The following document is intended to serve as a template for building out a Pathways Care Coordination Process SOP. It will first discuss each section, then show an example SOP template with example text.
When building your own SOP, please refer to the Best Practices resource while filling out the template as the example text provided is not exhaustive.
Table of Contents
Instructions
As you go through the SOP Template, you'll see it's divided into sections.
- Purpose: Edit this section to describe the overall purpose of care coordination in Pathways. This should help staff understand the role they play in supporting engagement, reinforcing care plans, and identifying risks.
- Roles and Responsibilities: Customize this table to reflect your staffing model. You may have separate roles for outreach and monitoring, or it may all fall to one coordinator.
- Daily and Weekly Monitoring Tasks: Edit this section to outline how often coordinators should review the Pathways Dashboard, Alerts tab, and any other systems. Consider including regular proactive engagement, even when no alerts are present. Many organizations include these actions as part of standard workflows.
- Outreach Triggers and When to Reach Out: Divide this section into proactive and reactive outreach scenarios. Use the tables below to describe when outreach should happen and what kind of message or action is expected. Edit to reflect your actual workflows, including how to locate any templated/saved responses for easy sending.
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Managing Disengagement or Hesitancy: Use this section to guide how care coordinators should respond when a patient isn’t engaging or expresses uncertainty. This should include what types of outreach to try, how often to try, when to stop, and when to notify the provider. Customize steps and language to fit your workflows.
Note: Patients who complete at least three days of activity in their first week are significantly more likely to stay engaged throughout their care plan. That’s why timely, intentional outreach during early disengagement is critical. - Outreach Cadence and Escalation: Use this section to define a structured outreach cadence and provide guidance for when to escalate concerns to a clinician or provider. This includes both proactive and reactive communication needs, as well as appropriate documentation with that communication. Edit to reflect your actual workflows.
- Documentation: Explain where and how staff should record outreach attempts, concerns, and patient responses. Include EMR, spreadsheets, or platform-specific tools.
- Reference Materials: List helpful documents or links here, such as message templates or sample scripts, workflow guides and documentation, etc.
Example SOP Template
Document Title: SOP: Care Coordination for Pathways
Version: April 15th, 2025
Owner: Sample Clinic
Audience: Virtual Care Coordinators
Review Cycle: Quarterly
1. Purpose
This SOP outlines how care coordinators monitor, support, and engage patients enrolled in Pathways. It includes daily and weekly workflows, outreach timing, documentation, and escalation procedures. Coordinators are responsible for supporting adherence, identifying barriers, and ensuring continuity of care between visits.
2. Roles and Responsibilities
| Role | Responsibilities |
| Care Coordinator | Monitor patient activity, respond to alerts, conduct proactive outreach, escalate as needed |
| Treating Clinician | Review escalated concerns, adjust care plan, communicate with patient if needed |
3. Daily and Weekly Monitoring Tasks
Daily
- Check the Pathways Invite and Engagement tabs in the Dashboard daily for new patients and engagement information to determine who needs outreach.
- Check the Alerts tab at least once per business day for alerts of low engagement, reported falls, or pain alerts (e.g., no login in 49+ hours).
Weekly
- Conduct weekly check-ins with patients to reinforce engagement and identify early signs of disengagement, and follow up on any previous conversations around pain or fall alerts.
4. Outreach Triggers and When to Reach Out
Proactive Outreach (Scheduled or Expected Reach-Outs)
| Situation | What to Do | Example Message Snippet |
| New patient (within 1–2 days) | Send a welcome/check-in message. If not treating clinician, introduce yourself. | “Hi, [Name]. I’m Dr. Smith and I’m working alongside Dr. Lee, your PT. I wanted to check in and see if you need any assistance with Pathways, your digital PT program. Let me know if you’d like help getting started or have questions.” |
| Weekly engagement check-in | Reach out to active patients on a set cadence | “Just checking in—how’s the program feeling this week? Let me know if anything needs adjusting.” |
| Scheduled milestones | Reach out when patients hit key program checkpoints | “You're about halfway through your plan. Nice work! How are things feeling so far?” |
Reactive Outreach (Triggered by Patient Behavior or Alerts)
| Trigger | What to Do | Example Message Snippet |
| Patient hasn’t logged in (3+ days) | Check for barriers; offer help | “I noticed you haven’t logged in recently. Want help getting back in, or is there anything I can clarify?” |
| Pain alert | Acknowledge concern, ask for details, escalate if needed | “I noticed your pain score increased. Was there a specific exercise or task that was bothering you?” |
| Incomplete tasks pattern | Ask if something’s unclear or not working | “I noticed some tasks have been left incomplete. Is anything getting in the way?” |
| Patient submits concern | Respond, resolve, or escalate as appropriate | “Thanks for letting me know. I'll take a look and follow up shortly.” |
5. Managing Disengagement or Hesitancy
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First check-in (48 hours of no engagement, or Day 3–4 of no engagement): Provide friendly nudge, reinforce value, and offer setup help.
Example for new patient:- “I noticed you haven’t logged in yet. Is there anything I can help you with to get started, or is there anything you are stuck on?”
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Second outreach (Day 6–7): Acknowledge nonengagement without assumption, and offer flexible support.
Example for new patient:- “It looks like you haven’t logged in since we started your program last week. Anything getting in the way I can help with? I want to make sure we don’t get off track.”
Examples for existing patient:
- “It looks like you haven’t logged in for about a week. Are you experiencing any issues with the Pathways program? I can make adjustments if we need to.”
- “Hi, [Name]. I saw you haven’t logged in recently. If anything is getting in the way (like pain, time, or the technology), I’m happy to help. Let’s get back on track together.”
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Third outreach (Week 2): Clarify intent to pause outreach while leaving the door open. Consider whether the patient has responded to previous outreach. If they haven’t responded and haven’t logged in, consider whether escalation is appropriate—such as informing the treating provider or flagging the concern for discussion in an upcoming appointment.
Example (new patients, no reply):- “It looks like you haven’t logged in yet, and I haven’t heard back. I’ll pause outreach for now, but I’m here if you’d like to get started later, and I'll let your doctor know you weren't able to start the program as planned.”
Examples (existing patients, no reply):
- “I'm still not seeing any recent logins, and I haven’t heard back, so I’ll step back for now. Please reach out if you’d like to cancel your Pathways program.”
Example (if patient replied earlier):
- “Thanks again for your earlier message. I haven’t seen any new activity, so I wanted to check and see if there were any issues that came up. Let me know if you’d like help reengaging.”
- Disengagement: If there is no response or continued inactivity, update their status in [your EMR, etc.] and stop outreach unless a new clinical risk appears.
Refer to Section 6 for full escalation guidelines and communication protocol.
6. Outreach Cadence and Escalation
| Timing | Reason for Outreach | Suggested Focus | Responsible Role |
| Day 1 | Welcome new patient | Confirm login success, offer help | [Insert Role] |
| Day 3 | Not activated | Check for barriers, resend instructions | [Insert Role] |
| Days 6–7 | Low engagement | Reinforce value, troubleshoot obstacles | [Insert Role] |
| Weekly | General check-in | Encourage consistency, answer questions | [Insert Role] |
| Pain alert | Patient reports increased pain | Ask for details, flag for provider if needed | [Insert Role] |
| Concern received from patient | Patient reports issue or confusion | Respond, resolve, or escalate as appropriate | [Insert Role] |
Escalation Guidelines
If outreach reveals a potential clinical concern or repeated disengagement, follow these guidelines:
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Escalate to the treating clinician if
- The patient is at risk of harm or delayed recovery due to non-engagement.
- The patient reports new symptoms that affect their care plan.
- The provider has requested specific updates or alerts.
- The patient expresses frustration, dissatisfaction, or confusion that may warrant direct clinician follow-up.
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How to escalate
- Use the internal messaging system, email, or handoff workflow defined by your clinic.
- Include concise notes: what was observed, what outreach has occurred, and recommended next steps.
- Example: “Patient hasn’t logged in in 10 days, reported persistent pain, not responding to messages. Recommending provider follow-up.”
7. Documentation
- Log all outreach attempts in [EMR/note template/spreadsheet].
- Note response and next steps (e.g., “Left voicemail, will try again in 2 days”).
- Track disengaged patients with status label or note in [EMR/spreadsheet/etc.] for easy review.
8. Reference Materials
- [Message templates or sample scripts]
- [Documentation guide or EMR workflow]
- [Escalation contact list or handoff guide]
- [Internal training or onboarding resources]
Once finalized, this SOP should be reviewed with all care coordination staff and included in ongoing training and onboarding materials.