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Community-wide Coordinated Care. 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 .

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Presentation Transcript
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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

What forms need to be filled out?

Did they get

my referral?

Clinical notes?

What happened tomy patient?

Was insurance

eligibility confirmed?

Is the appointment scheduled?

When will I get a report back?

Did my patient

show up?

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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

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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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Clarity Solution: Community Wide Care Coordination

Clarity Service Center

  • Eligibility verification
  • Network Checks & authorizations
  • SNF and ALF placement
  • Other administrative processing

PCPs

  • Initiate referrals
  • Review status of referrals and confer with consultants
  • Review radiology findings and determine care plans
  • Hospitals
  • Accept patients into ambulatory setting
  • Perform radiology and other services

Consultants/Specialists

  • Receive and schedule referrals visits
  • Manage referrals to additional specialists
  • Maintain dialogue with remainder of care team
  • SNF / ALF / Home Healthcare
  • Collaborate with other parties on admissions
  • Manage interventions
  • Provide feedback on care plans

Platform

  • Other Services
  • (PT, counseling, etc.)
  • Accept referrals and provide patient status
  • Consult with providers on treatment options and progress
  • Case Managers
  • Monitor cases across the entire care cycle
  • Provide input on care decisions
  • Review overall performance of the care system
  • Health Plans/ACOs
  • Collaborate with providers around care decisions
  • Manage care across a managed care/ACO population
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Clinically-Integrated Community

Linked around common patients

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Specialty

Imaging Center

Skilled Nursing Facility

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