Care coordination is defined differently in each organization. While the purpose is to improve the patient’s ability to navigate through the healthcare system, reduce fragmentation in care, and improve health outcomes, each organization must determine the extent of the staff members’ involvement.
“Coordination maximizes the value of services delivered to patients by facilitating beneficial, efficient, safe, and high quality patient experiences and improved healthcare outcomes.” – National Quality Forum, NQF-Endorsed Definition and Framework for Measuring Care Coordination
The team at Zenith Technology Solutions can help your organization:
- Manage virtual care teams that range across the organization and community
- Develop a system that will help you manage and track referrals
- Develop methods to securely communicate with patients and community based organizations
A customer wanted to reduce risk as they entered into value-based contracting. The State had identified high-risk Medicaid patients with chronic conditions and enrolled them into Health Homes to receive Case Management services. The customer wanted to ensure that their non-Health Home, at-risk patients received the same services.
The team at ZTS helped the customer with:
- Identifying those non-Health Home patients at high risk for hospitalization or high ER utilization
- Creating a workflow for their care management staff on the best approach for these patients
- Creating tools to document the staff interaction and for recording outcomes
- Developing registries and receiving admission/discharge data feeds to monitor hospitalizations or ER use
Overall the customer is monitoring over 300 high-risk patients with improved clinical outcomes. ER and inpatient utilization by those patients has decreased by over 80%.