Care Coordination

Streamlining Care Coordination

HealthEC’s analytics-driven care management dashboards and patient-specific workflow prompts promote high-priority care interventions to drive patient engagement and smarter resource utilization, one targeted initiative at a time.The tool consolidates all relevant clinical and claims data to summarize the patient’s programs, any gaps in care, current medications, upcoming appointments, admissions and discharges, problem lists, goals and barriers. Built-in resources include social determinants of health assessments, care team task assignment tools and value-based care program reporting assistance.

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:

  • >6 ER visits in rolling 12 months
  • >3 inpatient admissions in rolling 12 months
  • >$100,000 healthcare spend to date
  • A likelihood of becoming a high-resource user or to become hospitalized, based on computational models

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:

  • Quality scores and variation
  • Laboratory result trends
  • Prescription use and spend
  • Assessment data such as vital signs, pain scores, etc.
  • Compliance with health activities
  • Total cost of care by month

The individualized care plan is modified base on the patient’s response, which may involve activities such as:

  • Increasing or reducing the frequency of monitoring
  • Referral to specialists or domain experts for further assessment, education or assistance
  • Involvement of other family members
  • Addition of community-based resources
  • Transition to long term or hospice care, or home health referral

BEST EFFECTIVENESS MATTERS
HealthEC’s care coordination tool drives care team effectiveness by streamlining workflow and proactively driving interventions:
  • Begins with comprehensive, high quality data
  • Creates a comprehensive, individualized plan
  • Communicates and facilitates transitions
  • Simplifies monitoring, follow up and response to changes
  • Empowers the patient with self-management goals
  • Links to community resources
  • Aligns resources with patient needs
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Optimizing Care Coordination, Risk Stratification and Data Analysis


Addressing Social Determinants of Health

Social determinants of health are a key component in care coordination, as they affect a wide range of health, functioning, and quality-of-life outcomes and risks. By incorporating social health determinant factors into individualized care plans, along with other healthcare interventions and activities, Coordinators help patients navigate barriers and offer creative services to meet their needs. Examples of encounters that dramatically improve outcomes:
  • Addressing health literacy challenges by walking diabetic patients through a grocery store to discuss healthy, low-cost food choices
  • Overcoming knowledge barriers by meeting with pharmacists to review medication lists
  • Sending alerts and messages via mobile technologies
  • Providing bi-lingual support staff to bridge gaps between patients and providers
  • Engaging Social Workers to help patients secure resources and transportation for medical care
  • Collaborating with free community resources to resolve basic needs including meals on wheels, behavioral health, drug therapy and job placement counseling and education


Supporting a Team Approach

Automated workflows ensure a team approach to care coordination:
  • Physicians
    • Serve as the Leader
    • Create availability to see high risk patients
  • Care Coordinators
    • Conduct and regularly update a comprehensive needs assessment
    • Develop and update an individualized care plan
    • Facilitate access to medical care, home and community-based services
    • Regularly monitor and communicate with the team
  • Health Homes
    • Assist with identifying community based resources
  • Community-based resources
    • Services to overcome social barriers