................................................................................... 13
SERVICE DELIVERY-General .............................................................................................................................................. 15
My Case load ............................................................................................................................................................ 16
Client Service Delivery Program(s) Status ................................................................... Error! Bookmark not defined.
Show Scheduler ........................................................................................................... Error! Bookmark not defined.
SERVICE DELVERY- CLIENT ................................................................................................................................................ 17
New Visit Tab ........................................................................................................................................................... 48
New Care Plan Tab ....................................................................................................................................................... 69
Care Plan: Demographics & Summary Tab .............................................................................................................. 70
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Care Plan: Goals & Objectives Tab ........................................................................................................................... 73
Care Plan: Services Tab ............................................................................................... Error! Bookmark not defined.
Care Plan: Cost & Maintenance Tab ........................................................................... Error! Bookmark not defined.
Care Plan: Notification Tab ......................................................................................... Error! Bookmark not defined.
View Care Plans Tab ........................................................................................................ Error! Bookmark not defined.
Receiving Referrals in PHL ............................................................................................................................................ 76
Making a New PHL Referral = Creating a New Participant in SASH ............................................................................. 78
PHL Training “Help” ...................................................................................................................................................... 87
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General PHL Information
A. The PHL platform allows for a number of different User types and can be modified by Preferred Population
Health Management (PPHM) to meet the needs of a licensee.
B. Individuals whose data is entered into PHL are referred to as “clients” in PHL.
C. The term “visit” in PHL is equivalent to a contact. A “visit” may be conducted in a variety of formats
including: face-to-face, via telephone, via email, text message, voice message, via fax, etc.
D. To access all the information on a given PHL page use the “page view bar” on the right-hand side of the
screen or the scroll feature on your mouse to move up and down a page, as there may be more information
on a page than is viewable on the computer screen (see EXAMPLE below):
E. The client “CBO #” is a number automatically assigned to the client by PHL once the client is “enrolled” in
PHL. Note: Client CBO #s are listed in PHL in capital letters (EXAMPLE: SASHVT122334), however these
numbers are not case sensitive and can be entered as either capital or small case in the client search feature.
F. To locate a client previously enrolled in PHL, enter any of the following information under the “CLIENT
SEARCH” feature at the bottom of the Home Page OR under the “Client” Tab, “Search Client” feature.
a. Client CBO #
b. Last name
c. First name
d. Gender
a. Date of birth
Then click the “Client Search” button (see EXAMPLE below):
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This will generate a table that includes a list of clients (see EXAMPLE below). Highlight and click on the
correct entry to open the “Client Tab” for the selected client.
G. No data entered and saved in PHL is ever deleted, it is rather inactivated. Data entered in error can be
cleared prior to saving by clicking the “clear” button at the bottom of a page, however once saved, it will
always be part of the PHL history.
H. Local Administrators have rights to add additional information or change information in PHL dropdown boxes
or multiple checkbox fields to configure the platform for local use. For example, on the “Client’s
Demographics” page, under the dropdown box for “Spoken Language” it currently lists only English and
Spanish, you may want to add additional options to reflect the population(s) you serve (see EXAMPLE below).
The process of configuring PHL is explained in detail in the PHL Administrative User Manual.
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PHL User Rights
The PHL platform allows for a number of different types of Users. These User Types can be modified by Preferred
Population Health Management (PPHM) to meet the needs of the licensee. Current levels of Users in PHL are:
Master User, Super User, Administrator, Manager or Supervisor, User, Contract User, Clinician, Subcontracted User,
Referral User and Other. Each role is defined and described below.
Users- These individuals, also called “Field Staff” in PHL, are staff such as social workers, nurses, options
counselors, case managers, etc. identified at each organization who are assigned to complete program
documentation and oversee individuals (i.e. clients) whose information is included in the PHL platform.
Users:
Access, enter, and update information pertaining to the clients that have been assigned
to their caseload, by the organizational PHL Manager/Supervisor or local Administrator
Request their organizational PHL Administrator reset passwords and transfer clients to
another social worker, nurse, options counselor, etc. as needed.
Report any issues related to PHL to their local Administrator
Manager or Supervisor- Each organization can identify individuals who will have limited Administrative
rights, based on the needs of the organization, generally these individuals would be Managers or
Supervisors who oversee the work of the staff assigned as PHL Users. Manger or Supervisors:
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Complete Administrative duties that are assigned to them as defined by the organization
(i.e. assign referrals to Users, etc.)
Answer questions related to PHL for local Users
Provide ongoing training related to PHL for local Users, as assigned by local PHL
Administrator
Report any issues related to PHL to their local Administrator
Contract Users- Each organization that purchases a PHL license may identify individuals who are contracted
by the organization to provide services to clients and work within the PHL platform. These individuals may
be given limited rights to PHL as designated by the licensee (i.e. ability to make referrals, read data, etc.).
Contract Users:
Access information pertaining to the clients assigned to their organization by the local PHL
Administrator or Super User
Complete other duties as authorized by the licensee (i.e. accept referrals via PHL; provide
status updates in PHL, etc.)
Report any issues related to PHL to the local PHL Administrator or Super User
Clinician- Each organization that purchases a PHL license may identify local healthcare Clinicians who will be
given limited rights to PHL as designated by the licensee (i.e. ability to make referrals, read data, etc.).
Clinicians:
Access, enter, and update information pertaining to the clients that have been assigned
to their caseload, by the organizational PHL Administrator
Request the organizational Administrator reset passwords and transfer clients to
another clinician as needed
Report any issues related to PHL to the local PHL Administrator
Subcontracted Users- Each organization that purchases a PHL license may identify individuals from sub-
contracted organizations who will be given limited rights to PHL as designated by the licensee (i.e. ability to
make referrals, read data, etc.). Subcontracted Users:
Access information pertaining to the clients assigned to their organization by the PHL
Administrator
Complete other duties as authorized by the licensee (i.e. accept referrals via PHL; provide
status updates in PHL, etc.)
Report any issues related to PHL to the local PHL Administrator
Referral Users- Each organization that purchases a PHL license may identify individuals from local
organizations who will be given limited rights (i.e. referrals, read data, etc.) to PHL as designated by the
licensee to make or receive referrals via PHL. Referral Users:
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Access information pertaining to the clients assigned to their organization by the PHL
Administrator
Complete other duties as authorized by the licensee (i.e. accept referrals via PHL; provide
status updates in PHL, etc.)
Report any issues related to PHL to the local PHL Administrator
Other- Each organization that purchases a PHL license may identify individuals either within their
organization or from local organizations that do not fit into one of the designated categories above who will
be given limited rights (i.e. referrals, read data, etc.) to PHL as designated by the licensee. For example one
customer has a clerical staff that enters preliminary data about clients in PHL and this User is identified as
“Other” so she/he has the proper security rights to areas of PHL. Other Users:
Access information pertaining to the clients assigned by their PHL Administrator
Complete other duties as authorized by the licensee (i.e. accept referrals via PHL; provide
status updates in PHL, etc.)
Report any issues related to PHL to the local PHL Administrator
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PHL User Activities
The following are tasks to be completed by PHL Users (also called “Field Staff” in PHL). “Users” are defined as those
staff that work directly with clients and enter data related to the client into PHL.
PHL Login
Prior to logging into PHL for the first time a User must be enrolled in PHL by a local PHL Super User/ Administrator
and be assigned a PHL User login and temporary password. The User will be prompted to reset their password once
they have entered the PHL platform for the first time. The PHL Password should be a unique password that is NOT
used for other programs. This process will be described later in the PHL User Manual.
1. To login the User will connect via the PHL link provided by their local PHL Administrator which will take
them to the PHL login screen. The User should bookmark this link for easy access to the site (see
EXAMPLE below):
2. The User will enter their User Name (will generally always be the User’s organizational email address )
and the temporary password provided by their local PHL Administrator and click the “Submit” button.
3. The first time the User completes this login process they will be prompted to reset their password, see
directions below under “Resetting Password.” Once the User has established their own password PHL will
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take the User to their “landing page” which will be the PHL “Field Staff Home” page. (see EXAMPLE
below):
4. The Field Staff Home page includes two tables, “My Case Load” and “Client Service Delivery Program(s)
Status.” If the User does not have any assigned client’s these tables will be blank. The “My Case Load”
Table includes a list of clients assigned to the User (the clients will only appear in this list once) and the
“Client Service Delivery Program(s) Status” Table includes a list of the client’s assigned to the User
including each program/service to which the client has been referred. In this table the client(s) may
appear more than once if they have been referred for more than one program/service (see EXAMPLE
below). In the example below Mr. Lee Kong’s name appears once in the “My Case Load” Table and
appears twice in the “Client Service Delivery Program Status” Table because he has been referred for two
different programs: Care Transitions and Home Delivered Meals.
Resetting PHL Passwords
1. Once a PHL User has logged on using the temporary password provided by their PHL Administrator, they
will be prompted to change their password. The User will see the following screen (see EXAMPLE below):
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2. Enter the temporary password in the field “Old/Temp Password.”
3. Select and enter a unique new password in the following fields “New Password” and “Re-enter New
Password” (The User should NOT use a common password they have used for other programs to protect
the security of PHL).
4. Then click “Change Password” to save the new password.
5. Be sure to follow the PHL Password Rules (see Password Rules below):
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6. The PHL User Name will NOT change; it will generally always be the User’s organizational email address
7. Once the new password is saved the User will see the following window which will allow them to login to
PHL using the new password (see EXAMPLE below):
8. If a User enters the incorrect login or password they will receive an error message indicating the
credentials entered are invalid. After 5 unsuccessful attempts to login a user is locked out of the system
and will need to contact their local PHL Administrator to reset their password (see EXAMPLE below):
9. PHL passwords need to be changed every 90 days. The User will receive a notification when it is time to
change a password.
10. PHL Users should not share their PHL password with any other PHL User; it is for their use only.
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Receiving a Referral in Population Health Logistics (PHL)
Follow the process outlined below to receive an assigned referral in PHL.
1. The PHL User will receive an email from PHL (or their local supervisor) indicting they have a new referral in PHL (see EXAMPLE of email message below):
2. Open PHL to the “Field Staff Home” page which provides the User with two tables, “My Case Load” and
“Client Service Delivery Program(s) Status” (see EXAMPLE below):
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3. New clients generally appear at the bottom of the “My Case Load” table. Click on the new client's name in
the "My Case Load" table and contact the client to begin the process for enrolling in that particular program /service (i.e. arrange home visit if required, complete phone assessment to determine eligibility for service, etc.). NOTE in PHL the term “visit” equals a contact. A “visit” can be completed face to face, via phone, via email, with the client, with a caregiver or with another provider who may be working with the client.
4. Click on the "New Visit" Tab to document the contact with client (see EXAMPLE below):
5. Once information from the contact is documented, click “Save visit info” button and the “visit” will be added to the “Visit Table” on the left-hand side of the “Visit” screen (see EXAMPLE below):
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6. Complete a “visit” as required by the program protocol and document "New Visit" and all information
required for that program/service in PHL.
SERVICE DELIVERY-General
“Field Staff Home” Tab
Field Staff also called “Users” in PHL are those staff assigned by the organization to work directly with the clients
whose data will be entered into PHL. Users (field staff) are identified by the organization and assigned referrals in
PHL by an organizational staff that has PHL Administrative or Supervisor rights. Users may be social workers,
options counselors, nurses, case managers; care transitions coaches, etc. based on the program using PHL.
1. The “Field Staff Home” Tab is located at the top of the PHL Home Page (see EXAMPLE below):
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2. The assigned User clicks on the “Field Staff Home” button to access the Field Staff Home page (or the
organization can choose to have User open PHL directly to this page). The User will see two separate
tables on this page, “My Case Load” and “Client Service Delivery Program Status” (see EXAMPLES below):
My Case load
a. The “My Case Load” Table contains a list of all the active clients assigned to the User.
b. If the User clicks on a specific client, PHL automatically opens to the “Client’s Demographics” page
where the User can review or update any information contained under the “Client” Tab.
1. A window (titled “User Tasks”) will open which lists the names of the clients from the User’s case load
that have tasks which need to be completed over the next 7 days, any overdue items will appear in red
text (see EXAMPLE below):
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SERVICE DELVERY- CLIENT
“Client’s Demographics” Tab
Access this Tab by clicking on “New Client” (under the Client Tab) or by finding an existing client via the “Search
Client” feature (under the Client Tab or on the PHL Home Page).
The “Client’s Demographic” page must be completed before other Tabs in the Client Section become active (i.e.
Contact, Insurance, Caregiver, Household, Needs/Barriers, Income/Assets, Level of Care, Goals/Objectives, Staff
Goals/Objectives, Resources, Summary, Visit Notes, and Files).
1. All fields marked with a red asterisk (*) are required and must have information entered to complete the
save process (see EXAMPLE and item descriptions below):
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a. Client CBO#- This number is automatically generated by PHL once a client is “enrolled” in PHL
b. Company*- Select from items in dropdown box, required. This should be the name of your
organization
c. First Name*- Text field, required
d. Middle Name- Text field
e. Last Name*-Text field, required
f. Marital Status- Select from items in dropdown box
g. Gender*- Select from items in dropdown box, required
h. Race- Select from items in dropdown box
i. Social Security Number (SSN)- Enter as a number, if entered in error, you may click on the “X”
to clear the field
j. Date of Birth (DOB)- Click on the field and a calendar will open, you may select the DOB from
the calendar or text enter the date as a 2 digit month, 2 digit day and 4 digit year (EXAMPLE:
11/04/1937); if entered in error, you may click on the “X” to clear the field
k. Veteran- Check this box if client is a veteran, if not leave blank
l. Spoken Language- Select from items in dropdown box
m. Save client info- Click on this button to save information entered, remember once saved all
information is stored indefinitely in the PHL; it can be inactivated but not erased
n. Clear- Click on this button to erase information prior to it being saved
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o. People with HIPAA consent- This section will auto populate based on data entered under the
“Emergency Contact” or “Household” Tabs, if that data has not been entered this section will
be blank
“Contact” Tab
1. Access the Contact Tab by clicking on “Contact,” under the Client section of PHL (see EXAMPLE below):
2. New contact info- Click on this button to enter new contact information for the client
3. To update an existing entry- Click on desired row to edit (see EXAMPLE below):
4. Once you open the New Contact Info, click on the “PICK A CONTACT METHOD FOR NEW CONTACT INFO”
dropdown box and select from the items listed (i.e. address, phone, or email). Once a method is selected,
an additional window will open for the User to enter contact data (See EXAMPLE below):
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5. Enter the client’s contact information in the new window . Check the box following the word “primay” if
this is the “primary” way to contact this individual. Check the “Active” box if this is active data. You can
remove the check in the “active” box if data is no longer active (for example if a phone number is no
longer working but you want to save it in the PHL history, if you remove the check in the active box it will
no longer appear as active data but will NOT be erased from the data history). (see EXAMPLE below):
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6. Enter information about each contact method (phone, address, email) as desired and save. Once saved
the data will be added to the “Client’s Contact” Table at top of Contact Tab (see EXAMPLE below):
Making a New PHL Referral = Creating a New Participant in SASH Any PHL User with referral rights can make a referral in PHL. Follow the steps outlined below to make a referral.
1. Hover over the “Client Management” Tab and select “New Referral”
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2. This will open a new window “Add Referral” (see EXAMPLE and item descriptions below):
3. The “Referral Source,” “Referral Source Full Name” and “Referral Source Email” will auto populate with the
information of the User who has the PHL platform open, this information can be changed if need be by
selecting other information from the dropdown box or typing over the auto populated information.
4. Select the “Referral Program” the client is being referred to from the dropdown box provided.
5. Define SASH Programs here and instruct for staff
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6. Complete all required fields that are marked with a * and any additional fields your organization requires.
a. Save Referral Info- Click this button to save information entered, remember once saved, all
information is stored indefinitely in the PHL system; it can be inactivated but not erased
b. Save Referral Info and Next- Click this button to save information entered and enter additional
referrals, remember once saved, all information is stored indefinitely in the PHL system; it can be
inactivated but not erased
c. Clear- Click this button to erase information prior to it being saved
7. Once the referral is saved, additional information will appear at the bottom of the page (see EXAMPLE
below)
Primary Contact Same as Above: Check this box if the Client listed is
also the primary contact.
Background info for Immediate Follow up: This is a required field.
Some organizations use this text box to share directions to the
client’s home or specific client needs.
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8. Click on “Show Clients Window” this will open a new window (“Client Validation”) that displays all clients
enrolled in PHL who have a name similar to the client who is being referred (i.e. in this example the client
being referred is Tony Wright. See client’s with similar names listed below):
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9. If the client is already enrolled in PHL, select his/her name from the Client Validation box by clicking the
client’s name (make sure you scroll through all of the pages by using the arrows in the lower right corner)
10. Clicking on the client’s name will open another window where you can determine if the client has already
been referred for the current service (in this example Tony Wright is being referred for HDM. The new
Table below indicates he has been referred for Care Transitions 30 day program but not HDM). If the client
has not previously been referred, the User should click the “Accept Referral” button to accept the new
referral (in this example Tony Wright for HDM). If the client had already been referred the User could click
the “Reject Referral” button so there is not a duplicate referral for the same service.
11. Once the Referral is accept, PHL will return the User to the Referral Page and ask the User to select a valid
MCOC (Managed Care Options Counselor ) or Social Worker (see EXAMPLE below):
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12. The User should check the “Accept Referral?” box and select both an “Agency” and “MCOC or Social
Worker” from the dropdown boxes provided and provide any instructions in the text field.
13. The final step is to click the “Save Referral Info” button again. The User will than receive the following
message from the PHL platform (see EXAMPLE below):
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14. If you are unable to find the client in the Client Validation Table (in this Example, the client’s name is Cecil
Canfield) the User should click the “Unable to Locate Client” button (see EXAMPLE below):
15. This will activate an additional button , “Create a New Client” which will be located next to the “Cancel”
button. Click the “Create a New Client” button and you will be taken to the “Client’s Demographic” Tab
which will be auto populated with information entered in the referral for this new client.
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16. Select the Company (this is the PHL license holder) and select Save Client Info
17. Once you save the “Client’s Demographic” Tab information, PHL will return you to the “Edit Referral” Tab.
Select “Show Clients Window” again to verify that the client information was saved in PHL.
18. The new client’s information should now appear on the “Client Validation” Table. Select the client’s name
in Table and you will receive the following window:
19. Click the “Accept Referral” button and you should receive a message from PHL indicating the Referral is
Updated Successfully (see EXAMPLE below):
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20. Now check the “Accept Referral” checkbox and assign the referral to an Agency and MCOC or Social Worker
and then click the “Save Referral Info” button (see EXAMPLE below):
21. Once saved the User will receive a second message indicating the Referral was updated successfully (see
EXAMPLE below):
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“Insurance” Tab
1. Access this Tab by clicking on “Insurance” under the Client section (see EXAMPLE and item descriptions
below):
2. Once information is saved the User should see a message indicating the information was successfully
added and the details will appear in the “Add or Edit Client’s Insurance Information” Table on this page
(see EXAMPLE below):
4. To update existing information, click on the line to edit in the “Add or Edit Client’s Insurance Information”
Table, update the information and click the “Update Insurance Info” button to save the updated
information. The updated information will override the old information in the “Add or Edit Client’s
Insurance Information” table.
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“Emergency Contact” Tab
1. Access this Tab by clicking on “Emergency Contact” under the Client section (see EXAMPLE below):
2. Click on the “Add Emergency Contact” button to enter information about a new caregiver (see EXAMPLE
below):
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Emergency Contact Details
3. Once the “Add Emergency Contact” button is clicked a new window, “Emergency Contact Details” will
open to allow entry of emergency contact information (see EXAMPLE and items descriptions below):
a. Active? – Check this box to indicate this data is for an active emergency contact. Note: if no
longer an active emergency contact, remove check from box. No data that has been saved in
the PHL platform is ever deleted from PHL, it is only inactivated. By removing the check, you
will be indicating that this person is no longer the emergency contact but they will not be
removed from the PHL history
b. Save emergency contact details- Click on this button to save information entered
c. Clear- Select this button if data was entered in error, prior to saving. Once data is saved, it
can NOT be deleted from PHL, only inactivated
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Emergency Contact’s Contact
4. The Emergency Contact “Contact Tab” allows the User to enter contact information for a individual
including: address, phone, and email data. Please note, you must first complete the “Emergency Contact
Details” page prior to entering contact information for an individual (see EXAMPLE below):
5. Enter contact data for emergency contact and then click the “Save Contact Info” button (see EXAMPLE
below):
6. Once contact data is saved it will be added to the “All Client’s Care Givers” Table at the top of the
Caregiver Tab (see EXAMPLE below):
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7. To update existing contact data- Click on row of data in the “All Client’s contact’s” table. This will open a
page that will allow the user to edit existing caregiver data.
“Needs/Barriers” Tab
1. Access this Tab by clicking on “Needs/Barriers” under the Client section (see EXAMPLE below):
2. The first 12 items on the Needs/Barriers Tab (“Services Being Provided” through “Education”) allow the
User to select multiple items from each dropdown box by checking the box next to each item in the list
(see EXAMPLE and item descriptions below):
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a. Services being provided- Indicate the services a client is currently using, if any, by selecting the
check box next to each item in the dropdown box. Check all that apply.
b. Case Management- Indicate the type of case management the client needs, if any, by selecting
the check box next to the appropriate option in the dropdown box. Check all that apply
c. Food- Indicate the type of food needs, if any, the client has by selecting the check box next to
the appropriate option(s) in the dropdown box. Check all that apply.
d. Housing- Indicate the type of housing needs the client has, if any, by selecting the check box
next to the appropriate option(s) in the dropdown box. Check all that apply.
e. Home Modification- Indicate the type of home modification needs the client has, if any, by
selecting the check box next to the appropriate option(s) in the dropdown box. Check all that
apply.
f. Utility Assistance- Indicate the type of utility assistance the client needs, if any, by selecting the
check box next to the appropriate option(s) in the dropdown box. Check all that apply.
g. Transportation- Indicate the type of transportation needs the client has, if any, by selecting the
check box next to the appropriate option(s) in the dropdown box. Check all that apply.
h. Medical- Indicate the type of medical needs the client has, if any, by selecting the check box
next to the appropriate option(s) in the dropdown box. Check all that apply.
i. Financial- Indicate the type of financial needs the client has, if any, by selecting the check box
next to the appropriate option(s) in the dropdown box. Check all that apply.
j. Legal- Indicate the type of legal needs the client has, if any, by selecting the check box next to
the appropriate option(s) in the dropdown box. Check all that apply.
k. Employment- Indicate the type of employment needs the client has, if any, by selecting the
check box next to the appropriate option(s) in the dropdown box. Check all that apply.
l. VA Benefits?- Check this box if the client has or needs to apply for VA benefits
m. Notes- The User may enter notes in this text box, however no reports will be generated from
data entered in this field
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n. Save Needs/Barriers- You must save all information entered, select this button to save
information before moving on
o. Clear- Select this button if data was entered in error, prior to saving. Once data is saved, it can
NOT be deleted from PHL, only inactivated
3. Once the User clicks the “Save Needs/Barriers” button the Needs/Barriers information it will be added to
the “Needs & Barriers Selected” Table at the top of the Needs/Barriers Tab (see EXAMPLE below):
“Goals/Objectives” Tab
1. Access this Tab by clicking on “Goals/Objectives” under the Client section (see EXAMPLE below):
2. Needs & Barriers Selected- This section is automatically populated by PHL from items selected by the User
on the Needs & Barriers Tab (see EXAMPLE below):
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3. Add a goal- Select this button to add a goal (See EXAMPLE below):
4. Once the “Add a goal” button is selected another window will open to allow the User to select a goal
from the list in the “Goal” dropdown box (See EXAMPLE and item descriptions below):
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a. Goal- Select a goal from the possible options in the dropdown box. Note: if you select “Other”
a text box will appear that allows you to document the specific goal (See EXAMPLE below):
b. Status- Select the status of the goal from the options in the dropdown box
c. Primary- Check this box if this is the client’s primary goal, if not leave blank
d. Save goal details- You must save all information entered, select this button to save
information before moving on
e. Add a Goal- this button allows you to add an additional goal
5. Once a goal is saved it will populate the “Client’s Current Goals and Objectives” Table (see EXAMPLE
below):
6. In addition, once a goal is saved a new button, “Add Objective” will appear next to the “Add a Goal”
button- select the “Add Objective” button and a new window will open (See EXAMPLE and item
descriptions below):
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a. Objective- Select from the items in the dropdown box
b. Objective Status- Select from the items in the dropdown box
c. Primary- Check this box if this is the primary objective for this goal, if not leave blank
d. Save Objective- You must save all information entered, select this button to save
information before moving on
e. Add Objective- Select this button to add additional objectives
f. Clear- Select this button if data was entered in error, prior to saving. Once data is saved, it
can NOT be deleted from PHL, only inactivated
7. Once an objective is saved the information will be added to the “Current Objective for Goal:---“ Table
(see EXAMPLE below):
“Summary” Tab
1. Access this Tab by clicking on “Summary” under the Client section (see EXAMPLE below):
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2. The Summary Tab includes 2 sections: “Client Summary” and “Client Participation” (See Below):
Client Summary: Physician Follow-up Letter
1. The “Client Summary” allows the User to develop a “Hospitalization Notification Physician Follow-up
Form” that can be shared with the client’s Primary Care Provider. This WORD document details
information collected by the User during a post hospitalization home visit with the client. This form auto
populates with data pulled for various sections of PHL.
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2. To generate this WORD document the User must first select the desired Primary Care Provider (PCP) from
the dropdown box under the “Client Summary” section (see EXAMPLE below):
3. Once the correct PCP has been selected the User should click the “Download Summary” button (see
EXAMPLE below):
4. Clicking on the “Download Summary” button will generate the WORD document which can be found in
the bottom left hand corner of the computer screen. Click on the WORD document to open it (see
EXAMPLE below):
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5. The WORD document will open in “Protected View.” The User can edit the document by clicking the
“Enable Editing” button at the top of the page (see EXAMPLE below):
6. This WORD document details information collected by the User during a post hospitalization home visit
with the client. This form auto populates with data pulled for various sections of PHL, including the
“Readmit Root Cause” Tab, the “Care Utilization’ Tab and the “Visit Details” Tab.
7. Once the Client Summary Document is complete with any additional edits by the User, the document can
be saved to the Users computer files as a PDF and then uploaded to the client’s PHL file via the “Files”
Tab. This process is detailed under the “Files” section of this User Manual.
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Client Summary: Client Participation Notification
1. The Client Participation Feature on the “Summary” Tab allows the User to download another document,
the “Notification of Patient Participation.,” This document is designed to pull different data from
throughout the PHL platform that includes information from the “Needs & Barriers” Tab, Assessments
Tabs (i.e. Fall Risk Assessment, PHQ2), “Medication Review” Tab and make recommendations for
referrals to evidence-based programming (see EXAMPLE and item descriptions below):
a. Agency- Select from the items in the dropdown box
b. Program - Select from the items in the dropdown box
c. Visit Type - Select from the items in the dropdown box
d. Visit Date Range From- Text field, required; enter as date (i.e. 01/01/2001)
e. Visit Date Range To-Text field, required; enter as date (i.e. 01/01/2001)
f. Search- Click this button to search for clients that meet the criteria you entered above
g. “Results” Table- Any clients that meet the search criteria entered will display in this table
2. To open the desired document, highlight the client’s name on the “Results” Table and click the
“Download Selected” button.
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3. Clicking on the “Download Selected” button will generate a WORD document which can be found in the
bottom left hand corner of the computer screen. Click on the WORD document to open it (see EXAMPLE
below):
4. The WORD document will open in “Protected View.” The User can edit the document by clicking the
“Enable Editing” button at the top of the page (see EXAMPLE below):
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5. This WORD document details information collected by the User during an assessment visit with the client.
This form auto populates with data pulled for various sections of PHL, including the “Needs & Barriers”
Tab, Assessments Tabs (i.e. Fall Risk Assessment, PHQ2), and “Medication Review” Tab and allows the
User to make recommendations for referrals to evidence-based programming. This document can be
used to keep the PCP, home health agency, funder, client or long distance caregiver informed about
information gathered during an assessment visit.
6. Once the Notification of Patient Participant Document is complete with any additional edits made by the
User, the document can be saved to the Users computer file as a PDF and then uploaded to the client’s
PHL file via the “Files” Tab. This process is detailed under the “Files” section of this User Manual.
“Visit Notes” Tab
1. Access this Tab by clicking on “Visit Notes” under the Client section (see EXAMPLE below):
2. This Tab displays a list of notes entered from previous client “visits” and including the date and time of
visit, and any notes entered related to that visit by the User. If no notes have been entered from previous
visits this section will be blank. Notes can NOT be entered on this Tab, this is only a place to view
previously entered notes from the “Visit” section (see EXAMPLES below):
EXAMPLE: Client with previous visit notes
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“Files” Tab
1. Access this Tab by clicking on “Files” under the Client section (see EXAMPLE below):
2. This Tab allows the User to upload and view other documents in the client’s PHL file (see EXAMPLE
below):
3. Click the “Choose File” button and then locate/select the desired file from the User’s computer folder by
selecting “Open” (see EXAMPLE below):
EXAMPLE: Client with no previous visit notes
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4. Once the desired file is “Open,” click “Upload File”, to add the file to PHL (see EXAMPLE above):
5. Once uploaded the file appears on the “Existing Files” Table (see EXAMPLE below):
6. To view a file loaded on PHL click on the “Click to download” item in the “File ID” column (see EXAMPLE
above).
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“Visit” Tabs
There are two Tabs in the Client section of PHL related to client visits- “View Visits” and “New Visit.” A “Visit” in
PHL is equal to a contact, so a “Visit” may be completed face to face, via a phone call, via an email exchange, via
fax, etc.
New Visit Tab
The “New Visit” Tab allows Users to enter information about a new contact with or about a client (i.e. coordinating
resources, contact with a caregiver, etc.). The “New Visit” tab is located in the Client section of PHL (see EXAMPLE
below):
1. The User can open the client’s PHL chart via the “Search Client” feature or at their Case Load window (field
staff home). Once you are on the Client’s Demographics page click on the “New Visit” tab (see above). This
will open the “Visit Details” window where information about the visit (any sort of contact with or about
the client) can be entered (see EXAMPLE and item descriptions below):
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a. Select Program That You are Doing This Visit For*- Select from the items in the multiple check box
field, check all that apply, required field. If at least one service or program is not selected PHL will
give the User an error message upon saving (see EXAMPLE below):
b. Visit Date*- Text field, required. Enter the date of the interaction
c. Visit Type*- Text field, required. Select from the items in the dropdown box
d. Visit Coordinator*- This field will default to the User who is signed into PHL but the User can
select another individual from the dropdown box if appropriate, required field
e. Inactivate Visit?- Leave blank, this can be used later if this visit needs to be Inactivated for some
reason.
f. Save Visit Info- Select this button to save information before moving on
g. Clear- Select this button if data was entered in error, prior to saving. Once data is saved, it can
NOT be deleted from PHL, only inactivated
2. Once the “Visit Details” are saved, the User has access to multiple other Tabs via the “Visit Details” page.
(see EXAMPLE below):
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View Visits Tab
The “View Visits” Tab offers a list of the recent visits connected to the client whose information is open in PHL (See
EXAMPLE below):
1. Place your curser on “View Visits” Tab to open a dropdown box with a list of previous visits (see EXAMPLE
below):
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2. Click on any item in the “View Visits” list, this will take you to the “Visit Details” page for that visit. In
addition, the “View Visits” Tab allows the User to access all the additional Tabs your organization has
chosen to have available to Users.
3. Both the “New Visit” and “View Visits” Tabs have multiple sections which mirror each other (see
EXAMPLES below):
4. The top left hand corner of the Visit Tabs contains a list of previous “visits” (contacts). If no visit
information is entered for the client this section will be blank. This table includes the visit date and type of
visit (contact) (see EXAMPLE below):
Full screen shot of “New Visit” tab. If there is
information entered in PHL from a previous
visit, the “View Visits” page contains similar
information, see section descriptions below.
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5. The User can view information from a previous visit by clicking on the visit date; this will open the “Visit
Details” from that visit (see EXAMPLE below):
6. In addition, the User can add information about a new visit by clicking the “Add Visit” button under the
Visit Table on the left hand side of the page and can move back to the Client’s Demographics page by
clicking on the “Client Details” button which is located under the “Add Visit” button (see EXAMPLE above).
7. Once “Visit Details” are saved the information is added to the “Visit” Table in the upper left hand corner of
the page (see EXAMPLE below):
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“Care Utilization” Tab
The “Care Utilization” Tab is located in the “Visit” section and is where the PHL User can track the client’s
utilization of healthcare services (i.e. hospitalizations, ER visit, outpatient services).
NOTE: SASH Vermont users will have utilization automatically fed into PHL from PatientPing starting soon. No
need to enter here once that begins.
1. Click on the “Care Utilization” Tab (under the “New Visit” Tab or under the “View Visits” Tab if data was
entered for a previous visit). If there is previous information entered on the “Care Utilization” Tab it will
appear in the “Client’s Previous Care Utilization Details” Table at the top of the page, if no previous
information was entered this Table will be blank (see EXAMPLE below):
2. The User can add information about a current or recent care utilization occurrence by clicking the “Add
Care Utilization Details” button (see EXAMPLE below):
3. Complete the “Add Care Utilization Since Last Visit” details
4. Once Care Utilization details have been saved the information will be added to the “Client’s Previous Care
Utilization Details” Table at the top of the page (see EXAMPLE below):
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“Clinician” Tab
The “Clinician” Tab is located in the “Visit” section of PHL and allows the User to document data about the
1. Click on the “Clinician” Tab to open a new page that includes the Client’s Clinician Details” Table and the
location to enter new information or edit existing data (see EXAMPLE below):
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2. The “Client’s Clinician Details” Table includes a list of information entered in PHL to date for this client; if
no clinician information has been entered this Table will be blank. Also note if a clinician is no longer
providing service to a client, they can be inactivated. This is noted in the column labeled “Active” on the
“Client’s Clinician Details” Table, a “true” in this column indicates the clinician is active while “false”
indicates the clinician is not an active provider for this client (see EXAMPLE and item descriptions below):
a. Clinician Name*- Text enter name of clinician, required (this information will be used to auto
populate a number of other dropdown boxes within PHL, so the clinician information entered
here is extremely important. If a clinician’s name is missing from a dropdown box elsewhere
in PHL this is the location it will need to be entered to populate the other field.)
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3. Once the Clinician Details have been saved the new information will be added to the “Client’s Clinician
Details” Table at the top of the page (see EXAMPLE below):
“Diagnosis” Tab
The “Diagnosis” Tab is located in the “Visit” section of PHL and allows the User to enter details about the client’s
medical diagnoses.
1. Click on the “Diagnosis” Tab to open a new page that lists the current information about the client’s
diagnosis (“Client Diagnosis” Table) and allows the User to enter new data or edit existing diagnosis data.
Diagnoses can be listed in PHL either by ICD 10 Codes or via a dropdown box that reflects the most
common diagnosis seen by an organization or self-reported by client’s (“Non-Clinical Diagnosis”). SASH
will NOT be using the ICD 10 Codes so the User may ignore these fields (see item descriptions below):
a. Non-clinical Diagnosis- = Chronic Conditins - Select from the items listed in the dropdown
box. .
b. Effective Start Date of Dx Code- Click on field to open a calendar and select date; this field can
be left blank or the User can enter the date of the assessment if it is not a new diagnosis
c. Effective End Date of Dx Code- Click on field to open a calendar and select date
d. Date of onset/exacerbation- Click on field to open a calendar and select date; it is not
necessary to complete this field.
e. Clinician- Select from the items listed in the dropdown box, if the current clinician is not listed
in dropdown box, the information will need to added under the “Clinician” Tab. Information
from the Clinician Tab auto populates this dropdown box
f. Questions this client has about their diagnosis- Text field
g. Would this client like a consult about their diagnosis?- Click button that corresponds to the
client’s answer to this question
h. Would this client like to get another option about their diagnosis from another clinician? Click
button that corresponds to the client’s answer to this question
i. Active?- Check this box to indicate this data is active in PHL
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j. Save Diagnosis Info- Select this button to save information before moving on
k. Add Diagnosis- Select this button to add information about additional Diagnoses
l. Clear- Select this button if data was entered in error, prior to saving. Once data is saved, it
can NOT be deleted from PHL, only inactivated
2. Once the “Diagnosis Details” have been saved the information will be added to the “Client’s Diagnosis”
Table at the top of the page (see EXAMPLE below):
“Meds” Tab
The “Meds” Tab is located in the “Visit” section of PHL and allows the User to enter details about the client’s
medications.
1. Click on the “Meds” Tab to open a new page that lists current information about the client’s medications
entered into PHL ( “Client Medications Details” Table) and allows the User to enter new data or edit
existing medication data (see EXAMPLE and item descriptions below):
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a. Medication Name*- Select from the items listed in the dropdown box, required
b. Strength- Text field
c. Units- Select from the items listed in the dropdown box
d. Dosage Frequency- Select from the items listed in the dropdown box
e. Dosage Number- Select from the items listed in the dropdown box
f. Dosage Method- Select from the items listed in the dropdown box
g. Special Instructions- Select from the items listed in the dropdown box
h. Medication Compliance Status- Patient– Select from items in multiple checkbox field (check all
that apply)
i. Medication Compliance Status- System Level– Select from items in multiple checkbox field
(check all that apply)
j. Prescribing Provider- Select from the items listed in the dropdown box, if the current clinician
is not listed in dropdown box, the information will need to add under the “Clinician” Tab.
Information from the “Clinician” Tab auto populates this dropdown box
k. Prescribed on Date- Click on field to open a calendar and select date
l. Expected Refill Date- Click on field to open a calendar and select date
j. Dispensing Pharmacy- Select from the items listed in the dropdown box
n. Pharmacy Notes- The user may enter pharmacy notes in this text box, however no reports will
be generated from data entered in this field
o. Client would like to consider an alternative medication if available? – Check this box if the
client is interested in this
p. Client would like additional information about why they are taking this medication? – Check
this box if the client is interested in this
q. Where this information was gathered?- Select from items in multiple checkbox field (check all
that apply)
r. Active?- Check this box to indicate this data is active in PHL
s. Notes- The User may enter general notes in this text box, however no reports will be
generated from data entered in this field
t. Save Medication Info- Select this button to save information before moving on
u. Add Medication- Select this button to add information about additional medications
v. Clear- Select this button if data was entered in error, prior to saving. Once data is saved, it
can NOT be deleted from PHL, only inactivated
2. Once the Medication Details have been saved the information will be added to the “Client’s Medications
Details” table at the top of the page (see EXAMPLE below):
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“Allergies” Tab
The “Allergies” Tab is located in the “Visit” section of PHL and allows the User to enter details about the client’s
allergies.
1. Click on the “Allergies” Tab to open a new page that lists the current information about the client’s
allergies entered into PHL ( “Client’s Allergy” Table) and allows the User to enter new data or edit existing
allergy data (see EXAMPLE and item descriptions below):
a. Allergy Name- Text field
b. Allergy Notes- Text field, the User may enter notes in this text box, however no reports will be
generated from data entered in this field
c. Intolerance Name- Text field no reports will be generated from data entered in this field
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d. Intolerance Notes- Text field, the User may enter notes in this text box, however no reports
will be generated from data entered in this field
e. Active?- Check this box to indicate this data is active in PHL
f. Save Allergy Info- Select this button to save information before moving on
g. Add Allergy- Select this button to add information about an additional Allergy
h. Clear- Select this button if data was entered in error, prior to saving. Once data is saved, it
can NOT be deleted from PHL, only inactivated
2. Once saved the “Allergy Details” information will be added to the “Client’s Allergy” Table at the top of the
page (see EXAMPLE below):
“Vitals” Tab
The “Vitals” Tab is located in the “Visit” section of PHL and allows the User to enter data about the client’s vital
signs.
1. Click on the “Vitals” Tab to open a new page that lists the current information about the client’s vital
signs entered in PHL ( “Client Vitals” table) plus an area that allows the User to update or add
information, “Add Vitals” (see EXAMPLE and item descriptions below):
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2. Once the information entered into the “Vitals” Tab is saved the information will be added to the “Client’s
Vitals” Table at the top of the page, this will allow for a comparison with previous data. Scroll across the
table to see all data included in the table (see EXAMPLE below):
“PSMS” (ADLS) Tab
The “PSMS (ADLS)” Tab is located in the “Visit” section of PHL and allows the User to enter data about the client’s
Activities of Daily Living (ADL) status. PSMS is the abbreviation for “Physical Self-Maintenance Scale. This tool is
useful for indicating specifically how a person is performing at the time of the assessment. The higher the score the
more assistance an individual requires with ADL’s . Repeated scoring serves as documentation of the person’s
functional improvement or deterioration over time.
1. Click on the “PSMS” Tab to open a new page that lists information about the client’s previous PSMS scores
entered in PHL ( “Client’s Previous PSMS” Table) plus an area that allows the User to update or add
information, “Add Physical Self-Maintenance Scale (PSMS)” (see EXAMPLE and item descriptions below):
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2. Once saved, the User will see a message indicating the information was added. There is no “score” for the
SASH ADL/IADL. It is a screening tool for level of daily function ability.
“IADL’s” Tab
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The “IADLS” Tab is located in the “Visit” section of PHL and allows the User to enter data about the client’s
Instrumental Activities of Daily Living (IADL) status. This tool is useful for indicating specifically how a person is
performing at the time of the assessment.
1. Click on the “IADL” Tab to open a new page that lists information about the client’s previous IADLS scores
entered in PHL ( “Client’s Previous IADLS” table) plus an area that allows the User to update or add
information, “Add Instrumental Activities of Daily Living (IADLS)” (see EXAMPLE and item descriptions
below):
2. Once saved, the User will see a message indicating the information was added or updated successfully.
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“PHQ 9” Tab
The “PHQ 9” Tab is located in the “Visit” section of PHL and allows the User to enter data on the Patient Health
Questionaire-9 (PHQ-9). The PHQ-9 is a multipurpose instrument for screening, diagnosing, monitoring and
measuring the severity of depression. The PHQ-9 incorporates DSM-IV depression diagnostic criteria with leading
major depressive symptoms into a brief self-report tool.
1. Click on the “PHQ 9” Tab to open a new page that lists information about the client’s previous PHQ-9
scores entered in PHL ( “Client’s PHQ9 Details” table) plus an area that allows the User to update or add
information, “Patient Health Questionnaire-9” (see EXAMPLE and item descriptions below):
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Over the last two weeks, how often have you been bothered by any of the following problems?
2. Once saved, the PHQ9 Score will be added to the “Client’s PHQ9 Details” Table at the top of the page, this
will allow for a comparison with previous data (see EXAMPLE below):
“Nutrition Assessment” Tab
The “Nutrition Assessment” Tab is located in the “Visit” section of PHL and allows the User to enter data on a
nutritional assessment to determine the client’s nutritional risk plus an area that allows the User to update or add
additional information, “Client’s Nutrition Assessment Details” Table (see EXAMPLE and item descriptions below):
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1. The User should ask the client the questions on the Nutritional Assessment and document their
responses directly in PHL or they can print the Nutrition Assessment and ask the client to complete the
tool and then enter the data into PHL at a later time.
2. Once saved, the results of the assessment will be added to the “Client’s Nutrition Assessment Details”
Table at the top of the Nutrition Assessment Tab, this will allow for a comparison with previous data (see
EXAMPLE below):
“Falls Risk Assessment” Tab
The “Falls Risk Assessment” Tab is located in the “Visit” section of PHL and allows the User to enter data on the
potential risk of falls for the client and update or track information on the, “Client’s Fall Assessment Details” Table
(see EXAMPLE and item descriptions below):
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1. The PHL User should ask the client the questions on the Falls Risk Assessment and document their
responses directly into PHL or print the assessment tool, ask the client to complete the paper assessment
tool and then enter the data at a later time.
2. Once the client’s answers are entered in PHL the User should click the “Save Fall Risk Info” button (see
EXAMPLE below):
3. Once the information is saved, PHL will calculate the risk level for the client and the User will receive a
risk level message in PHL (see EXAMPLE below):
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“Notes” Tab
The “Notes” Tab is located in the “Visit” section of PHL and allows the User to enter encounter notes related to
visit. Please be aware that the User may enter notes on this Tab, however no reports will be generated from data
entered in the notes field.
1. Click on the “Notes” Tab to open a new page that lists information about previous notes entered in PHL
via this Tab ( “Client’s Notes” Table) plus an area that allows the User to add additional notes, “Add
Notes” (see EXAMPLE and item descriptions below):
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1. Once the Notes are saved, they will be added to the “Client’s Notes” Table at the top of the Notes Tab (see EXAMPLE above).
New Care Plan Tab
This section of PHL is still under development and this section of the User Manual will be updated as changes are
made to the Care Plan in PHL. Currently, the “New Care Plan” Tab is located in the “Client” section of PHL and
allows the User to develop a report or care plan based on data entered in PHL. The Tabs in this section may take a
bit longer to open because they are pulling data from multiple locations in the PHL platform.
1. To add a “New Care Plan” for a client enrolled in PHL, the User should open PHL to the “Client’s Demographics” page and click on the “New Care Plan” button in the blue line following the client’s name, address, etc. (see EXAMPLE below):
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2. When you click on the “New Care Plan” button a new window will open which includes 5 additional tabs: Demographics & Summary, Goals & Objective, Services, Cost & Maintenance, and Notification.
Care Plan: Demographics & Summary Tab
The “Demographics & Summary” Tab includes a variety of information which is auto populated by PHL including sections with data on “Client Information, Diagnosis, and Level of Care (see EXAMPLE and item descriptions below):
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a. Back to Client- Select this button to return to the “Client’s Demographics” page; to return to the Care
Plan “Demographics & Summary” page click on the Demographics & Summary tab
Client Information
b. CBO#- Auto populated by PHL; this unique number is assigned to a client by PHL once they are
enrolled in the PHL platform
c. RID#- Auto populated by PHL if the information was enter into the platform; this number is equal to
the Medicaid number
d. First Name- Auto populated by PHL
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e. Middle Name- Auto populated by PHL if the information was enter into the platform
f. Last Name- Auto populated by PHL
g. Date of Birth- Auto populated by PHL
h. SSN- Auto populated by PHL if the information was enter into the platform
i. Race- Auto populated by PHL if the information was enter into the platform
j. Gender- Auto populated by PHL if the information was enter into the platform
k. Address- Auto populated by PHL if the information was enter into the platform
l. Phone- Auto populated by PHL if the information was enter into the platform
m. Risk Stratification Category- Auto populated by PHL with most recent score if information was enter
on the Risk Stratification Tab; shown as a Risk Category (High, Moderate, Low)
n. Health Literacy- Auto populated by PHL with most recent score if information was enter on the Health
Literacy Tab; shown as a Health Literacy level (High, Moderate, Low)
o. Falls Risk- Auto populated by PHL with most recent score if information was enter on the Falls Risk
Assessment Tab; shown as a Falls Risk level (High, Moderate, Low)
p. Medication Risk- Auto populated by PHL with most recent score if information was enter on the
Medication Review Tab; shown as a Medication Risk level (High, Moderate, Low)
q. Isolated Adult?- Check this box if you believe this individual qualifies as an isolated adult
r. Notes- The User may enter notes in this text box, however no reports will be generated from data
entered in this field
s. Update- Select this button to save any information that was added to this section of the care plan
1. The “Diagnosis” section of the Demographics & Summary Tab includes a Table that is auto populated with a list of the diagnosis entered in PHL under the “Diagnosis” Tab. The User should place a check next to those diagnosis they would like to include on the final version of the report or care plan (see EXAMPLE and item descriptions below):
a. “Include” Column- Check the box next to “Include” to select all diagnoses in the table to include in the
final report/care plan OR check the individual boxes next to only those diagnosis you want to include
(see EXAMPLES below):
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Care Plan: Goals & Objectives Tab
The “Goals & Objectives” Tab on the Care Plan includes a variety of information which is auto populated by PHL including sections with data on Client Goals, Objectives and a section where the User can add a text narrative to the care plan.
1. Click on the “Goals & Objectives” Tab to open a new window which includes 3 sections: Narrative, Client
Goals & Objectives, and Objectives (see EXAMPLE and item descriptions below):
By checking the box in front of “Include” you
automatically select all diagnoses listed to
appear on the summary report or care plan
OR, if you check the box in front of the individual
diagnosis, you select only those highlighted to
include in the summary report or care plan
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a. Back to Client- Select this button to return to the “Client’s Demographics” page; to return to the Care
Plan Demographics & Summary page click on the Demographics & Summary Tab
b. Narrative- This test box allows the User to add a narrative about this client to be included in the
report/care plan.
c. Clients Goals & Objectives- This section of the page includes a Table auto populated with the client’s
goals entered in PHL under the “Goals & Objectives” Tab. If no goals were selected, this Table will be
blank. Place a check next to those goals they would like to include on the final version of the
report/care plan (see EXAMPLE and item descriptions below):
d. “Include” column- Check the box next to “Include” to select all goals in the table to include in the final
report/care plan OR check the individual boxes next to only those goals you want to include.
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2. Add Goal- Click this button to add additional Goals; this will open a new window to allow the User to enter
data about a new goal (see EXAMPLE and item descriptions below):
3. The “Objectives” section of the “Goals & Objectives” Tab includes a Table that is auto populated with a list of the objectives that were entered in PHL under the “Goals & Objectives” Tab. If no objectives were entered this Table will be blank. The User should place a check next to those objectives they would like to include on the final version of the report or care plan (see EXAMPLE below):
4. To add an Objective, click the “Add Objective” button which will open a new window where the User can enter data about an objective (see EXAMPLE and item descriptions below):
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Receiving Referrals in PHL
Follow the process outlined below to receive an assigned referral in PHL.
1. A PHL User will receive an email from PHL (or their local supervisor) indicting they have been assigned a
new referral in PHL (see EXAMPLE of email below):
2. The User should open PHL to the “Field Staff Home” page which provides the User with two Tables, “My
Case Load” and “Client Service Delivery Program(s) Status” (see EXAMPLE below):
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3. Click on the new client's name in the "My Case Load" Table, this will take the User to the “Client’s
Demographics” Page. Than the User can contact the client to begin the process of enrolling the client in
that particular program/service (i.e. arrange home visit if required, complete phone assessment to
determine eligibility for service, etc.). NOTE in PHL the term “visit” equals a contact. A “visit” can be
completed face to face, via phone, via email, with the client, with a caregiver or with another provider
who may be working with the client.
4. Click on the "New Visit" Tab to document the contact with client (see EXAMPLE below):
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5. Once information from the contact is documented, click the “Save Visit Info” button at the bottom of the “Visit Details” page and the “visit” will be added to the “Visit Table” in the top left corner of the screen (see EXAMPLE below):
6. Complete a home visit if required, document "New Visit" and all information required for
program/service in PHL.
Making a New PHL Referral = Creating a New Participant in SASH Any PHL User with referral rights can make a referral in PHL. Follow the steps outlined below to make a referral.
22. Hover over the “Client Management” Tab and select “New Referral”
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23. This will open a new window “Add Referral” (see EXAMPLE and item descriptions below):
24. The “Referral Source,” “Referral Source Full Name” and “Referral Source Email” will auto populate with the
information of the User who has the PHL platform open, this information can be changed if need be by
selecting other information from the dropdown box or typing over the auto populated information.
25. Select the “Referral Program” the client is being referred to from the dropdown box provided.
26. Define SASH Programs here and instruct for staff
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27. Complete all required fields that are marked with a * and any additional fields your organization requires.
d. Save Referral Info- Click this button to save information entered, remember once saved, all
information is stored indefinitely in the PHL system; it can be inactivated but not erased
e. Save Referral Info and Next- Click this button to save information entered and enter additional
referrals, remember once saved, all information is stored indefinitely in the PHL system; it can be
inactivated but not erased
f. Clear- Click this button to erase information prior to it being saved
28. Once the referral is saved, additional information will appear at the bottom of the page (see EXAMPLE
below)
Primary Contact Same as Above: Check this box if the Client listed is
also the primary contact.
Background info for Immediate Follow up: This is a required field.
Some organizations use this text box to share directions to the
client’s home or specific client needs.
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29. Click on “Show Clients Window” this will open a new window (“Client Validation”) that displays all clients
enrolled in PHL who have a name similar to the client who is being referred (i.e. in this example the client
being referred is Tony Wright. See client’s with similar names listed below):
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30. If the client is already enrolled in PHL, select his/her name from the Client Validation box by clicking the
client’s name (make sure you scroll through all of the pages by using the arrows in the lower right corner)
31. Clicking on the client’s name will open another window where you can determine if the client has already
been referred for the current service (in this example Tony Wright is being referred for HDM. The new
Table below indicates he has been referred for Care Transitions 30 day program but not HDM). If the client
has not previously been referred, the User should click the “Accept Referral” button to accept the new
referral (in this example Tony Wright for HDM). If the client had already been referred the User could click
the “Reject Referral” button so there is not a duplicate referral for the same service.
32. Once the Referral is accept, PHL will return the User to the Referral Page and ask the User to select a valid
MCOC (Managed Care Options Counselor ) or Social Worker (see EXAMPLE below):
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33. The User should check the “Accept Referral?” box and select both an “Agency” and “MCOC or Social
Worker” from the dropdown boxes provided and provide any instructions in the text field.
34. The final step is to click the “Save Referral Info” button again. The User will than receive the following
message from the PHL platform (see EXAMPLE below):
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35. If you are unable to find the client in the Client Validation Table (in this Example, the client’s name is Cecil
Canfield) the User should click the “Unable to Locate Client” button (see EXAMPLE below):
36. This will activate an additional button , “Create a New Client” which will be located next to the “Cancel”
button. Click the “Create a New Client” button and you will be taken to the “Client’s Demographic” Tab
which will be auto populated with information entered in the referral for this new client.
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37. Select the Company (this is the PHL license holder) and select Save Client Info
38. Once you save the “Client’s Demographic” Tab information, PHL will return you to the “Edit Referral” Tab.
Select “Show Clients Window” again to verify that the client information was saved in PHL.
39. The new client’s information should now appear on the “Client Validation” Table. Select the client’s name
in Table and you will receive the following window:
40. Click the “Accept Referral” button and you should receive a message from PHL indicating the Referral is
Updated Successfully (see EXAMPLE below):
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41. Now check the “Accept Referral” checkbox and assign the referral to an Agency and MCOC or Social Worker
and then click the “Save Referral Info” button (see EXAMPLE below):
42. Once saved the User will receive a second message indicating the Referral was updated successfully (see
EXAMPLE below):
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PHL Training “Help”
In addition to the PHL User Manual, there over 70 brief Training Videos available to Users in PHL. The Training
videos range from 2-6 minutes in length. Access the Training Videos under the “Help” Tab on the PHL Home Tab
(see EXAMPLE below):
1. Click on “Training Videos” under the Help Tab. This will open a new window (see EXAMPLE below):
a. Click on title of the video you would like to see and the “selected video” will appear on the right
side of the screen (see EXAMPLE below):
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b. Click on down arrow in the bottom right corner of the video screen below the selected
video (see EXAMPLE below):
c. A new box should appear in the lower left hand corner of your computer screen, click on
this box and your video will open in full screen view and begin to play.
