Key elements of our care coordination program
Program management (including care coordination and care management)
- Tools to manage care managers (monitoring of CM team including time spent, consolidated patient view)
- Tools to manage care managers (monitoring of CM team including time spent, members reached, programs initiated and completed, etc.)
- Chronic disease management
- Online health risk assessments
Role-based reporting (clinician, executive, administrative, etc.)
We provide role-based, near real-time reporting to our providers and managers to ensure efficient and effective communication and care that best fits the needs of our patients and their families. Our proprietary care coordination platform provides a single platform to document and access information offering complete transparency for providers and the care team. Our platform seamlessly integrates with EMR systems and includes automated data feeds, clinical notes, and authorizations to manage care effectively.
Analytics & AI
Our tech-enabled platform utilizes some of the most advanced technologies available today, like Analytics and Artificial Intelligence (AI) for tasks like:
- Patient/risk stratification
- Quality measures calculations
- Common predictive analytics for proactive care management
Concise, Actionable Information to Support Patient Engagement
Patient engagement is a key performance metric for high quality care. Engaged patients are more likely to track their
progress and maintain their treatments. And this can lead to improved health outcomes, especially for chronic disease management.
As a care coordinator, we are tasked with making care services more transparent, more useful, and ultimately more valuable for our patients. Communicating clear, useful information is one surefire way to do so. Actionable information is important for integrated care coordination because it invites patients into the overall process. It ensures we and our patients are on the same page, building trust. It also promotes efficiency, as it can encourage additional effort from the patient, as well as reduce potential confusion.
Data Aggregation
Timely aggregation/ incorporation of ADT feeds, Pharmacy, prescription data, Inpatient clinical (EMR) data, Outpatient clinical (EMR) data are critical to ensuring highest quality of Care Coordination.
The Patient Journey
1. Identification and Patient Consent
Qualify and enroll your patient in a program. A Patient profile is created, communication and care preferences are defined, Patient Consent is obtained, care team member is assigned.
2. Assessment
Define Problems, Risks, Goals. Patient assessment forms are completed, care and patient goals are defined and updated in the Patient Profile.
3. Enrollment
Patients are enrolled in the best suited program. The care team is assigned, care plans are reviewed, first appointment or start date is scheduled, and reminders are set to check-in on defined cadence.
4. Care Delivery
Enrolled patients are nurtured and cared for through the care plan. Carehub’s care coordinators regularly communicate with patients, set up tasks, reminders and automated follow ups, schedule scoring assessments, analyze results and track outcomes.
5. Monitor and Course Correct
Keeping patients on track with their care plans. Any gaps in care are identified, meaningful alerts are generated, and patients are notified when they have not adhered to their plan. Appropriate escalations are communicated to the Primary Care team, and course corrections are made as necessary.
6. Evaluation
Final assessments are completed; data and analytics are utilized to determine completion or maintenance if necessary.