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Published byStella Wright
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Community-wide Coordinated Care
© 2011 Clarity Health Services The typical primary care physician has 229 other physicians working in 117 practices with which care must be coordinated, equivalent to an additional 99 physicians and 53 practices for every 100 Medicare beneficiaries managed by the primary care physician. Annals of Internal Medicine (2/17/09) The Challenge: Care Coordination is Complex 2 P P S P P P S S P P
© 2011 Clarity Health Services Commitment –Commitment to serve your patients –Commitment to serve your colleagues –Commitment to share all pertinent information Collaboration Narrative & Understanding Shared Framework or Context Develop shared practice Routine practices become standard process –Process can be rendered in tools and automation –Process enables measurement & improvement And the cycle continues – constant and incremental change The Evolution of Coordinated Efforts within a Practice 3
© 2011 Clarity Health Services Local workflows & protocols Individual & institutional relationships Ownership and affiliations Physical, Dental & Behavioral health domains Local information systems Existing Connectivity –Shared EMR –Point to Point Connections –Secure Messaging –Local & Regional HIEs The Context within a Community 4
© 2011 Clarity Health Services No standard communication protocol for referrals Poor or no visibility to the complete patient record No simple way to acknowledge receipt, scheduling, or visit status Inordinate amount of resources focused on the revenue cycle Latency or absence of clinical reports and notes Current State of Affairs Between Practices 5 Did they get my referral? Is the appointment scheduled? Did my patient show up? Clinical notes? What happened to my patient? Was insurance eligibility confirmed? When will I get a report back? What forms need to be filled out?
© 2011 Clarity Health Services Community provider directory and patient panels Staff initiates a referral or transition Which patient, reason for referral, referral destination or provider Include appropriate members of the patient’s Care Team Attach required clinical information Accompany with message(s) to assist coordination Service or Payer “processes” the referral Verify insurance, obtain authorization, check network status Transmit complete package to the recipient Recipients “receive” and “respond” Acknowledge receipt Request further information Provide scheduling status and visit status Provide results to “close the loop” Transitions and records archived and shared by Care Team Starting Point – The Referral 6
© 2011 Clarity Health Services Experience helping to build highly engaged integrated care communities Platform –Cloud based –Value-based pricing with no up front costs –Communication infrastructure –Patient Index & Provider/Practice Directories –Transaction/work-flow based with support for multiple work flows –Functions within heterogeneous IT environments –Integrates with EHRs & other Clinical Information Systems (RIS, et al) –Supports any care settings: Physical, Dental & Behavioral –Performance Measurement & Reporting Service infrastructure & organization to fill the gaps Platform and Service can be adapted to support any transition and the supporting care team A Community needs a Partner with a Platform 7
© 2011 Clarity Health Services Community-wide “leadership” engaged around a common purpose Create structure for clinical community Align community-wide expectations around service levels and standards of care Adopt standards of measurement Hold each other accountable - It’s a “public” not a “private” practice Share your plans and promote your success Getting Started 8
© 2011 Clarity Health Services Identify high-risk patients in the hospital Coordinate the care that they receive from the inpatient side to the outpatient side Have a discharge program or set of activities around discharge that include making sure the patient understands their medicines and that there's follow-up in an appropriately acute amount of time, and Increase emphasis on better communication with the outpatient providers during acute stay, at discharge and beyond Use Case: Successful Post-acute Transitions 9 P P S P P S S P PCP Specialty Skilled Nursing Facility
© 2011 Clarity Health Services Robust Community-wide Care Coordination Platform –Facilitates care transitions across all care settings –Enhances communication –Provides a shared repository of patient information Broad-based community service –Inclusive – any one can participate –Any setting – from single providers to health systems –Any transition – from outpatient referrals to post-acute transitions Incremental –No capital expenditure –No installation or integration is required –Monthly subscription and service fees based on activity Provides a Basis for Meaningful Accountability…. Clarity Overview 10
© 2011 Clarity Health Services Health Plans/ACOs Collaborate with providers around care decisions Manage care across a managed care/ACO population Health Plans/ACOs Collaborate with providers around care decisions Manage care across a managed care/ACO population Clarity Service Center Eligibility verification Network Checks & authorizations SNF and ALF placement Other administrative processing Clarity Service Center Eligibility verification Network Checks & authorizations SNF and ALF placement Other administrative processing Hospitals Accept patients into ambulatory setting Perform radiology and other services Hospitals Accept patients into ambulatory setting Perform radiology and other services SNF / ALF / Home Healthcare Collaborate with other parties on admissions Manage interventions Provide feedback on care plans SNF / ALF / Home Healthcare Collaborate with other parties on admissions Manage interventions Provide feedback on care plans Case Managers Monitor cases across the entire care cycle Provide input on care decisions Review overall performance of the care system Case Managers Monitor cases across the entire care cycle Provide input on care decisions Review overall performance of the care system Other Services (PT, counseling, etc.) Accept referrals and provide patient status Consult with providers on treatment options and progress Other Services (PT, counseling, etc.) Accept referrals and provide patient status Consult with providers on treatment options and progress Consultants/Specialists Receive and schedule referrals visits Manage referrals to additional specialists Maintain dialogue with remainder of care team Consultants/Specialists Receive and schedule referrals visits Manage referrals to additional specialists Maintain dialogue with remainder of care team PCPs Initiate referrals Review status of referrals and confer with consultants Review radiology findings and determine care plans PCPs Initiate referrals Review status of referrals and confer with consultants Review radiology findings and determine care plans Clarity Solution: Community Wide Care Coordination 11
© 2011 Clarity Health Services Clinically-Integrated Community Linked around common patients 12 P P S P P P S S P P PCP Specialty Imaging Center Skilled Nursing Facility
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