Best Coordinated Community Networks Products
Social determinants of health—the conditions in which people live, learn, work, play, and worship—are inextricably linked to an individual’s physical health. Emerging evidence suggests addressing health-related social needs can improve health outcomes and reduce cost. Unmet social needs, such as food or housing insecurity, may increase the risk of developing chronic conditions, reducing an individual’s ability to manage these conditions, which may lead to avoidable health care utilization.
Outside of the traditional role of the health system, the knowledge to appropriately match patients to services in the community is often locked in paper documents, outdated binders, and individuals’ minds. With systems increasingly bearing risk and losing money on treating uninsured, Medicaid, and increasingly, high-deductible populations, streamlining this process and identifying these gaps is an important piece of any strategic plan. Health systems are beginning to invest in partnerships and technologies to identify the right community partnerships and make the connections.
VitalCare integrates vital signs, nutritional inputs, medication reminders and simple communication tools to interact with provider teams remotely.
Through virtual care and engagement, patients stay focused on their care plans and achieve better health outcomes.
Patients can utilize a VitalTech provided tablet or bring their own device, providing a sense of comfort to patients. The real-time connection between patients, their provider team, as well as their family and caregivers engages patients in their managing their health and wellness.
By providing provider teams with vital information, they are able to assist patients manage their health and intervene before an event happens, leading to
|EMRs supported||Epic, Cerner, Athenahealth +5 more|
|Solutions||Social Determinants of Health (SDOH) Analytics, Asynchronous Virtual Visit Tools, Connected Platform - Remote Monitoring|
|Keywords||remote patient monitoring, virtual care, sdoh +28 more|
|Categories||Remote Monitoring (RPM), Coordinated Community Networks, Virtual Health +5 more|
Dedicated behavioral health clinician(s) available in consistent, preestablished blocks of time for initial evaluations, medication management, therapy, collaborative care and doc-to-doc consultation.
Roundtrip is a leading digital B2B solution for Health Systems and Health Plans that optimizes care coordinators' workflows in managing patient transportation. We seamlessly connect users to our nationwide network of non-emergency medical transportation providers, offering various vehicle types for each patient's unique medical needs. Our integrations with industry-standard software, such as EMR and CAD systems, enhance user efficiency and visibility substantially. With over 60 customers across the nation, we have proven results in reducing no-shows, expediting discharges, and enhancing patient and staff satisfaction. At Roundtrip, we are dedicated to removing transportation as a barrier to wellbeing.
|EMRs supported||Epic, Cerner, Meditech +18 more|
|Solutions||Non-Emergent Medical Transportation Providers, Non-Emergent Medical Transportation Platform|
|Keywords||transportation, social determinants of health, ehr integration +21 more|
|Categories||Coordinated Community Networks, Non-Emergency Medical Transportation (NEMT), Health Equity +1 more|
Innovaccer’s care management solution enables health systems to drive cost-effective, coordinated care with an integrated solution to unlock value for health plans, from care management to referrals to prior authorization. The patient-centered solution that connects every care journey touchpoints into personalized 1-to-1 health moments powered by 360-degree patient profiles and prospective patients inclusive of EMR, clinical, financial, SDoH, patient data for better care delivery. With predictive models, the solution can predict any health system’s total cost of care to a much higher degree of accuracy than industry standards for better management of resources. It also offers wide range of workflows that assists cares teams to simplify redundant tasks, bridging care and coding gaps, facilitating contextual, relevant, and dynamic bidirectional communication to deliver care outcomes.
|EMRs supported||Allscripts, Allscripts/Eclipsys, athena +11 more|
|Solutions||Care Management Platforms, Care Plan Automation, Social Determinants of Health (SDOH) Analytics|
|Keywords||care management, ccm chronic care management, medication adherence +12 more|
|Categories||Coordinated Community Networks, Care Management, Social Determinants Analytics +3 more|
The solution simplifies collection of social determinants with pre-built SDoH assessments which leverages proprietary Social Vulnerability Index (SVI) to address socio economic needs that directly or indirectly affects overall wellbeing of a patient. It allows providers to connect community resources and centralize social referrals to keep everyone informed in real-time on the needs of patients, which community resource they are referred to, and what’s the social referral status.
Innovaccer’s Quality Management providers get a consolidated view of the patient, with insights on care gaps, coding gaps (dropped codes), risk scores, acute visits, specialty visits along with Pre-visit Summary. It also makes it easy to report to CMS for the MSSP ACO program using either web interface or eCQM reporting and help providers calculate quality performance, run measure analytics, add supporting evidence, and export in payer specific format to report out to different payers/upload to their portals.
The solution helps health systems to take a step-by-step approach to manage risk from population- to patient-level with easy to use dashboards powered by clinical and claims data. First, it helps understand the current state of risk management in the network with historical comparison to previous years risk scores. Second, it can answer “where to focus” by identifying the cohorts with the least risk recapture rates or maximum dropped/suspect codes, chronic disease distribution, month on month risk capture trend and more. Third, it helps prioritize patients with the largest number of coding gaps and get patient-level risk information to redirect resources strategically that reduces overall risk for the population.
|EMRs supported||Allscripts, Allscripts/Eclipsys, athena +10 more|
|Solutions||Risk Identification and Stratification, Risk Stratification & Predictive Analytics Tools, Natural Language Processing Platforms|
|Keywords||risk management, risk score, risk stratification +6 more|
|Categories||Risk Identification & Stratification, Coding & Documentation, Coordinated Community Networks|
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