Care Coordination & Engagement

Caradigm solutions enable care team collaboration and increased patient adherence that drive improved outcomes for patient populations.

As healthcare organizations seek to expand their population health management initiatives, scaling care management is a foundational strategy. The challenge of care management is that it requires the coordination of a diverse group of clinicians often working with incomplete patient information and inefficient manual workflows. Caradigm® Care Management helps providers optimize care management for large patient populations across all risk segments.

Patient engagement is a key component in managing the health and wellness of populations. The influence of patient lifestyle and behaviors on health outcome has five times the influence of the efforts of providers or health plans. Your organization needs to engage patients for smoother recovery from health episodes, encourage informed patients to select appropriate treatment options and promote ongoing self-management.

Three opportunities exist for you to engage patients for better results.

  • Patients within the episode of care—making patients part of the care team, engaging with them early in the episode and in the hospital, preventing readmissions and providing them with tools for self-care
  • Patients with chronic conditions—addressing the segments of the population that generate the highest cost, yet are often motivated and open to patient engagement, by providing the tools for ongoing care management in the home
  • Healthy patients—engaging them around wellness and health maintenance and promoting fitness and positive behaviors to prevent health episodes and cost

 

Patient Outreach provides a scalable, cost-effective engagement tool across a range of patient management needs, including:

  • Onboarding
  • Assessments
  • Readmissions Reduction
  • Quality Gap Closures
  • Reminders
  • Condition Monitoring
  • Custom Programs

 

 

 

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Care Management enables a multi-disciplinary care team to provide coordinated care for high-risk and rising-risk patient populations while working at top of license. Care Management helps improve the efficiency of care by automating numerous tasks repeated across a case load. It enables organizations to create and employ evidence-based assessments that can auto-generate care plans and recommend mitigations, and helps care managers plan their day and prioritize tasks. Care Management supports a number of value-based initiatives including shared savings programs and bundled payments. Care Management utilizes the Patient Activation Measure® (PAM®) to promote patient adherence to medication and treatment plans that reduce expensive services while increasing patient satisfaction.

 

See How It Works.
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Knowledge Hub is an application that surfaces actionable information from other Caradigm applications within electronic health records (EHRs). Knowledge Hub is an overlay that presents real-time data and information (e.g. care plans) from across the care continuum that can prompt action such as closing a gap in care while a physician is in the presence of a patient. With a shared longitudinal view of the patient, care can be better coordinated between physicians and other care team members.

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Patient Outreach is a solution designed to effectively reach patients outside of the care setting – with the right message at the right time – to trigger health-related behavior change.

 

See How It Works.
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