The HealthEC system analyzes comprehensive data (from EHRs, claims, HIEs, laboratory systems, pharmacy benefits management systems, etc.) and applies a robust risk stratification algorithm to identify high risk patient populations. Care Coordinators are presented with patient lists made up of individuals with:
Prior to speaking with the patient, Care Coordinators are able to review a complete longitudinal record within the HealthEC tool (medical history, diagnoses, medications, encounter notes, etc.), which supports them in having a meaningful conversation with the patient, thereby creating trust and confidence in the program.
Throughout the initial conversation with the patient, Coordinators complete questionnaires that assess functional status, preventive care activities, social determinants of health, and any disease-specific parameters.
Armed with an understanding of the patient’s care needs, the Care Coordinator schedules interventions to address problems, goals and barriers.
They also assign an acuity value to provide an estimate of the patient’s needs within the program.
The patient also verbalizes a self management plan to identify their commitment to health and wellness, which empowers them to change.
Daily worklists help Care Coordinators manage large patient populations by identifying interventions that are due, overdue and in-process. In addition, gaps in care quality measures are automatically closed if electronic data is available to support such action (e.g. an endocrinologist is seeing a diabetic patient but the order is missing within the primary provider’s EMR).
Worklists are user friendly and color-coded, and simplify documentation of activities, scheduling or re-scheduling of new care tasks and sharing/reassignment as appropriate.
ER visits and hospital discharges within the past 24 hours also trigger follow up activities to reduce the risk of another encounter
Both the patient’s status and the effectiveness of the care plan are evaluated based on a number of criteria including:
The individualized care plan is modified base on the patient’s response, which may involve activities such as: