Deploy a care coordination platform for population health management
Integrated Healthcare Delivery System
A population health management department inside a fifteen-hospital integrated delivery system
The population health management team needed an operations platform to track and manage activities intended to reduce unnecessary care, manage costs, and encourage appropriate utilization of services across the organization’s 11 accountable care organization partnerships. Registered nurses and care coordinators manage over 300,000 lives covered under at-risk, value-based contracting arrangements.
Status:Go created a system to allow care coordinators to track patient management activities, including interventions and provider follow-up.
Care coordinators use a task list tool to prioritize the delivery of services and manage activities on a daily, weekly, and monthly basis. Additional functionality includes:
- A tool to place patients under a management program, easily allow administrators to update eligibility registries and add new ACO partnerships
- The platform was customized to match the workflow of the care coordination department processes and integrated with the contact center application in the centralized contact center to provide after-hours support
- An integration with the organization’s electronic medical record provides care coordinators real-time admission, discharge, and transfer updates
- Dashboards allow care coordinators to plan their workday, stay updated on patient progress, and manage daily job requirements
- The system allows communication with hospital case managers and provider offices to collaboratively manage patient care and ensure follow-through with care plans
- Administrators can track and report important metrics including total cost of care, employee utilization, and health improvement metrics
- Each ACO and defined population is tracked separately in the system so that group details and population specifics can be specifically measured for each contract.
- Measured across all ACO contracts and managed lives, total cost of care was reduced by 2% in the six months following implementation
- 77% of attributed ACO patients deemed to be “high-risk” were contacted at system implementation
- Percentage of high-risk populations referred to affiliated providers and kept “in network” increased by 24% in the first six months of implementation
- Provider follow-up improved dramatically, with care coordinators able to deliver patient updates to providers following an intervention 91% of the time
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