Grouping Rules and Actions
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Last Modified on 07/28/2021 11:21 am EDT

Version 14.19

About

This article explains how Grouping Rules and Actions can be used in Care Plan Triggers. The table uses the example columns (Grouping Rules, Item Name, Condition, and Values) to allow you to begin thinking how the rules have an impact for qualifying patients.

  • Each Begin Group has its own evaluation, but they will be evaluated as a complete statement to qualify a patient for the Care Plan.
  • From example columns below:
  • In the first Begin Group, the trigger is searching for children between the ages of 5 to 10 with one of the SNOMEDs entered in the problem list or a medication prescribed from the NCD list.
  • In the second AND Begin Group the trigger is searching for children over the age of 15 with one of the SNOMEDs entered in the problem list.
  • In the third OR Begin Group the trigger is searching for children over the age of 15 with a BMI or BMI% at a specific value.
Grouping Rule
Definition
Example


Grouping Rules
Item Name
Condition
Value(s)
Begin Group
Must always start the Triggers evaluation with the Begin Group Statement.Begin GroupAge in yearsis greater than or equal5
AND
Include the trigger to qualify a patient. Using the AND grouping rule would require all AND statements to be met for the patient to qualify for the Care Plan.
AND

AND
Age in years

Active problem SNOMED		is less than or equal
is in list		10

'70156005','41040004',
'205615000','205616004',
'254264002','371045000'
OR
This rule allows you to evaluate multiple values and will qualify a patient if any OR statement is met.
OR
Takes medication by NDCis in list'31722021230','68180035202'
AND Begin Group
Using this grouping rule begins a new set of trigger conditions to include to qualify a patient.
AND Begin Group
Age in yearsis greater than or equal15


AND
Active problem SNOMEDis in list'70156005','41040004',
'205615000','205616004',
'254264002','371045000'
OR Begin Group
Using this grouping rule begins a new set of trigger conditions where either group may be true to qualify a patient
OR Begin Group
Age in yearsis greater than or equal15


OR

OR
Most recent BMI

Most recent BMI%		is greater than or equal
is greater than or equal		30

90


Example: How do I setup the Triggers if I want to see boys between the ages of 9-13 or girls ages 11-14 who have ADHD and are active patients:
  1. BEGIN Group, Sex, is equal to, 'M'
  2. AND, Age in years, between, '9' AND '13'
  3. OR Begin Group, Sex, is equal to 'F'
  4. AND, Age in years, between, '11' AND '14'
  5. AND Begin Group, Active problem SNOMED, is in list, (Enter all the SNOMED codes for ADHD)
  6. AND, Patient Status, is equal to, 'ACTIVE'


Example: How do I setup the Triggers if I want to see all active patients ages 2-18 with BMI <5% or >95% and has insurance for Blue Cross/Blue Shield:
  1. BEGIN Group, Patient status, is equal to, 'ACTIVE'
  2. AND, Age in years, between, '2' AND '18'
  3. AND, Primary payer, is equal to, '(enter in your code for the health plan)'
  4. AND Begin Group, Most recent BMI, is less than or equal, 5
  5. OR, Most recent BMI%, is greater than or equal, 95


Version 14.10

Overview

This article explains how Grouping Rules and Actions can be used in Care Plan triggers. The table uses the example columns (Grouping Rules, Item Name, Condition, and Values) to allow you to begin thinking how the rules have an impact for qualifying patients.

  • Each Begin Group has its own evaluation, but they will be evaluated as a complete statement to qualify a patient for the Care Plan.
  • From example columns below:
  • In the first Begin Group, the trigger is searching for children between the ages of 5 to 10 with one of the SNOMEDs entered in the problem list or a medication prescribed from the NCD list.
  • In the second AND Begin Group the trigger is searching for children over the age of 15 with one of the SNOMEDs entered in the problem list.
  • In the third OR Begin Group the trigger is searching for children over the age of 15 with a BMI or BMI% at a specific value.
Grouping Rule
Definition
Example


Grouping Rules
Item Name
Condition
Value(s)
Begin Group
Must always start the Triggers evaluation with the Begin Group Statement.Begin GroupAge in yearsis greater than or equal5
AND
Include the trigger to qualify a patient. Using the AND grouping rule would require all AND statements to be met for the patient to qualify for the Care Plan.
AND

AND
Age in years

Active problem SNOMED		is less than or equal
is in list		10

'70156005','41040004',
'205615000','205616004',
'254264002','371045000'
OR
This rule allows you to evaluate multiple values and will qualify a patient if any OR statement is met.
OR
Takes medication by NDCis in list'31722021230','68180035202'
AND Begin Group
Using this grouping rule begins a new set of trigger conditions to include to qualify a patient.
AND Begin Group
Age in yearsis greater than or equal15


AND
Active problem SNOMEDis in list'70156005','41040004',
'205615000','205616004',
'254264002','371045000'
OR Begin Group
Using this grouping rule begins a new set of trigger conditions where either group may be true to qualify a patient
OR Begin Group
Age in yearsis greater than or equal15


OR

OR
Most recent BMI

Most recent BMI%		is greater than or equal
is greater than or equal		30

90



Example: How do I setup the triggers if I want to see boys between the ages of 9-13 or girls ages 11-14 who have ADHD and are active patients:
  1. BEGIN Group, Sex, is equal to, 'M'
  2. AND, Age in years, between, '9' AND '13'
  3. OR Begin Group, Sex, is equal to 'F'
  4. AND, Age in years, between, '11' AND '14'
  5. AND Begin Group, Active problem SNOMED, is in list, (Enter all the SNOMED codes for ADHD)
  6. AND, Patient Status, is equal to, 'ACTIVE'


Example: How do I setup the triggers if I want to see all active patients ages 2-18 with BMI <5% or >95% and has insurance for Blue Cross/Blue Shield:
  1. BEGIN Group, Patient status, is equal to, 'ACTIVE'
  2. AND, Age in years, between, '2' AND '18'
  3. AND, Primary payer, is equal to, '(enter in your code for the health plan)'
  4. AND Begin Group, Most recent BMI, is less than or equal, 5
  5. OR, Most recent BMI%, is greater than or equal, 95



Tags: Care Plans

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