Care Coordinators: Boon to Healthcare Community

Abhinav Shashank
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Every day millions of members of healthcare community try harder to improve the population health. Doctors, researchers, nurses and other numerous prominent members try their level best to fight the challenges current healthcare industry faces. But more often than not, we see health deteriorating with age. The older you are, the more prone you are to diseases, but this does not mean that if one is young, there is any assurance that one would remain 100% healthy.

Doctors work very hard to keep patients healthy, but there are always certain things that go out of control. For instance, what if after being discharged patient forgets to take his/her medicine or misses the follow-up visit?

In many cases similar to this, Care Coordinators could provide the much needed helping hand. They can make sure that patient doesn’t miss out on essential amenities like medication, plans, follow-up visits, etc. But then again there is a catch to it. What if Care Coordinators cannot find out about the patient’s follow-up visit details before the date of visit? Or worse, they have no idea when a patient was discharged? How to overcome such unforeseen troubles?

John Doe, CEO Beatles ACO, explains in an interview with AllTime Magazine how with the help of an intuitive Big Data platform he enhanced his ACO’s current care coordination network. (Hypothetical)

 

Your network’s performance has gone up exponentially. Did you make changes in your network or what?

Changes? No. Wouldn’t call it changes per se rather an addition to the network. We saw that there is a lot of scope for improvement once we implement a platform which can deal with humongous amount data like we have. For example, imagine out of the millions of patients data that too divided categorically into claims, medical, financial, etc. all you have to deal with are pie charts, bar graphs, lines and other interactive figures,  wouldn’t that make life easier? After implementing such big data platform, it was just a matter of finding opportunity checkpoints one by one and achieving them.

 

What kind of opportunity checkpoints?

There could be many like our past performance, weaker links in the network, contact performance, cost/episodes, probable yearly savings, quality metrics and so much more. Consider patients and care delivery, if a patient visits our network, we’ll not only have access to his medical history, but also work on what’s best for him with the help of Patient 360 and care coordinators.

 

What is Patient 360? How does it help in Care Coordinators?

Patient 360 is the holistic view of a patient where you will find all the relevant medical information about the patient. Like Medical History, Social Determinants, Risk scores, Care Opportunities (HH, MM, LL), Disease registries and much more.

Imagine your Facebook timeline view, now replace it with a patient where all his vitals and medical history is present with relevant risk scores (according to different measures). A Care Coordinator in our network would access such profile of patients assigned to him and find out who needs immediate intervention or whose follow-up visit is coming up etc.

 

But didn’t you say that you have millions of patients? How can hundreds or even thousand Care Coordinators monitor millions of profile effectively?

Oh, believe me, that is a good question! This problem troubled us for way too long! But not anymore! With our new Big Data Platform, our Care Coordinators don’t have to worry about visiting every profile. Whenever a Care Coordinator logins into his device he’ll get the update of recently discharged patients, at-risk patients or the ones who require immediate intervention!

So, if I’m a Care Coordinator, whenever I log in to my portal, I’d get push notifications about patients who have to be reminded about the medications, follow-up meet or checkup. All I’d have to do is point and click and finish my job!

 

That is great! But as a CEO how do you monitor the progress?

For me it’s just a matter of clicks to monitor anyone’s progress. As a CEO, I get to access Drilled down performance on an aggregate level like national or regional and also on lowest level like county or provider/facility level. The platform provides hierarchical access to everyone, so, someone responsible for a particular set of patients would get access to only those patients and analytics relevant to them. A Care Coordinator would be able to access the patients assigned to him and their progress.

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The Road Ahead

In the 21st century, today our vision should be similar to John Doe, to leverage automated systems and other advanced technology to make the lives of millions of patients better. We all know how hard Doctors work to help their patients and how hard it is for them succeed at their mission almost every time. But if we have a small window of opportunity to help them improve health care, then I firmly believe we shouldn’t hold ourselves back and provide them with whatever we can and whatever they might need! If Care Coordinators are helping them, then we should work on helping Care Coordinators provide efficient and effective quality care.

 

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