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 after care has been provided. This requires proactive patient outreach programs and coordinated care with Primary Care Physicians (PCPs) and Post-Acute Care service providers such as Skilled Nursing Facilities (SNFs), Rehab Centers, and Long-Term Care Hospitals (LTCHs).
VLink’s approach 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 implemented a tool for COPD registry by integrating data from the Cerner Electronic Medical Record (EMR) system, and billing systems such as Centricity Business and Cerner Invision (A similar solution can be replicated for CHF, Obesity, Asthma, Diabetes, and more). A registry was built 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.
- IBM Netezza Data Lake
- Aginity Workbench
- Cognos Dashboards
• A defined patient population based on flexible definitions (problem lists, diagnosis, procedures, medications ordered/administered or lab tests and results).
• Patients were identified based on the need for care (for example, checkups and tests not performed in over a year based on the patient condition).
• 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.
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