Care Coordination Platform
A platform that allows coordination of care activities between two or more healthcare providers involved in a patient’s care to facilitate appropriate delivery of health care services. As an efficient Care Coordination Software, it helps in reducing care fragmentation by ensuring that effective referrals and transitions take place. It provides a robust foundation for community health by connecting ambulatory primary care with multi-specialty, acute, sub-acute and other healthcare entities to serve the needs for an Accountable Care Organizations (ACO).
Longitudinal Patient Record
The Care Coordination Platform also maintains Master Patient Index and Longitudinal Health Record for each patient. It serves as a query based exchange that allows providers to search and retrieve specific sets of patient information. It supports standards based query and exchange using the Patient Demographics Query (PDQ) and Cross Enterprise Document Sharing (XDS), respectively. Our Care Coordination Software also supports exchange of information using C-CDA and CCR standards.
The Care Coordination Platform provides a secure network of trusted healthcare providers to facilitate easy and efficient "Transition of Care". The providers can search and connect to other healthcare providers using the directory services with identification of in-network and out-of-network providers. Referrals and consultation can be shared instantaneously and securely and delivered right into the recipients’ EHR. Providers, who do not have an EHR, can use the provider portal to exchange referrals and consultations.
Care Planning and Monitoring
The Care Coordination Software platform provides risk assessment and decision support tools for prevention and monitoring of patients with chronic conditions. It also provides advanced care planning and management for patients with acute problems to reduce hospitalization and readmissions. Care planning and monitoring process is further aided using dashboard to review progress of the patient population with ability to drill-down to patients’ longitudinal medical record.
There are multiple dashboards provided in Care Coordination Platform to proactively monitor the clinical and financial goals for a community. Population Health Dashboards provide data visualization of patient population using diagnosis / procedure codes, age, gender, geographic regions and more. Further it provides a capability to drill into this population and understand the cost of caring for these members. It aids in identifying high-risk/high-cost patients and analyzing comorbidities to arrive at common characteristics driving higher costs. Such insights enable focused care management efforts leading to improved outcomes that can be monitored through the dashboards. It also provides dashboards for clinical quality measures based on Meaningful Use / PCMH / HEDIS definitions, which can be further customized to payer-specific definition.
The platform promotes wellness by actively engaging healthcare consumers in their own care using intuitive and interactive tools on their smart phones, tablets or a web-browser. Patients can access their own health record and receive automated reminders for medications, home monitoring tests, diet and exercise based on the care management protocols. They can also submit home-monitoring data and provide feedback on the care management protocols driven questionnaire using an easy and intuitive interface of Care Coordination Software.
It also helps in measuring and improving delivery of healthcare services using easy-to-use AHRQ CAHPS patient satisfaction surveys, resulting in satisfied and engaged patients.
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Words from Our Clients
C. Verl Woolsey
MSHS, PA-C Cardiac Physician Assistant, Capital Heart Associates, PC