Transforming Patient Care
with Comprehensive Care
Coordination and Management
Project Insight
Advanced Care Management System
Our client, one of the largest home health and hospice companies, sought to develop an advanced care coordination and management system. The objective was to enable care teams to connect with patients and their providers seamlessly, develop individualized care pathways and plans, and streamline the entire care management process. The system aimed to leverage historical claims data to provide a comprehensive patient profile for effective risk stratification and support value-based care arrangements.
Solution Implementation
We co-invested with the client to design and implement a robust care coordination and management tool with the following features:
Care Pathways and Plans: Developed functionalities for care teams to create, customize, and manage care pathways and care plans tailored to individual patient needs.
Patient Profile and Risk Stratification: Integrated historical claims data to generate a horizontal patient profile, aiding in accurate risk stratification and informed decision-making.
Communication Interface: Implemented an interface with a patient app to facilitate audio and video communication between patients and care providers, enhancing engagement and accessibility.
Operational Management: Provided tools to operationalize the activities of the care management team, including task assignments, scheduling, and performance evaluations based on patient outcomes.
Performance Tracking: Enabled the tracking and evaluation of care team performance, aligning activities with patient outcomes to ensure accountability and continuous improvement.
Results
The launch of the care coordination and management system brought significant benefits:
Improved Patient Outcomes: Care management teams were able to make substantial improvements in patient outcomes, particularly in value-based care arrangements, by utilizing comprehensive care plans and pathways.
Enhanced Communication: The integration with the patient app for audio and video communication improved patient-provider interactions, resulting in better patient engagement and satisfaction.
Efficient Operations: The system streamlined the operational activities of the care management team, improving task assignments and performance tracking, leading to more efficient care delivery.
Accurate Risk Stratification: The use of historical claims data for risk stratification allowed for more precise identification of high-risk patients, enabling proactive and targeted care interventions.
This case study highlights our expertise in developing and implementing advanced care coordination and management systems that enhance patient outcomes, streamline care team operations, and support value-based care. Our solution successfully addressed the challenges of managing patient care pathways and plans, improving the overall efficiency and effectiveness of care delivery in the healthcare sector.
Domain & Technology
- Patient app integration
- Historical claims data analysis
- Communication tools (audio and video)
- Care management software
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