Community-wide Coordinated Care
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Transcript of Community-wide Coordinated Care
Community-wide Coordinated Care
© 2011 Clarity Health Services 2
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
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• 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
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• 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
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• 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
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Did they getmy referral?
Is the appointment scheduled?
Did my patientshow up?
Clinical notes?What happened to
my patient?
Was insuranceeligibility confirmed?
When will I get a report back?
What forms need to be filled out?
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• 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
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• 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
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• 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
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• 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
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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
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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
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
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
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
Clarity Solution: Community Wide Care Coordination
Platform
© 2011 Clarity Health Services
Clinically-Integrated CommunityLinked around common patients
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Imaging Center
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