CCMS Whole Person Care User Guide
  • What is CCMS and Whole Person Care Summary?
  • How do I access Whole Person Care Summary?
    • For Avatar Users
    • For DPH Users Only
    • For DPH, CCSF, and Other Users
    • For LCR/Invision Users
    • For eCW Users
  • How do I use Whole Person Care Summary?
    • Homepage Features
      • Client Search
      • Client Alert Flags
      • Client Identifiers
      • Left-Navigation Links
      • Introduction
      • Action Plan
      • Care Team Members (Active)
      • Financial Benefits
      • Vulnerabilities
      • Future Health Appointments
      • Urgent Emergent Health Services Summary
      • Frequency of Encounters
      • Longitudinal Graphical Display of Service Utilization
      • Contact Us
    • Left-Navigation Links
      • Hlth Svcs Summary
      • Hlth Svcs Detail
      • Progress Notes
      • Housing History
      • Provider History
      • Diagnostic Summary
      • Diagnostic Detail
      • Financial Detail
      • Source Records
      • Viewed By
      • Death Registry
  • FAQs
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  1. How do I use Whole Person Care Summary?
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Vulnerabilities

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Last updated 5 years ago

Summarizes health and social factors which contribute to risk of early mortality or decreased quality of life. Those with Level U/E Use of Top 1% are considered high users, and are particularly at-risk and require immediate care coordination.

Field Name

Description

Source

Fiscal Year

e.g. FY1920 = 7/1/2019 through 6/30/2020

N/A

Level U/E Use

The value in this column (e.g., Top 1%) denotes that the patient is among the fiscal year's top 1% in count of urgent/emergent services used

CCMS

Homelessness

Marked "Y" if the patient was known to be homeless

Multiple Sources

Jail Health Days

Marked "Y" if the patient was known to Jail Health Services

Jail Health Services

Conserved

Marked "Y" if the patient was under conservatorship

Avatar

Active PMD

Marked "Y" if the patient has a Primary Medical Doctor (known in other sections as Primary Care Provider/PCP)

LCR

Active CM

Marked "Y" if the patient has a known Case Manager assigned

Avatar

Jail Health Days

Number of days in the designated fiscal year for which the patient has a record in Jail Health Services (a measure of length of stay in SF County)

Jail Health Services