It takes a village - the Health Social Network
A Health Social Network is the social network that surrounds a given patient which is empowered with managing their health and wellness. The network can consist of friends, family, caregivers and care providers. The Health Social Network is goal driven, the focus of this private micro community is to advance the health of the patient.
The intended crowd sourcing effect of such a network is the key to reducing health care costs and improving adherence and compliance with health provider recommendations. While the notion and existence of the Health Social Network has existed for many years, (consider a family with distributed members caring for a relative) it has not been defined or leveraged in a systematic way to optimize care delivery and management.
With the ensuing growth in health care services demand based on the the aging US population, a mandated shift from Fee-for-Service to Value Based Care has created several programs and payment models to promote patient centric healthcare. As a key tenant to patient centered healthcare, care plan and care management tasks must be communicated and coordinated with care team members and the patient. Thus, the patient's Health Social Network becomes critical to the success of value based care programs.
Value Based Care programs use clinical quality metrics to score your practice and determine overall reimbursement. Re-focus your practice on quality and engage patients to ensure mutual success.
Start your transition by participating in current Value Based Care programs that provide increased revenue and begin to focus resources on Care Management and Quality Metrics. Gain valuable experience early and excel as the shift to Value Based Care accelerates to reach 90% penetration over the next few years.
CareCliques offers a Web and mobile care management app for patients, caregivers and providers. All parties have a view of the patient's timeline of care tasks and comprehensive care plan. Phone, chat or telehealth communications can be initiated via these apps at anytime.
Our services provide frequent interactions and engagement by our care coaches to ensure caregivers and patients are aware of care tasks and their successful completion. 24 x 7 responsive service -- live / timely response to inquiries via chat, messaging, phone or telehealth by clinical staff. Our clinical nurses have full access to key clinical records and patient centric care plans to guide responses. A summary of patient interactions are transferred to the PCP's E H R same day, as are escalation alerts.
The system can import a standard CCDA clinical summary as the basis for the medical care plan. A built-in set of patient assessment tools are then used to evaluate psycho-social and functional gaps. In combination, this information is used to create a comprehensive, patient centric care plan. Each care plan is comprised of a set of modular blocks that are mapped to a set of patient facing care tasks. The system can offer appropriate care tasks based on patient risk and chronic conditions. Administrators and users can customize and share the modular care plan sets with the CareCliques community.
Support for over 200 health devices, including mobile apps, wearables and in-home monitors. Sign-up for a new device with just a few clicks
The system has integrated tools that offer secure real-time chat, and asynchronous messaging. Inbound and outboand call management is integrated via our on soft-phone, with rollover, forwarding and voicemail features. Video teleconference and webinar capabilites are also fully integrated for use on a scheduled or ad-hoc basis. The technology is HIPAA compliant and seamlessly integrated into the web and mobile apps. All interactions are resource and time tracked to allow compliance with CMS guidelines and utilization reporting.
As mentioned in the items above, the system can accept CCDA patient summaries from host E H R systems and export detailed care plans and event/case log summaries via directed exchange. This minimizes integration issues and provides secure communication of clinical data between systems.
The system can identify appropriate patients within a practice and assist in the process of patient enrollment. Uploaded practice management system reports can be used initally to segment and stratify patients. Once loaded, a simple step-by-step wizard on-boards staff, caregivers and patients.
Once setup, the care plan is represented as a set specific care tasks on a timeline for the patient and their care team. These tasks include educational resources (video, handouts, video consultations, self care guidance, and medication adherence advice) as well as reminders for visits and therapy. In addition, tasks can be adjusted to collect critical information (surveys, registry data, health status and outcomes). Additional tasks are designed for planned social visits and other activities. Each task can be socialized within the care team via shared comments and photos.
Each care team member has role-based access to the system and can adjust the care plan and tasks as is appropriate. Thus the care tasks timeline is a synchronized calendar of events that foster tight coordination of resources and effort. In addition, all care managers have access to real-time engagement, complaince and utiliztion metrcis. A case notes system automatically tracks system events as well as care coach notes.
As the system is designed to foster tight coordination between the care team members, it acts as a first stop for acute problems related to the patients chronic conditions. Transition of care documents are imported into the system and inform care plan and related care task adjustments that are visible to all care team members. The system is well suited to synchronize all care team members as to recent care transitions and revised care tasks.
Each month a comprehensive billing report will be sent to the practice itemizing the patients that have recieved care management services or have qualified for CMS CCM payments. The report will detail clinical labor time for each patient. Billing managers can further access the patient's paperwork and case log to clarify any billing or audit questions.
Administrative dashboards are provided to demonstrate progress with several Value Based Care Programs, including disease management programs & associated clinical quality metrics, CMS Chronic Care Management (CCM), Pre-diabetes/Diabetes Prevention (DPP), and MIPS/MACRA. Patient hotlists are provided each day to highlight high and medium risk accounts. Canned or custom reports related to population/patient behavior are also available.
$100/provider/mo + service fees
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