Care Coordination

In the 2003 report “Priority Areas for National Action Transforming Health Care” the Institute of Medicine identified care coordination as one of 20 national priorities for action to improve quality. There is a growing recognition of the role that social determinants play in health care spending.
Research from the University of Wisconsin- Madison School of Medicine and Public Health that indicates social determinants may contribute to up 40% of health care spending. To address the health care disparities providers in underserved communities, require greater access to technology, our cloud-based platform requires minimal IT support thus addressing barriers to care coordination.
Using HL7 messaging standards and (Application Programming Interfaces) API’s CAARA imports ADT messages from hospital EMR systems. The messages trigger alerts to care managers when patients on their panel are admitted or discharged. The alerts prompt care managers to initiate a transition care plan including, reviewing discharge instructions, medication reconciliation, coordinating care and scheduling follow up visits with PCP’s and specialist.

Our newest care management solution Opioid Risk Identification and Monitoring (ORIM) extends our care coordination capability to substance use disorder (SUD). ORIM flags opioid risk from EMR data and creates alerts for care managers. Available drug claim history and medical claim history including diagnosis and procedures can be accessed to provide physicians and care managers with information to engage with and support patients and health plan members.



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