Summary: Coordinated care and information sharing among multiple healthcare providers leads to better outcomes for patients.
Healthcare delivery is significantly fragmented leading to inefficiencies in the way care is provided to patients with chronic and episodic conditions. Increased rates of re-admission, complications, and mortality are potentially associated due to lack of care coordination after the patients are discharged from the hospital. Efficient management of patient population based on their conditions requires an assessment of the patient’s needs both before and aftercare has been provided. This requires proactive patient outreach programs and coordinated care.
VLink’s approach not only enabled the assessment of the type of care that was needed but also provided flexibility in defining patient populations, measuring specific types of care required, utilization, and outcomes.
Our team built a registry using the identified adult patient data (18 years old and older) with COPD. Where available, our team examined each patient’s spirometry results and calculated their COPD severity based on the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines, which were then categorized according to each patient’s severity.
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Our Healthcare delivery client wanted a way to effectively manage patient population after discharge to avoid readmissions.
Our team implemented a tool for COPD registry by integrating data (EMR) system, and billing systems. This enabled them to examine each patient’s spirometry results and severity based on their the COPD Global Initiative for COPD guidelines.
Measured quality outcomes and avoidable hospital utilization for discharged patients with specific conditions. • Identified variation in utilization by care settings; identified super-utilizers and high-cost utilizations. • Developed a reporting platform which focused on the patient and identified the patients’ problems and past utilization.