LACE Index for Readmission Risk

Plentiful evidence shows that patients with multiple comorbidities, frequent emergency room visits or other frailty indicators are more likely to present for readmission to hospital within a short time following their last discharge. Many of these readmissions are preventable, mostly through anticipation, communication and provision of post-discharge supports. 

AHS uses the "LACE readmission risk index" to stratify patients into those who are at low, moderate or high risk for early readmission. The index considers the patient's length of stay, admission type, comorbidities and frequency of emergency room visits. 

Most of the information needed to calculate a LACE Index is available to Connect Care in-system, and does not need to be entered by prescribers. An automatically calculated LACE Index has been developed for Connect Care and has been tested during summer 2022. It is now in production, continually updated for all inpatients. 

Countdown Checklist L5, T-minus 66: Plan Workload Adjustments

Continuing a list of essential actions for Connect Care Launch 5 prescribers readying for launch November 6, 2022...
  • Understand Prescriber Workload Adjustments for your Area
It is not a given, or often possible, that clinical service levels decrease at Connect Care launch. A number of strategies can maximize prescriber productivity, clinical service resilience and capacity for change.

Be sure to ask your clinical leaders (division, department, section, specialty, clinic, ward, NP manager, etc.) about plans to adjust prescriber availability and support in your area at launch. Discuss and confirm understandings at planning meetings.

Also anticipate your role in making things better for your team. Usually your best contribution is to take training seriously, especially personalization training, and to take the time to practice in the system after training. This decreases the likelihood that you will burden colleagues or slow clinical service around the time of launch.

See our Byte about workload planning for more information.


All User Bulletin - Cognitive Assessment Tools

All-user-bulletins highlight stumbling blocks that all prescribers need to be aware of when using the Connect Care clinical information system.

Change in Embedded Cognitive Assessment Tools

Connect Care provides access to a wide range of clinical scores, scales, calculations and assessment tools. These are described in the Clinician Manual.

Alberta Health Services (AHS) takes care to ensure that permission is obtained from copyright holders for any scores, scales or tools embedded in the Connect Care clinical information system.

The copyright contract for two popular cognitive assessment tools will expire August 31, 2022: the Standardized Mini-Mental State Examination (SMMSE) and the Montreal Cognitive Assessment (MoCA). AHS has carefully reviewed evidence-based alternatives and has elected to obtain permissions for a panel of these in Connect Care. 
Prescribers can find cognitive assessment tools via the Flowsheets activity within an opened chart. They are also available in a clinician-friendly format in both a "Scores and Scales" navigator (use chart search for "score" and select "jump to Scores and Scales") and the inpatient chart sidebar (use the sidebar index to navigate to a "Scores" view). Both the navigator and the sidebar have groupings for AHS approved cognitive assessment tools. 

The sidebar tools are interactive, in that any score can be selected to update its data then closed with the refreshed data showing in the sidebar. The Sidebar also provides links to the Navigator as well as other clinically useful quantitative tools.


Countdown Checklist L5, T-minus 68: Get Ready for Patient Movement

Continuing a list of essential actions for Connect Care Launch 5 prescribers readying for launch November 6, 2022...
  • (Optional) Register for the Patient Movement Readiness Series
The Patient Movement Readiness Series focuses on building a baseline knowledge of how to move a patient from one location to another using Connect Care as a tool. Make sure you sign up for these sessions, as patient movement is cited as one of the most confusing concepts to grasp at launch.

The week of September 12-16, 2022 includes Patient Movement Fundamentals readiness events. These sessions outline basic functions that support safe movement of patients through a facility; related workflows are explored. Each of these one-hour sessions are described in a Patient Movement Readiness Handbook, where registration links are provided. Note all sessions will be recorded and posted a few days after on Insite.

A self-guided learning video series with videos relevant to your work area is also available via a guide, linked below.


Countdown Checklist L5, T-minus 73: Report Wireless Gaps

Continuing a list of essential actions for Connect Care Launch 5 prescribers readying for launch November 6, 2022...
  • Report Wireless Coverage Gaps
As part of launch readiness efforts, the wireless networks in Launch 5 sites are upgraded to clinical-grade (high-density, high-performance) WiFi. Teams have walked the facilities to confirm that connectivity is universally present and up to the needs of providers and patients.

Coverage seems to be complete. Please help the wireless team by checking for AHSRESTRICT wireless networking signal and stability in all your clinical work areas. Please report any gaps or other challenges with WiFi at your site to IT Service desk (1-877-311-4300), providing details of the day, time and specific location of the problem.


Countdown Checklist L5, T-minus 75: Confirm Remote Access

Continuing a list of essential actions for Connect Care Launch 5 prescribers readying for launch November 6, 2022...
  • Ensure that you have online REMOTE ACCESS
"Remote access" refers to any use of the clinical information system (CIS) outside of Alberta Health Services (AHS) networks ("intranet"). 

Will you need this? Some prescribers rarely work out-of-AHS. Some will only remote access through mobility (Haiku, Canto), which is good enough for results review, communicating, ordering, billing and simple documentation. 

Many prescribers need full Hyperspace externally. A security FOB is required, as explained in the Connect Care Manual. For physicians, existing Netcare FOBs are automatically set up for Connect Care and require no new action; those needing remote Hyperspace who do not currently have a FOB should apply now (note - the process is normally initiated by Zone Medical Affairs).
For nurse practitioners (NPs), remote access needs to be requested via Provincial NP Services. NPs can submit their request by following the instructions at the following link:
Physicians in Launch 5 are authorized for remote access by Zone Medical Affairs, who should be contacted for support (Calgary Zone: CAL.MedAffairsConnectCare@ahs.ca; Central Zone: CZMAprivileging@ahs.ca; North Zone: NZ.Privileging@ahs.ca; Cancer Care Alberta: cmio.cca@ahs.ca). For NPs needing remote access support, contact Provincial NP Services (advancedpracticenursing@ahs.ca).


Countdown Checklist L5, T-minus 78: Choose Personal Device(s)

Continuing a list of essential actions for Connect Care Launch 5 prescribers readying for launch November 6, 2022...
  • Pick Personal Device(s) for Connect Care Use
Many of us will prefer doing some clinical information system (CIS) tasks on mobile or personal computing devices. These are set up to our liking, move with us, and work well in Connect Care facilities. 

This is a good time to check whether what we have is what we'll want. Indeed, it may be time to consider purchasing a new mobile device for clinical use. 

The following information can help decide what to procure or prepare:


Countdown Checklist L5, T-minus 80: Confirm AHS Network Access

Continuing a list of essential actions for Connect Care Launch 5 prescribers readying for launch November 6, 2022...
  • Ensure that you have online ACCESS
This one's easy.

Make sure that you have a working Alberta Health Services (AHS) "Healthy" network username and password. These credentials are used to log in to AHS computers, email, Connect Care and many other systems. Your profile needs to be turned on for Connect Care access. Make sure that your username and password work at:
If you try logging in from outside an AHS facility, you will need to additionally have a security FOB. More about that in the next task. Check out the Access section in the Connect Care Manual. Contact AHS IT Service Desk (1-877-311-4300) if your username and password do not work with myapps.ahs.ca.


Countdown Checklist L5, T-minus 82: Complete InfoCare (On Our Best Behaviours) Training

Continuing a list of essential actions for Connect Care Launch 5 prescribers readying for launch November 6, 2022...
  • Complete InfoCare Privacy Awareness Training
This one applies to everyone. Every prescriber must complete an online self-directed eLearning module entitled "InfoCare - On Our Best Behaviours" (OOBB). This solidifies understanding about responsible behaviours when working with personal health information. 

All prescribers must complete the module. Completion is demonstrated in a final section where commitment to privacy protection is affirmed with a series of statements. Access to Connect Care is not possible without OOBB affirmation. AHS physician privileges are also contingent. 

Log in to MyLearningLink.ahs.ca (MLL) with your AHS username and password. Search the available courses using "InfoCare". Anticipate spending about 20 minutes.

Get in touch with help.cmio@ahs.ca if you have difficulty getting credit for course completion. Macintosh users: save time by checking our MLL Manual section and tip sheet first. These resources also explain how to use an attestation tool if MLL does not credit course completion.


On Other Channels...

Thank you for continuing to check the Connect Care update blog for prescribers (ideally, subscribe to multiple channels; see instructions). Recent additions to this blog and its various channels:

Countdown Checklist L5, T-minus 85: Bookmark Manual and Updates

Continuing our list of essential actions for Connect Care Launch 5 prescribers readying for launch November 6, 2022...
A Connect Care Manual is available for desktop, tablet and smartphone use. The Manual summarizes essential clinical information system (CIS) information for prescribers. We keep it brief, in the spirit of clinicians helping clinicians. Details are exposed through links to Connect Care guides, tip sheets and training materials. Bookmark "manual.connect-care.ca".

The Connect Care Blogs are also worth bookmarking. Instructions for subscribing appear on all blog pages. The blogs include a general interest channel (default, "blogs.connect-care.ca") with news and updates, as well as important support information during the launch period. Other channels include:
Bookmark "blogs.connect-care.ca" and consider subscribing to one or more channels (each channel must be subscribed to separately).

It can be really useful to access the Manual and blogs on a smartphone, for easy reference when working with Connect Care. 


Countdown Checklist L5, T-minus 89: Check Alberta Referral Directory

Continuing a list of essential actions for Connect Care Launch 5 prescribers readying for launch November 6, 2022...
  • Physician Registries - Check ARD 
Alberta has multiple sources of physician information. Connect Care uses these to inform a single physician registry. This is a good time for Launch 5 physicians to ensure that provincial databases have current and correct information.

The Alberta Referral Directory (ARD) is one such database. It is a secure, online listing that provides access to consultant demographics, referral guidelines and referral forms.

All physicians are encouraged to update their ARD entry, or have clinic staff take care of this for all clinic providers. ARD is incorporated into Connect Care referral workflows.


Countdown Checklist L5, T-minus 92: Consider Training Options

Continuing a list of essential actions for Connect Care Launch 5 prescribers readying for launch November 6, 2022...
  • Consider Connect Care Launch 5 Training Options
While our response to COVID-19 continues across the province, we are carefully moving forward with preparations for the implementation of Connect Care Launch 5. Training activities continue, with appropriate COVID-19 awareness and precautions.

Virtual as well as in-person classes are available. In-person classes have all the necessary measures in place to offer safe training. Contingency plans are in place in the event of facility-level outbreaks. If required, all in-person training can be converted to virtual training. We remain flexible and ready for COVID-19 related change in the weeks and months to come.

Registration for Launch 5 Connect Care training remains open through MyLearningLink (mylearninglink.ahs.ca). Besides completing the training, please remember that completion of the privacy training, On Our Best Behaviours (OOBB), is also mandatory for access to Connect Care. Registration information for medical staff is provided by Zone Medical Affairs, and for nurse practitioners by Provincial NP Services.


Countdown Checklist L5, T-minus 94: Get Training

Continuing a list of essential actions for Connect Care Launch 5 prescribers readying for launch November 6, 2022...
  • Get Basic Training! 
  • Reach out to colleagues who may not be registered.
Prescribers will not be allowed access to the Connect Care clinical information system (CIS) unless they have completed basic training. There are no exceptions. Lack of access to the legal record of care means being unable to practice. Privileges are contingent on use of the implemented CIS. 

So, this is important. Colleagues will be inconvenienced if forced to cover for a prescriber who does not have CIS access.

First-time users of the CIS must complete an instructor-led basic training session. Launch 5 instructor-led basic training begins August 29, 2022, and registrations are filling fast.

If practicing at a Launch 5 site and still lacking information about how to register or complete basic training, contact:


Countdown Checklist L5, T-minus 96: Are you in?

Continuing a list of essential actions for Connect Care Launch 5 prescribers readying for launch November 6, 2022...
  • Are you in Connect Care Launch 5? 
An obvious first checklist task is to determine whether Launch 5 tasks even apply!

For most physicians, that determination is made by Medical Affairs. Lists of clinic physicians, those with hospital privileges, visiting specialists and on-call contributors are used to generate invitations to Launch 5 physicians. Despite this, it is possible that some physicians with new site responsibilities -- and some physicians who have already trained in earlier waves -- might be missed. Physicians should check the clinics and hospitals slated for Launch 5 and be sure that they have been invited to participate if they expect to work at those sites:
For nurse practitioners (NPs), Provincial NP Services makes the determination based on HR lists. However, it is recognized that many NPs cover cross-site/-zone programs or have multiple "casual" positions; Provincial NP Services contacts all NPs and their managers directly to confirm. NPs expecting to work at a Launch 5 site who have not been contacted should email Provincial NP Services.

Other online resources can be checked for the latest information: