Table 1.

Structure of CM and CHW applications.

App	Form name	Description
CM	CM_Initial_Contact	Used during the first interaction with a patient after they are enrolled in the program. Used to review contact information, discuss home blood pressure monitoring, and schedule the first CM phone call.
	CM_Medical_Record_Review	Used to capture baseline blood pressure, body mass index, and key lab results. CMs manually populate this form using data from the hospital’s EMR.
	CM_Problem_List	Used to capture a patient’s latest blood pressure, body mass index, and key lab results. CMs manually populate this form using data from the hospital’s EMR. The form is also used to develop a care plan. CMs indicate a patient’s status (at goal, not at goal, not relevant) for each risk factor and can add free-form notes that are visible only to them.
	CM_Medications	A collection of forms, organized by risk factor, that are used to capture medications prescribed to a patient. CMs manually populate these forms using data from the hospital’s EMR.
	CM_First_Phone_Call	Used during the first CM phone call to capture current health status, blood pressure, medication adherence, smoking status, and transportation barriers and to schedule the first clinic visit.
	CM_Huddle	Used during care team huddles to guide discussion about a patient. The form pulls the care plan from the Problem List and allows the team to make revisions.
	CM_Clinic_Visit	Used to guide clinic visits. The form pulls the care plan from the Problem List and allows CMs to make revisions. The end of the form generates a clinic visit summary that CMs can copy and paste into the hospital’s EMR.
	CM_Follow-Up_Phone_Call	Used to document additional CM phone calls. Tasks can also be created in this form.
	CM_Edit_Patient_Schedule	Used to skip the next interaction that is being suggested in the Patient List report.
CHW	CHW_Home_Visit	A collection of forms used to guide home visits. Each form addresses a different topic: stroke literacy, blood pressure, cholesterol, diabetes, antithrombotic use, smoking cessation, depression, diet, physical activity, alcohol and illicit drug use, transportation, communication preferences, and access to care. Forms are organized into 6 sections: assessment, information provision, self-management and adherence, adjustment of medications, clinical support, and resource provision for the patient. Tasks can be created in any of the forms.
	CHW_Review_of_Key_Patient_Data	Used to view the care plan, baseline and latest values for various stroke risk factors, latest medications, which home visit forms have been completed, and a patient’s contact information.
	CHW_Follow-up_Phone_Call	Used to document additional phone calls by the CHW. Tasks can also be created in this form.
	CHW_Register_New_CDSMP_Series	Used to register a new CDSMP workshop series, which consists of 6 weekly sessions. The form captures details such as session dates and meeting location.
	CHW_CDSMP_Series_Checklist	Used during each of the 6 CDSMP sessions to document patient attendance and self-management goals.
CM and CHW	CC_Edit/Update_Patient_Info	Used to update a patient’s home address, preferred language, phone number, family contact information, and primary care physician information.
	CC_Add__Appointment	Used to capture a patient’s appointments with health care providers outside of the SUCCEED care team.
	CC_View/Update_Appointments	Used to view a list of appointments with health care providers outside of the SUCCEED care team, update the appointment details, or close a completed appointment.
	CC_Create_New_Task	Used to create a new task. Tasks can be assigned to another care team member.
	CC_Task_List by_Panel_	Used to view a list of all CM–CHW care team tasks for all patients. The list cannot be filtered by person responsible for completing the tasks (CM or CHW). A task can be revised or closed once it has been completed.
	CC_Task_List_by_Patient	Used to view a list of all CM–CHW care team tasks for a specific patient. The list cannot be filtered by person responsible for completing the tasks (CM or CHW). A task can be revised or closed once it has been completed.