ABCs of Care Coordination Part 2

As we are examining potentially confusing terms in care coordination it might help to review some software terms as well. As even casual computer users know, software has its own specialized vocabulary. Add in the specialized vocabulary used in medical health, behavioral health, and community-based care and you can see how confusing terms can quickly proliferate.

Below are some of the common terms and buzzwords used in describing different aspects of the technology  and the industry it serves:

Care coordination platform — The care coordination platform is the software system that enables a system of care coordination. Using a care coordination platform, providers across the spectrum of care delivery can collaborate on patient needs, communicate with other providers, view results, and monitor outcomes. The care management platform is the tool that unites providers across different disciplines and medical specialties, such as primary care, chronic care, behavioral health, and community care.

Social Determinant Data — The social determinants of health are the complex factors outside the scope of traditional medical care that have a direct impact on patient health. Social determinant data includes factors such as employment, education, economic stability, food security, home environment, and access to healthcare. The care coordination platform assesses patient conditions related to the social determinants of health, records care given to address needs and monitors patient progress against desired outcomes.

Interoperability — Interoperability is the process by which one computer system exchanges data with another system. Data exchange is a necessity throughout the healthcare industry as different providers, care systems, and even individual departments within the same facility may use different software systems as their primary system of record. A care management system, such as ClientTrack, should support common interoperability standards, such as FHIR and HL7.

Comprehensive Care Plan — A Comprehensive Care Plan is a living document that exists within the care coordination platform. This document is created from customized social and physical health assessments and is accessible to all members of the multi-disciplinary care team. Shared assessments, intake and enrollment, care plans, and progress notes are accessible at the point of care so providers are fully informed of all aspects of the patient’s condition. A Comprehensive Care Plan builds on the idea of bringing all patient data together, and then adds real-time care-planning and communication in order to provide true whole person care.

Comprehensive Health Record — The Comprehensive Health Record (CHR) is the term proposed to describe the “next generation” health record that will replace the Electronic Health Record (EHR). The CHR includes all the medical information currently contained in the EHR but adds additional information about the social determinants of health. The shift to the CHR is an acknowledgment by the Health IT industry that medical data alone is insufficient for patient care and that additional information is essential for high-quality care delivery.

Patient Stratification – Patient Stratification is the use of cost trends, chronic conditions, and social determinant data to identify the individuals most likely to benefit from care coordination. Patient stratification is widely used in population health to target high-risk patients for more intensive treatment.

Patient Engagement — Patient engagement refers to the knowledge, skills, ability, and willingness of patients to manage aspects of their own health care. Patient engagement can range from a patient regularly showing up for (or missing) provider appointments, to participating in health care discussions with a provider through a patient portal, to intensive collaboration with a team of care experts across multiple care disciplines.

The ClientTrack Care Coordination platform assists providers across multiple care disciplines — such as primary medical care, chronic care, behavioral health, institutional care, home care, and community-support providers — to share data, communicate, and collaborate together to deliver higher quality care. Through the use of tools such as interoperability, the comprehensive care plan, directly addressing the social determinants of health, and increased patient engagement, ClientTrack gives providers an impressive set of tools to deliver the next generation of healthcare.

RESOURCES

https://nam.edu/wp-content/uploads/2017/06/Effective-Care-for-High-Need-Patients.pdf

https://patientengagementhit.com/news/what-are-the-top-common-social-determinants-of-health

https://www.medicaid.gov/medicaid/managed-care/index.html

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