Care Management Tracking System (CMTS)

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Using a population-based approach to health care helps ensure that no patient falls through the cracks. Employing a technology tool that tracks clinical outcomes for populations of patients and supports systematic changes in treatment for patients who are not improving as expected is an essential piece of all successful Collaborative Care implementations. 

Registry options that use IT tools include a customized build in an Electronic Health Record (EHR), customized care management software, and the AIMS Center’s Care Management Tracking System (CMTS). Some clinics and organizations also choose to use a patient tracking spreadsheet while their EHR or other registry is being customized.

CMTS is a web-based application developed by the University of Washington AIMS Center to support Collaborative Care workflows. It tracks patient progress and goals, identifies patients who need more help, and cues providers when outreach is needed. It has been deployed in 22 implementations in 24 states throughout the US and Canada and has helped over 90,000 patients receive better care. Licenses to use CMTS are available to AIMS Center implementation and research partners. If you are interested in partnering with the AIMS Center or would like more information about CMTS, please contact us.

It is important that CMTS be used alongside an EHR so that the primary care team all share access to the most up to date information about patients enrolled in Collaborative Care programs. It is necessary for all members of the care team, including the psychiatric consultant, to have access to the EHR. 

Delivering Better Care
CMTS supports the core principles of effective integrated care that results in better clinical outcomes, higher patient satisfaction, and lower healthcare costs.

Patient-Centered Team Care
CMTS facilitates collaboration between providers and patients using shared care plans that incorporate patient goals.
Population-Based Care
CMTS tracks patient populations to prevent patients from falling through the cracks.
Measurement-Based Treatment to Target
CMTS tracks clinical outcomes to cue providers when a consultation or systematic change in treatment is needed.
Evidence-Based Care
CMTS structures clinical workflows, and uses validated measurement instruments to track patient progress.

Supporting Patient Goals
CMTS supports a patient-centered approach to health care by allowing clinicians to track on patient goals. The care manager can enter the goals in the patient’s own words and track them over time using a validated measurement instrument, such as the nine-item Patient Health Questionnaire (PHQ-9). Automatic alerts and reminders use clinical logic to help the care manager facilitate treatment adjustments or consultation when necessary. Consulting specialists, such as psychiatric consultants, can efficiently review treatment histories and suggest additional diagnostic or treatment strategies to primary care and mental health providers. The Psychiatric Consultant will use the EHR alongside CMTS during systematic case reviews with the care manager to determine the best treatment course for the patient. CMTS also allows clinicians from different organizations to use the web-based functionality in order to efficiently share and coordinate effective patient care. 

Offering Key Functions
CMTS helps clinicians manage a caseload of patients by providing flexible, easy-to-use functions including:

  • Alerts and reminders
  • Caseload reports, sortable by symptom scores and visit dates
  • Reports and templates for psychiatric consultation sessions
  • Medication recommendations/summaries
  • Flagging of high-risk patients
  • Referral Tracking
  • Printable provider and patient summaries
  • Data reporting and exports

Beyond an EMR
CMTS is not an EHR, nor is it intended to act as a replacement. Medical records are a storehouse of information about a specific patient’s care that can be used for clinical, billing, and/or legal purposes. Although some EHRs can use queries or filter functions to cue clinical activities or create specified patients list, most have limited functionality in this regard and need extensive--and oftentimes costly--customization to facilitate the delivery of evidence-based care for specific medical or behavioral health conditions.

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