Describe your case management workflow tools to support a patient population

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Response: To improve case management services, subject-specific marts are developed around case management, care coordination, or populations. Data from multiple sources across the continuum can be included if available (such as inpatient, ambulatory, and claims). This gives teams the data to drive improvement in workflow, operations, and clinical care. These implemented improvements are then tracked to ensure effectiveness and sustainability. Within each subject-specific mart that is developed (such as heart failure, pregnancy, and so on), case management components can be incorporated into the data that drives the process improvement teams. For example, a heart failure team can evaluate the data across the continuum to recognize key opportunities for improvement such as discharge effectiveness, appropriate follow-up, medications, readmissions, high-risk patients or members, prevention, indications for setting and provider, and so on. As teams identify opportunities, interventions are planned, implemented, and measured.