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Care Coordination

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0-10 Practices are currently using this product across the following Specialties


Capabilities: Care Coordination, Care Plan Management

Patient Adherence System Patient Benefits:

• Extends primary care practices’ reach by changing the rules of in-between-appointment engagement by empowering critically and chronically ill patients to follow their physician-prescribed care plans and identifying issues to the physician that indicate possibly more intensive and earlier intervention.

• Enables primary care practices with configurable, out-of-office support to better empower their critically and chronically ill patients in managing their conditional health in-between office visits, while preventing critical issues from cascading towards readmissions and recurrences without requiring the practice to change the way it delivers patient care.

• Provides a flexible, tailored support framework that right-sizes the support needed by chronic patients to ensure that they are systematically (as opposed to ad hoc) monitored and supported to ensure maximum care plan adherence. What is good for the patient is also good for the practice with better preventive service utilization, quality measures and profitability.

• Assists patients in understanding and following their care plans is a major challenge in itself, and patient non-adherence is a significant driver behind up to 33% of the ER or rehospitalizations. The ability for medical practices to provide all their critically and chronically ill Medicare patients with a tailored, systematic care plan outside of the office will dramatically improve clinical outcomes.

• Empowers critically and chronically ill patients with powerful adherence support tools to proactively manage their conditions and assist the physician in identifying issues to assist physicians in preventing hospitalizations, closing patient's adherence gaps, improving quality measures, and driving more proactive screenings and services adoption.

• Collaborates with the primary care practice team, integrates with the practices’ existing EHR, reduces staff workload billed through the practice, and is largely reimbursable from Medicare given the nature of the programs, though each patient will need to have their eligibility checked.

Patient Adherence System Functions:

• Scheduling - In collaboration with the regularly scheduled office visits, CareTrack schedules interval check-ins. If the patient is relatively stable and scheduled for an annual follow-up, the physician may prescribe a quarterly check-in to ensure that the care plan is being followed, there are no major changes in health, and to discover if there are issues that require scheduling an earlier visit. More intensive need patients may require monthly or weekly check-ins as determined by the physician.

• Care Plans – Dynamic and personalized care plans are developed with adherence program recommendations, latest developments, and real-time updates with the patient record so practices and patients can share health information.

• Preventive Care – Screenings and additional conditional specific services (lab orders and medications, reminders, and scheduling) are tracked to help keep patients up-to-date on every available resource the practice recommends.

• Early-warning system – Regularly scheduled intervals also provide a secondary function for the primary care practices by giving them a consistent model for engaging with patients outside of the office. These intervals, condition-specific structured workflows, physician-defined thresholds, along with alerts and escalations provide additional patient coverage without placing additional staffing burdens on the core staff.

• Patient accountability – Beyond the functional sum-of-the-parts, the patient adherence system provides the foundation for the increased patient accountability through increased engagement, reminders, and education. Patients are more aware about maintaining their health and understanding their specific care plan. The regular schedule provides behavioral reinforcement to help them maintain their prescribed home care program.

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