Best Coordinated Community Networks Products

The approach is grounded in using technology to connect those caring for the patient and enable real-time flow of information. In doing so, the networks enable coordinated care management, improve transitions of care, and close care gaps.

By utilizing the EMR and external data, patients at risk of heightened need for social support can be easily identified and referred to resources through digital tools. This allows health systems to accelerate the identification of at risk patients requiring specific resources and interventions to have their social needs met earlier in their care and improve their health outcomes.

This care is often delivered through a medical home and includes features such as patient-centered care, risk-stratified care management, greater accessibility, behavioral health integration, resources to address social determinants of health and more.

ED care navigators are nurses or CHWs who connect targeted ED patients to a primary care provider (PCP). Alerted in real time by triggers embedded in the EMR, they intervene at the bedside when the patient: 1) has minor conditions and 2) lacks a personal PCP. Beyond establishing a PCP, navigators also help connect patients with resources like transportation, housing or medication.