Community Care

My Folder

Product Overview

The Community Care Advanced Application is aimed at Primary Care Clinical Program leaders, primary care providers and care coordinators working in ambulatory settings, quality improvement teams, and staff responsible for reports related to the organization’s status as an Accountable Care Organization (ACO). The application focuses on providing data to help organizations review population health; compare their performance to national benchmarking standards for specific measures; identify opportunities for costs savings, and help practices track, monitor, and meet the needs of high-risk patients.

Features

  • Preventive and chronic care interventions and control measures for primary care physicians
  • Measurements are compared to external benchmarks and internal goals
  • Scores are calculated for the organization as a whole, clinic, department, provider and by patient
  • Patient panels by provider for use by care managers and others in proactive patient engagement

Benefits

Benefits Include:

  • Improved reporting on and compliance with best practice preventive and primary care measures (e.g., HEDIS, PQRS, etc.).
  • Improved screening and primary care for specific populations of high-risk patients, especially those with diabetes, heart failure, hypertension, hypercholesterolemia, and other chronic conditions.
  • Improved patient satisfaction related to the health system’s proactive outreach services.
  • Increased capacity for care providers to identify care gaps for specific patients and take action during the current office visit.

See Sample Screenshots of Community Care

Data Sources

  • EMR
  • Patient Satisfaction

Community Care: A Deeper View

Background

The healthcare industry is intensely focused on improving the quality of patient care while simultaneously lowering cost. It’s increasingly clear that a system built upon a foundation of strong preventive and primary care is critical to achieving these goals. Delivering high-quality, efficient, patient-centered care begins with a primary care system that can effectively manage the health of patient populations.

What types of problems does Community Care address?

AHRQ reports that 5 percent of the population accounts for 50 percent of healthcare costs; this fact is a primary driver of the need to effectively manage the health of populations. Many of the drivers of overall cost are chronic conditions. Being able to easily identify patients with preventive or primary care gaps is the first step in improving care and outcomes. Yet currently, most organizations lack the ability to track and monitor needed primary and preventive care metrics. They also lack the actionable analytics that support outreach to specific patients for care follow up and help providers easily see what screening, monitoring, and therapies are needed for patients during primary care visits.

Use Cases

  • A care coordinator wants to identify patients with cardiovascular disease who have hypertension and high LDL—these patients will be the focus of new outreach efforts aimed at preventing MI.
  • A primary care provider and diabetes educator want to gauge the impact of several new initiatives aimed at improving diabetes self-management.
  • An obstetrical provider wants to see how many of her patients have been screened for chlamydia.
  • After a particularly brutal influenza season, an organization wants to review immunization rates and patterns to help them design a community health campaign for the following year.

Anticipated Improvements

  1. Improved reporting on and compliance with best practice preventive and primary care measures (e.g., HEDIS, PQRS, etc.).
  2. Improved screening and primary care for specific populations of high-risk patients, especially those with diabetes, heart failure, hypertension, hypercholesterolemia, and other chronic conditions.
  3. Improved patient satisfaction related to the health system’s proactive outreach services.
  4. Increased capacity for care providers to identify care gaps for specific patients and take action during the current office visit.

Success Measures Examples

There are 3 types of success measures:

Opportunity Identification:

  • Identify gaps in preventive and primary care within your patient population.

Process Improvements:

  • Support delivery of a list of patients with care gaps for generating outreach letters encouraging patients to schedule an appointment or connect with a care manager. Improve compliance with best practices for delivery of preventive and primary care during the current or future follow-up care.

Outcomes Improvement:

  • Increase by XX% the percent of diabetes patients with HbA1c lower than 6.5%
  • Improve by XX% the percent of patients age 50 or older whose care is compliant with colonoscopy screening guidelines.
  • Increase percent of patients over 50 years of age who have received recommended pneumococcal and influenza vaccines.